Contents
Evolution of Health and Medicine ................................................................................................................ 3
Health ............................................................................................................................................................ 4
Determinants of Health ................................................................................................................................ 5
Health Indicators ........................................................................................................................................... 6
Disability........................................................................................................................................................ 8
Epidemiology................................................................................................................................................. 9
Disease ........................................................................................................................................................ 12
Control of Diseases ..................................................................................................................................... 13
Nutritional Problems in India ...................................................................................................................... 17
Nutrition...................................................................................................................................................... 20
Proteins ....................................................................................................................................................... 23
Carbohydrates............................................................................................................................................. 25
Fats .............................................................................................................................................................. 26
Vitamins ...................................................................................................................................................... 29
Iron .............................................................................................................................................................. 34
Iodine .......................................................................................................................................................... 37
Fluorine ....................................................................................................................................................... 39
Malnutrition ................................................................................................................................................ 40
Protein Energy Malnutrition (PEM) ............................................................................................................ 40
Food Borne Diseases ................................................................................................................................... 46
Food Fortification........................................................................................................................................ 49
Noise Pollution ............................................................................................................................................ 51
Radiation ..................................................................................................................................................... 53
Air Pollution ................................................................................................................................................ 55
Meteorological Environment ...................................................................................................................... 57
Water .......................................................................................................................................................... 59
Water Purification ....................................................................................................................................... 61
Waste Disposal ............................................................................................................................................ 65
Health
Definitions
Oxford: "Soundness of body or mind; that condition in which functions are duly and efficiently
discharged"
Webster: "Condition of being sound in body, mind or spirit, especially freedom from physical disease or
pain"
WHO: "Health is a state of complete physical, mental, and social well-being and not merely an absence
of disease or infirmity"
Operational definition, WHO: "Condition or quality of human organism expressing the adequate
functioning of the organism in the given condition genetic or environmental"
Dimensions of Health
Physical
Mental
Social
Spiritual
Emotional
Vocational
Determinants of Health
Health is multifactorial
Factors influencing health could be within the individual or externally in society
Individual Aspects
Sociocultural
o Faulty practices
o Cultural taboos
Aging of the population
o Increases non-communicable diseases
Science and technology
Education
o Especially female literacy
Families
Equity and social justice
Gender
Information and communication
Societies
Environmental (hygiene): Internal and external
Socioeconomic
o DM and Coronary artery disease
o TB in poor populations
o Stress involved
o Obesity
Communities
Human rights
Biological Genes
Behavioral (lifestyle factors)
o High risk behaviors: smoking, alcohol, risky sex
Determinants of Health
Medical Determinants
Agriculture, IT, Science, Technology
Awareness
Communication
Improving diagnostic modality, etc
Non-medical determinants
Health Indicators
Need for Health Indicators
1. To measure the health status of a community
2. Compare health statuses of 2 regions
3. For assessment of health care needs
4. Allocation of resources
5. To monitor and evaluate health services
Includes as measure of
Mortality: deaths
Morbidity: diseases
Disability
Mortality Indicators
Crude Death Rate
Death of the mother = during pregnancy or within 42 days of the termination of pregnancy
Ignores accidental or incidental deaths
Morbidity Indicators
Incidence
Prevalence
Attendance at OPDs
In-Patient days
Incidence
Number of new cases occurring in a defined population during a specified period of time
Prevalence
Number of people with a disease or an attribute at a specified point of time
Disability
