Ped Nutricon 2022 e brochure

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 1

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala ORG. TEAM Dr Darly S Mammen Dr Nisha V Krishnan Dr Keerthi K OB IAP KOTTAYAM SCIENTIFIC CHAIRPERSON: Dr Joseph Pattani Dr Preeja S Dr Sahla T K Dr Veerendrakumar M EDITOR PATRONS Dr Jayaprakash KP Dr Kurian Thomas Dr T U Sukumaran Dr Sushmabai ADVISORS Dr C Jayakumar Dr George F Moolayil Dr Balachandar D 2

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12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 FACULTY Dr Elizabeth K E Dr Zulfikar Ahamed M Dr Savida P Dr Shanavas A Dr Vijayakumar M Dr Mohandas Nair Dr Sreelatha P R Dr Bhanu Vikraman Dr Kristin Indumathi Dr Sheeja Sugunan Pillai Dr Jayaprakash KP Dr Anish George Paul Dr Thomas P Varghese 5

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12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE Dear Colleagues, Ped nutricon 2022 It is my great pleasure to note that IAP Kottayam is hosting the 12th Annual Conference of IAP Kerala Nutrition chapter on 10th July 2022. Our Friends at IAP Kottayam are all set to provide a day of resourceful academics with cream faculty from various parts of the country delivering on the newer concepts in child nutrition . I am sure that the well drafted scientific sessions will equip the practitioners with more scientific information to counsel the parents in a wiser manner. Congratulations to the organising committee led by Chairperson Dr Darly S Mammen, Secretary Dr Nisha V Krishnan, Treasurer Dr Keerthi K, Scientific Committee Chairperson Dr Veerendra Kumar& Souvenir Editor Dr Jayaprakash KP who have left no stone unturned to make the conference a great success. The tremendous and sincere support from IAP Kerala President Dr Vijayakumar M, Secretary Dr Johnny Sebastian, Treasurer Dr Gopimohan coupled with stalwarts from host branch President Dr Joseph Pattani, Secretary Dr. Preeja S&Treasurer Dr Sahla is really commendable.The Nutrition & IYCF Chapter Office Bearers have also been equally inspiring to the organising Team. Guidance from President Dr Sreeprasad T G,IYCF Chapter Kerala President Dr Elizabeth KE, Secretary Dr Kristin Indumathi and Treasurer Dr Priya Sreenivasan is sure to be instrumental in the success of the conference. I extend my warm wishes on behalf of CIAP for this conference. And I am sure the souvenir being brought out along with the conference will always remain as a worthy memoir with our delegates. Best regards, Jai IAP, Jai Hind Dr Remesh Kumar R President IAP 2022 7

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Ped nutricon 2022 Dear all I am happy to note that the 12 th chapter conference of nutrition chapter of IAP Kerala is being organised as a physical meeting. After 2 years of covid pandemic and virtual conferences, we are back with offline meetings and all recent chapter conferences were great success. I congratulate the team Kottayam for selecting appropriate topics and apt faculty for this CME , since ideal nutrition is the foundation for the well-being of any child. I wish the CME a grand success Regards Dr M Vijayakumar President IAP Kerala 8

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE Ped nutricon 2022 Congratulations to Nutrition Chapter of IAP Kerala for organising Ped nutricon 2022. Nutrition remains a core issue in care of children. With the epidemic of JUNCS food consumption and morbidities associated with them, the issue of Nutrition has become more relevant and urgent. My best wishes to meet the objectives of the conference. Dr A K Rawat Chairperson PAN Society Technical Expert NCOE KSCH New Delhi 9

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Ped nutricon 2022 The more our children understands about nutrition, the more excited they will be about eating healthy. The stress and emotional anxiety typical of the adolescent years can negatively impact teenagers’ nutritional equilibrium, resulting in insufficient or excessive food consumption. So its the prime responsibility of each and every pediatrician to make the society aware about the role of nutrition in child development. As the Office Bearers of nutrition chapter we are so happy to realise this souvenir .Hope it will be beneficial to all. Dr