Disability Indicators
Sullivan's Index:
Life expectancy - Duration of disability
Environmental Indicators
Health policy indicators
HPA Indicators
MDG Indicators
Epidemiology
Definition
"Epi" = above, among
"Demos" = people
"Logos" = study
Environmental Factors
Poor sanitation
Safe drinking water
Low socio-economic status
Period of Pathogenesis
Agent Factors
Agent: must be present for an infection to occur
Types of Agents
Biological - microorganisms
Nutrient - deficiencies and toxicity
Physical - radiation
Chemical - drugs, gases (poisons)
Mechanical - cause of injury
Social - alcohol, smoking, etc
Host Factors
Demographic
Biological
Socioeconomic
Lifestyle factors
Pre- Pathogenesis
pathogenesis Phase
Phase
Disease
A condition in which
Body health is impaired
A departure from a state of health
An alteration of the human body
Interrupting performance of vital function
Spectrum
Subclinical infection
Mild disease
Moderate disease
Severe disease
Fatal disease
Death
Iceberg Phenomenon
Apparent cases
Water line
In-apparent cases: not noticed/ undetected
Challenge
Hidden part of iceberg - undiagnosed reservoir of infection or disease in the community
Detection and control of this part of the iceberg
o Challenge to modern techniques in preventive medicine
Risk Factors
At risk groups
Biological situation - genetically susceptible, age, gender, obesity
Physical situation: environment in which they live
Socioeconomic situation: occupation, beliefs and customs, lack of physical activity/ sedentary
lifestyle
Control of Diseases
Disease Control
In disease control the agent is permitted to persist in the community at a level where it ceases to be a
public health problem according to tolerance level of the population
Disease Elimination
Precursor of eradication
Disease Eradication
Termination of all modes of transmission of infection by termination of infectious agents
Challenges in Eradication
Hidden foci of infection
Unrecognized modes of transmission
Resistance of vector to control measures
Prevention
Concept of Prevention
Depends on:
Knowledge of causation
Dynamics of transmission
Identification of risk factors and risk groups
Availability of prophylactic or early detection and treatment resources
Organization for applying these measures
Continuous evaluation and development of procedures applied
Levels of Prevention
Primordial
Primary
Secondary
Tertiary
Primordial Prevention
Prevention of the emergence or development of risk factors in countries or population groups in which
they have not yet appeared
Useful in prevention of chronic illnesses
Main interventions are through individuals and mass education: lifestyle modification
Primary Prevention
Action taken prior to the onset of disease, which removes the possibility that disease will ever occur
Signifies intervention in pre-pathogenesis phase of disease
In chronic diseases involves the modification or elimination of risk factors
Interventions are health promotion and specific protection
Secondary Prevention
Action which halts the progress of a disease at its incipient stage and prevents complications
Early pathogenesis phase
Expensive and less effective than primary prevention
The Specific interventions are early diagnosis and adequate treatment
Tertiary Prevention
All measures available to reduce or limit impairments and disabilities, minimize the suffering caused by
existing departures from good health and promotion of the patient's adjustment to non-remedial
conditions
Significant intervention in late pathogenesis
Intervention includes disability limitation and rehabilitation
E.g.: use of splints and remedial exercises to prevent contractures and deformities in rheumatoid
arthritis
Modes of Intervention
Primary
1. Health promotion
2. Specific promotion
Secondary
1. Early Diagnosis
2. Appropriate treatment
Tertiary
1. Disability limitation
2. Rehabilitation
Health Promotion
Process of enabling people to increase control over and improve health
Health education
Environmental modification: safe water, housing
Nutritional intervention: supplementary nutrition, fortification
Lifestyle and behavioral changes - diet and physical activity
Specific Protection
Immunization: polio
Chemoprophylaxis: malaria
Use of specific nutrients
Protection against accidents
Protection from occupational hazards: lead poisoning
Control of specific hazards in environment: air pollution
Disability limitation
Prevents the transition of the disease process from impairment to handicap
Impairment
Any loss or abnormality of psychological, physiological, or anatomical structure or function
Disability
Any restriction or lack of ability to perform an activity in the manner or within range considered normal
for a human being
Handicap
A disadvantage for a given individual resulting from an impairment or a disability that limits or prevents
the fulfillment of a role that is normal for that individual
Rehabilitation
Combined and coordinated use of medical, social, educational, and vocational measures for training and
re-training the individuals to the highest possible level of functional ability
Types
Medical restoration of function
Vocational restoration of capacity to earn a livelihood
Social restoration of family and social relationships
Psychological rehabilitation of personal dignity and confidence
Over nutrition
Anemia
Condition in which Hb content in blood is less than normal
Most frequent cause of nutritional anemia is Iron deficiency
Highest prevalence in developing countries
Common among women of child bearing age, young children, and during pregnancy and lactation
Factors leading to anemia
Iron deficiency may arise from
o Inadequate intake
o Poor bioavailability of dietary iron
o Due to excess loss
o Malaria
o Hookworm infestation
Over-nutrition
Consumption of too many calories relative to activity level → more calories than needed
Over time it leads to obesity which can result in
o DM
o HTN
o Heart disease
Nutrition
Nutrition - science of food and its relationship to health
Nutrient - specific dietary constituents
Macronutrients
o Proximate principles: form major bulk of food
Proteins: 7-15% of total energy intake
Fats: 10-30%
Carbs 65-80%
Micronutrients
Nutrition
Knowledge regarding
Origin
Chemical composition
Functions of food items
Energy requirements
For basal metabolism: 1 kcal/hr for every kg of body weight of an adult
For daily activity/occupational work: varies based on type of activities
Balanced Diet
Defined as one which contains a variety of foods in such quantities and proportions that the needed
energy, AA, vitamins, minerals, fats, carbs is adequately met for maintaining health and also makes a
small provision for a period of leanness (?)
Principles
10-15% of daily energy intake from protein
15-30% from fat
Carb rich in fibers should constitute remaining food
Food Pyramid
Dietary goals
Energy requirements
Factors affecting energy requirements
Reference man and woman
Vulnerable groups
Anthropometry
Height, weight, BMI, mid-arm circumference
Recorded over a period of time to reflect patterns of growth and development
Clinical Exam
Signs known to be
o Of value
o that need further investment
o Not related to nutrition
Drawbacks:
o quantification of malnutrition difficult,
o lack of specificity,
o subjective nature of features,
o lack of signs in many deficiencies
Functional Indicators
RBC fragility
Prothrombin time
Sperm count
Nerve conduction
Vital statistics
Morbidity
Mortality
Ecological Factors
Food balance sheet
Socioeconomic factors
Health and education system
Conditioning influence (infections)
Nutritional Surveillance
Keeping watch over nutrition in order to make deicsions that will lead to improvement in nutirtion
in population (difficult)
Growth monitoring (for children < 5) → individual over period of 7 years
For large population at 1 point in time
Look up comparison tables
Proteins
Sources
Animal Sources
Milk, egg, cheese, fish, meat
Vegetable Sources
Pulses, cereals, beans, nuts, oil seeds
Poor in essential AA
Functions
1. Body building
2. Repair and maintenance of body tissues
3. Synthesis of enzymes, antibodies, plasma proteins, Hb, hormones, coagulation factors
4. Energy (4 kcal/g)
When 2 or more vegetarian foods are consumed together, proteins supplement each other
Quality of Protein:
Assessed by comparison to reference protein (usually egg albumin - biologically complete)
Method of assessment
o AA score
o Net protein utilization
Examples:
Starch: 50-60
Animal foods: 70-80
Carbohydrates
Sources
Starch: cereals, roots, tubes
Sugars: mono and disaccharides
Cellulose: indigestible fibers
Uses
Main source of energy: 4 kcal/g, contributes to 50-70% of total energy intake
Essential for oxidation of fats
Synthesis of non-essential AA
Dietary Fiber
Mainly non-starch polysaccharides
Found in vegetables, fruits, and grains
2 kcal/g
Broadly divided into
o Insoluble fibers - cellulose
o Soluble fibers - non cellulose - pectin, inulin, plant gums
RDA: 40g/day
o Indian diet: 50-60g: whole grain, cereals, pulses, vegetables are consumed daily
Function
Absorbs water, increases bulk of stool, decreases constipation
Decreases putrefaction and formation of gases and toxic substances
No fecal mutagen synth and decreased chances of colon/stomach cancer
Associated with reduced incidence of coronary artery disease (reduction in cholesterol)
Gum and pectins: decrease post-prandial glucose levels
Refined Carbohydrates
Foods which have been processed (milling): strips the bran and grain from the whole grain
Concentrates the carbohydrate so that the body processes it quickly → increase in blood glucose
Gives food a finer texture and prolongs shelf life
Removes important nutrients: Vit B, fiber, bran
Eg: white rice, white bread, pastries, biscuits, dessert, toffee/sweets
Glycemic Index
A way of ranking carbohydrate foods based on how quickly they raise blood sugar levels
Factors affecting
o Texture
o Type of cooking
o Processing used
o Amount of sugar present
Foods with low Glycemic Index: oats, pulses, ground nuts
Foods with high glycemic index: white rice, bread, potatoes
Fats
Macronutrients that provide concentrated source of energy
9kcal / gram of fat
Found in blood and body cells
Types
Simple lipids: triglycerides
Compound lipids: phospholipids
Derived lipids: cholesterol
Fatty Acids
Fats → Hydrolysis → Fatty acids + glycerol
Classification
Unsaturated
Monounsaturated - oleic acid; olive oil, peanut butter, almonds, nuts
Polyunsaturated -linoleic acids; safflower oil, sunflower oil, walnuts
Oils at room temp
Lower total cholesterol → Heart healthy
Saturated
Animal sources - Stearic, Palmitic
Increase blood cholesterol → increased risk of heart disease and stroke
Cheese, whole milk, dark chocolate, butter, ice cream
Sources of Fats
Animal fats: milk, butter, eggs, cheese, meat
o Saturated fats except fish oil
Veg fats: groundnut, coconut, mustard
o Unsaturated fats except coconut and palm oils
Other sources: invisible fats in cereals, pulses, nuts
Invisible Fats
Not visible to naked eye, so difficult to estimate
Present in almost every food
Cereals, pulses, milk, etc
Hydrogenation
Insert hydrogenation picture
Refined Oils
Done by treatment with steam, alkali
Refining and deodorization of raw oils is done to remove from FA and rancid materials
Doesn’t change unsaturated FA content
Improves quality and taste of oils
Costly process
Trans Fas
PUFA → partial hydrogenation → Trans FA
Unsaturated FA → Saturated FA
Increases shelf life
Used to fry food over and over again with going rancid
Atherogenic and increased risk of CHD
Decreases HDL cholesterol, increases LDL
Ex: Margarine, deep fried foods, French fries, most bakery goods
Functions of Fats
Supply energy: 9kcal/g
Improves palatability of food
Slows digestion - resulting in satiety
Vehicle for fat soluble vitamins
Supports viscera - heart, kidneys, intestine
Fat beneath skin - insulation against cold
55% of energy from breast milk comes from fat
EFA: needed from growth of body, decreased platelet adhesiveness, decreased serum
cholesterol and LDL
Cholesterol: precursors for synthesis of steroid hormones and bile acids
PUFA - precursors for prostaglandins → vascular homeostasis, GI motility, lung and renal
physiology
Vitamins
Vitamins are organic substances that are essential for enzyme function in human metabolism
Thiamine was discovered in 1912 - thought to be "vital amine" → term "vitamin" coined
Categories
Fat soluble Water soluble
A, D, E, K C and B complex
Vitamin A
Rich Dietary Sources
Animal Plant
Functions
Vision: integrity of eye and formation of rhodopsin necessary for dark adaptation
Immunity: Important for activation of T lymphocytes and maturation of WBC
Maintaining integrity and normal functioning of glandular and epithelial tissue lining the skin
and internal organs
Growth and development
Anti-infective
Recommended Allowances
Life Stage RDA Retinol (mcg/day)
Infants 350
Children 400-600
Adolescents 600
Adults 600
Pregnant 800
Lactating 950
Advanced
Keratomalacia (ulceration and necrosis of cornea)
Endophthalmitis - inflammation of inner coats of eye
Blindness
Hyper-keratinization of skin
Loss of taste
Growth retardation
Treatment
Massive dose of 200,000 IU Retinol Palmitate orally on successive days
Early treatment can reverse early stages of xerophthalmia
Prevention
Short term action (NIN strategy)
Administration of single massive dose of oily preparation of Vit A
o 100,000 IU orally to children (6 mo-1 year)
o 200,000 IU orally to preschool children in community every 6 months (Ages 1-6 years);
Medium term action
o Fortification of foods with Vit A: ex. Dalda (hydrogenated vegetable oil)
Long term action
o Improvement of diet to ensure regular and adequate intake of Vit A
o Promotion of breast feeding
o Decreased frequency severity of contribution factors like PEM, measles, etc
o Improvement of environmental sanitation
o Immunization of infants
o Community participation
RDA
Adults: outdoor physical activities
Children 1-2 years: 10 mcg/ day
Sources
Sunlight
Milk
Animal fats
Fish oils
Sources
Citrus fruits (highest = gooseberry)
Other vegetables
RDA
Adults: 50-60 mg/day
Vitamin C Deficiency
Scurvy
Poor wound healing
Bleeding gums
Petechiae/ purpura
Hemarthrosis - bleeding into joint spaces
Vitamin B2 (Thiamine)
Function
Helps produce energy from carbohydrates
Precursor of TPP
Involved in peripheral nerve conduction
RDA
1-1.7 mg/day
Sources
Whole grain
Deficiency manifestations
Wet beriberi - CVS (Edema present)
Dry beriberi - Nervous system (edema absent)
Wernicke's encephalopathy - polyneuritis, ataxia
Seen in alcoholics
Vitamin B3 (Niacin)
Functions
Helps body use sugars, Fas
Helps enzymes function normally
RDA
Adults: 12-20 mg/day
Sources: poultry, fish, beef, peanut
Minerals
Iron
3-4 g in adult body
60-70% as circulating iron (hemoglobin)
Functions
Formation of HB
Carrier of oxygen from lung to tissues
Muscle activity (myoglobin)
Immune system
Component of enzyme systems
Dietary Iron
Heme iron: animal food like meats, fish, poultry
o Better absorption
o Readily available
Non-heme iron: plant: cereals, veg, legumes
o Poor bioavailability due to phytate, oxalates
o Milk and tea do not contain iron
RDA
Age Group mg/day
Infants 46 mcg/kg
Adolescents 26-32
Adult Males 17
Adult Females 21
Pregnant 35
Dietary Absorption
Site: duodenum and upper jejunum in ferrous state
Dependent on Fe status of the body, Fe needs, disorders of GIT, type of diet
Part of absorbed Fe - stored in RE system as ferritin
Absorption from habitual Indian diets < 5%
Iron Losses
Adults: 1-2 mg/day
Definition (WHO)
Reduction of Hb concentration below reference values
Adult Male 13
Adult Female 12
Pregnant 11
6-14 yrs 12
6m-6yrs 11
Causes of IDA
Inadequate iron intake
Poor bioavailability of dietary iron
Excessive loss
Increased iron demand
Clinical Features
Symptoms
Fatigability, irritability
Dizziness
Poor work performance
Pica: appetite for things that have no nutritional value: dirt, clay, metal, chalk
Signs
Dry, pale skin and mucosa
Glossitis, stomatitis, angular cheilosis
Spoon shaped nails (koilonychia)
Lab Findings
Microscopic hypochromic anemia
Decreased Hb
Decreased MCV, MCH, MCHC
Consequences of IDA
Nutritional anemia
Increased material and fetal mortality
Increased risk of premature delivery and low birth weight
Learning disabilities and delayed psychomotor development
Decreased work capacity
Impaired immunity (high risk of infection)
Management of IDA
Correction of Fe deficiency
Orally
Intradermally
IV
Treatment of underlying disease
Prevention of IDA
Short term approach: Fe supplementation
Long term approach: food fortification
o Addition of ferric ortho phosphate or FeSO4 with sodium bisulfate to common salt
o Consumption of iron fortified salt over 12-18 months
Supplementation pattern
Beneficiaries Elemental Fe Folic Acid Minimum Duration
Iodine
Essential micronutrient
Required for synthesis of thyroid hormones and normal growth and development
Recommended daily intake:
o 150 mcg
o Preg: 250 mcg
Lifetime required for 70 years is 5 g - one teaspoonful
o Total quantity is present in the body
Sources of Iodine
Food is the main source of iodine (90%)
Meat, fish, dairy products
o High amounts in sea foods
Vegetables, cereals
10% from drinking water
Iodine content of soil determines presence in water and locally grown foods
Goitrogens
Chemical substances leading to development of goiter
Interfere with iodine utilization by the thyroid
Cyanoglycosides and thiocyanates in brassica group of vegetables
o Cabbage
o Cauliflower
Problem Statement
Total goiter prevalence in general population: 15.8% (WHO 2005)
Prevalence of iodine deficiency in general population (39.8%) in SE Asia
71 million people affected by goiter and other Iodine deficiency in India
IDD was thought to be a problem in sub-Himalayan region
Progression of IDD
Historic National Goiter Control Program
Iodine deficiency = goiter = visible swelling
No pain, cosmetic problem
I Detectable goiter only by palpation but not visible when the neck is in the neutral position,
moves with deglutition
Hazards of Iodization
A person has to consume at least 10-50x normal daily dosage
Iodine to trigger hyperthyroidism
Risk of iodide goiter is less
Mild increase in thyrotoxicosis and Hashimoto's thyroiditis
Iodized Oil
Poppy seed oil in IM injection
1 mL provides protection for 4 years
Can be applied rapidly in places where iodized salt is in short supply
More expensive, logistical problems
Oral administration of iodized oil or sodium iodate tabs - simpler but more expensive
Fluorine
Required for normal mineralization
Bones and formation of dental enamel
Double edged sword
Deficiency - dental caries (cavities)
Excess - dental fluorosis and skeletal fluorosis
RDA = 4mg /day for adults
Malnutrition
Complications
Undernutrition
Over nutrition
Imbalance
Specific micronutrient deficiency
Causes of PEM
Inadequate food intake (quantity and quality)
Infections
Other factors
o Poor environmental conditions
o Large family size
o Poor maternal health
o Premature termination of breast feeding
o Cultural factors
Kwashiorkor
A type of severe PEM
Characterized primarily by protein deficiency
Appears about 12 months, when breast feeding is discontinued
But can develop at any time during a child's formative years
Symptoms
Edema in face, arms and legs
Liver enlargement and ascites
Dry peeling of skin (flaky point dermatosis)
Hair discoloration (sparse, easily pulled out, positive Flag sign)
Poor appetite
Mental retardation
Slow development (behavioral)
Marasmus
Inadequate calorie intake of all principle nutrients
Body breaks down own tissues to use for energy
Frequent infections
Dry and baggy skin
Sparse, dry, and brownish hair
Decreased body temperature
Absence of edema
Obvious muscle wasting
Grading
Normal 80%+
Grade I 71-80%
Grade II 51-60%
WHO Classification
Mean ± 2 SD
Waterlow's Classification
Height for age Normal Stunted
Degree of PEM Stunting (%) Height for age Wasting (%) Weight for height
From <http://en.wikipedia.org/wiki/Malnutrition#Waterlow>
Mid-Arm Circumference
Normal > 13.5 cm
Management
Domiciliary Management
Nutritional rehabilitation at home
For mild to moderate PEM
Prerequisite
Absence of severe infection
Parental guidance
Stress laid on locally available foods
Day care
Open from 8am to 6pm daily
Rooms for children, kitchen, teaching space
Residential Care
Larger and more organized
Center attached to a health center, pediatric dept. of teaching hospital
Consists of full time in-charge person
Supervisory staff - past time: doctor, nurse, economist, nutritionist, agriculture teacher,
extension worker
Criteria
Children especially at risk
o Who fail to gain weight over period of 3 months
o Who cannot catch up with growth after serious illness
Failure to breast feed
Twins
Mothers and children who find it difficult to cope with problem in spite of health education
Return of appetite
Weight gain of 10-15 kg
Disappearance of hepatomegaly, enteropathy, and increase in serum albumin
Transferred to home diet
Prevention of Malnutrition
Prevention at a Family Level
Breast feeding of infants for first 6 months
Nutritional supplementation after 6 months
Complementary foods
Milk, meat, eggs, or foods of increased biological value
Adequate immunity
Spacing between pregnancies
Nutritional Surveillance
Define character and magnitude of nutritional problems
To analyze causes of nutritional and other associated problems
To assess government in formulating a nutritional policy
To help government in planning, development, and implementation of projects
Nutritional Programs
ICDs
Mid day meal
SNP
WFP
Classification
Due to naturally occurring toxins
Lathyrism
Endemic ascites
Neurolathyrism
Due to consumption of lathyrus sativus (kesari dhal)
Toxin - Beta-oxalyl amino alanine (BOAA)
Seeds are used to adulterate bengal gram
Public health problem in certain parts of India (MP, Bihar, UP)
Consumption of diet containing > 30% kesari dhal for more than 2-6 months → neurolathyrism
Interventions
Vit C prophylaxis
Endemic Ascites
Due to contamination of millet panicium miliase with weed seeds of crota
Chemical: pyrolixidine alkaloids
Hepatotoxins: ascites and jaundice
Prevention measures
Education about
o the disease
o De-weeding of the Crotalaria plant
o Sieving at household level
Aflatoxins
Mycotoxin produced by fungi (A. Flavus and A. Parasiticus)
Fungi infest food grains
Moisture and temperature
Carcinogenic: Hepatotoxins produced
Ergot
A field fungus - Claviceps fusiformis
Infest during flowering stages
Infested seeds appear black and irregular
Symptoms
Acute: Nausea, vomiting, giddiness, etc
Chronic: painful cramps in limbs (vasoconstriction), peripheral gangrene
Epidemic Dropsy
Due to contamination of mustard oil with argemone oil
Toxin - sanguinarine
Interferes with oxidation of pyruvic acid
Argemone seeds resemble mustard seeds
Harvesting period is the same
Contamination - accidental or deliberate
Symptoms
Sudden bilateral swelling of legs
Dyspnea
Glaucoma
Cardiac failure
Death
Food Additives
Adding non-nutritious substances intentionally to food
Categories
First Category
Coloring agents
Flavoring agents
Sweetness
Preservatives
Acidity imparting agents
Second Category
Contamination incidental through
Packing
Processing
Farming practices
Hazardous to health
Food Fortification
The process
Whereby nutrients are added to foods (in relatively small quantities)
To maintain or improve the quality of diet of a group, cmmunity, or population
Examples
Fluoridation of water as a measure to prevent dental caries
Iodization of salt to prevent endemic goiter
Foor fortification with Vit A and B
Grain fortification
Food Adulteration
Mixing
Substitution
Selling decomposed foods
Misbranding
Addition of toxicants
Disadvantages
Consumers pay more for food stuff of lower quality
Adulteration
If proven, minimum imprisonment
Monitoring
Surveillance
Food laboratories
Kolkata
Ghaziabad
Pune
Mysore
PFA Standards
To maintain mnimum level of qualtiy of food stuff attainable under Indian conditions
Agmark standards
o Set by the director of marketing and inspection of gov
o Provides assurance
ISI on any foodstuff is an assurance of good quality
ISI and AGMARK - voluntary
Noise Pollution
Noise: derived from the Latin word nausea
Strong sound in wrong place at wrong time
Noise pollution: signifies the vast cacophony of sounds that are being produced in the modern life,
hazardous to health
Properties of Noise
Loudness (intensity)
Depends on amplitude of vibrations
Measured in decibels
Dangerous exposure -- max 85 db.
Frequency
Denoted by Hz
Human ear can hear from 20-20000 Hz
Instruments
1. Sound level meters: measures intensity
2. Octave band frequency analyzers: measure noise in octave bands
3. Audiometer - measures hearing ability
Health Impact
Globally: 20 million people -- disabling hearing difficulties
Developed cities: hearing impairment mostly restricted to work setting
Developing cities: due to community sound
Control of Noise
Careful planning on cities
Control of vehicles
Improve acoustic insulation of buildings
Protection of exposed persons
Legislation
Education
Radiation
Sources
Natural
Cosmic Rays
Terrestrial atmosphere
Internal: potassium-40 and carbon-14 isotopes
Man made
Medical and diagnostic: x-rays and radioisotopes
Nuclear reactors
Nuclear fallout
Occupational hazards
Misc.
TV, markers, radioactive dials on watches
Types
Ionizing
Has ability to penetrate tissues and deposited energy within them
Present in environment
Also produced by human
Nonionizing
Units
Roentgen: unit of exposure (SI unit: e/kg)
Rad: unit of absorbed dose
Rem: product of absorbed dose and modifying factor
o Indicates degree of potential health risk
o Unit: sievert
Biological Effects
Radiation when absorbed produces toxic free radicals
High level exposure - substantial damage to tissues, excess = death
Prolonged exposure - increased ill health
Somatic Effects
Immediate radiation sickness (acute radiation syndrome)
Delayed
o Leukemia
o Carcinogenesis
o Fetal development abnormalities
o Shortening of life
Genetic Effects
Chromosome / point mutation
Radiation Protection
Radiation hygiene
ICRP, IAEA, WHO
ICRP recommendation
o Dose to whole population from all sources additional to natural background radiation should
not be > 5 rem over 30 years
Radiation from outer space and background radiation = 0.1 rad/year
Steps
Avoid unnecessary x-ray
Adequate control and surveillance of x-ray installations, protection of workers, improvements
leading to dose reduction
Proper use of lead shields, read rubber aprons
Film badge (dosimeter)
Air Pollution
The presence in the ambient atmosphere of substances generated by human activities in concentrations
that interfere with human health safety or comfort or injurious to vegetation, animals and other
environmental media
Resulting in chemicals constituting additional sources of human exposure through food or water
Sources
Automobiles: hydrocarbons, CO, Pb, NO, particulate matter
Industries: smoke So2, Nitrogen oxides, fly ash, hydrogen fluoride, CO2, H2S, ozone, etc
Domestic Sources: smoke, dust, sulfur dioxide, nitrogen oxide
Others: burning refuse, pesticides, natural sources, nuclear energy program
Temperature Inversion
When there is rapid cooling of lower layers of air (temp inversion)
There is little vertical motion
Pollutants and water vapor remain trapped at lower levels --> smog
Second hand tobacco smoke, certain outdoor pollutants - risk factors for cancer
Indoor air pollution from biomass fuel is one of the major contributors to the global burden of disease
Meteorological Environment
Atmospheric Pressure
Atmosphere at the earth's surface = 1 atm = 760 mmHg
Measurement
Kew Pattern Station Barometer - widely used by Indian Meteorological department
Fortin's Barometer
Barograph - instrument for obtaining continuous record
Physiological effects
Increased respiration
Increased concentration of Hb
Increased CO
Heat Stress
COM MED NOTES – 3RD SEM CHINMAYEE POTTI
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Heat stress is the burden of heat that must be dissipated if the body is to remain in thermal equilibrium
Equatorial Comfort Index
Heat Stress Index
Predicted Four Hour Sweat Rate
Heat hyperpyrexia
Heat exhaustion
Inadequate replacement of water and salts
Heat cramps
Loss of NaCl in the blood
Heat Syncope
Humidity (Moisture)
Absolute humidity: weight of water
Relative humidity: % of moisture present in air, complete saturation being taken as 100%
Water
Improved water drinking source
An improved drinking water source is one that by nature of its construction adequately protects the
source from outside contamination, in particular from fecal matter
Chemical
Possible long term effects of low level exposure to chemical constituents (detergent solvents,
cyanides, heavy metals, minerals, organic acids, dyes, ammonia, organic compounds)
Others
Diseases transmitted due to inadequate use of water
o Shigellosis, trachoma, conjunctivitis, ascariasis, scabies
Diseases related to disease carrying insects breeding in or near water
o Malaria, filaria, arbovirus
Requirements
Basic physiological requirements: 2L/person/day
Rain water
Surface water
o Impounding resevoirs
o Rivers and streams
o Tank, ponds, lakes
Ground water
o Shallow wells
o Deep wells
o Springs
Sanitary Well
Well which is properly located and protected against contamination
Location
Not less than 15m from likely sources of contamination
No user will have to carry water fro > 100 m
Lining
Built
Water Purification
Purification of Water on a Large Scale
Storage of water: Natural or Artificial Reservoirs
1. Physical changes: 90% of suspended impurities settle down
2. Chemical changes: oxidation of organic matter
3. Biological changes: bacterial count drops by 90% in 5-7 days
Filtration
98-99% of bacteria, other impurities
Types of Filters
Slow sand or biological filter
Rapid sand or mechanical
Filter Box
Filter control
Valves and devices incorporated in outlet pipe system
Volume meter measure bed resistance or loss of head
Cleaning of filter
Supernatant water drained off top layer of sand scraped off
Advantages
Simple to construct and operate
Cheap
Quality of filtered water is very high
Steps involved
Coagulation: water treated with alum
Rapid mixing: violent agitation in mixing chamber
Flocculation: slow and gentle stirring in flocculation chamber for about 30 min
Sedimentation: coagulation water detained for 2-6 hours; flocculent particulates settle down
Filter beds
Sand is filtering medium (effective size 0.4-0.7mm)
Depth of sand bed is 1 meter
Gravel supports the sand bed
Under-drains collect filtered water
Filtration
Alum flow held back on sand bed
Forms slimy layer
Absorbs bacteria from water
Oxidation of ammonia
Backwashing
Washing accomplished by serving flow of water through sand bed
Advantages
Can deal with raw water directly
Filter beds occupy less space
Rapid filtration (AD 50x slow sand filter)
Disinfection
Chlorination
Chlorine kills pathogenic bacteria
No effect on spores, certain viruses (polio, viral hepatitis) protozoal cyst, helminthic ova
Oxidizes Fe, Mn, H2S
Controls algae and other organisms
Acid coagulation
Actions of chlorine
H2S + Cl → HCl + HOCl
HOCl → H+ + Ocl
Principles of chlorination
Water to be chlorinated should be clear
Chlorine demand of water estimated (difference between amount of chlorine added to water and
amount of residual chlorine remaining at end of 60 min, at a given temp and pH of water)
Point at which chlorine demand of water is met: "break point"
If further Cl2 is added, free chlorine appears (HOCl and OCl)
Presence of free residual chlorine for a contact period of at least the time essential to kill bacteria
and viruses
Minimum recommended concentration of free chlorine is 0.5 mg/L for one hour
Sum of chlorine demand plus free residual Cl of 0.5 mg/L constitutes the correct dose of Cl to be
applied
Method of Chlorination
1. Chlorine gas
a. First choice: cheap, quick, effective, easy to apply
b. Chlorinating equipment is required - Patterson's chloro)
2. Chloramine
3. Perchloron
Superchlorination
Addition of large doses of chlorine to water and removal of excess of chlorine after disinfection
(dechlorination) is applicable to highly polluted water
Other agents
1. Oxonation
a. Powerful oxidizing agent
b. Strong virucidal effect
c. No germicidal effect
d. Commonly employed (0.2-1.5 mg/L) in combination with chlorination
2. Ultraviolet irradiation
Disinfection of walls
Most effective and cheapest mosthod of disinfecting wells - bleaching powder
Chlonine demand of well water is stimated by using Horrock's apparatus
Waste Disposal
Solid Waste (Refuse)
Garbage
Rubbish
Demolition products
Sewage treatment residue
Dead animal, plants
Health Hazard
Favors fly breeding
Attracts rodents, vermin
Pathogens conveyed back to flood
Water and soil pollution
Unsightly appearance; bad odors
Methods of disposal
Dumping
In low lying area
Most insanitary methods
Controlled tipping (sanitary landfill)
Most satisfactory where suitable land
Material adequate compacted covered with earth
Methods:
Trench method: where ground level available
Ramp method: terrain is moderately sloping
Area method for filling land depressions, disused quarries and clay pits
Incineration
No suitable land available
Hospital waste
Compost pit
Combined disposal of refuse and night soil or sludge
Organic matter breaks down - bacterial action - forming compost
Compost: few or no disease producing organism, manure
Manure
Bangalore method (anaerobic)
Burial
Excreta Disposal
Sanitation Barrier
Sanitary latrine and a disposal pit or a sewage system and sewage treatment plant provide a barrier
which segregates excreta so that disease agent cannot reach new host either directly or indirectly
through various channels
Septic Tank
A water tight masonry tank into which household sewage
Working
Solid settles down "sludge"
Lighter solids, grease, fats rise to surface: "scum"
Stages of Purification
Anaerobic digestion
In septic tank
Sludge, much decreased in volume, rendered stable, inoffensive
Aerobic oxidation
Outside in subsoil
Liquid passing out: "effluent"
Numerous bacterial, cysts, helminthic ova, organic matter
Effluent percolates into subsoil by means of perforated pipes in trenches - 3 feet deep,
covered with soil
Anaerobic digestion
Screening
Grit chamber
Primary sedimentation
a. Large tank
b. Sewage flows very slowly
c. 50-70% solids settle
d. 30-60% decrease in coliform organism
e. Organic matter: sludge
Secondary enatment
a. Aerobic oxidation - trickling filter method
b. Activated sludge process
Secondary sed:
a. Oxidation sewage into sedentary sedimentation tank: 2-3 hours
b. "activated sludge" (after aerated)
c. Partly pump
Digestion
a. Disposal digestion: anaerobes auto digestion
b. Sea disposal
c. Compacting
Disposal of effluent
a. By dilution into water courses
b. On land
Secondary treatment
Aerobic oxidation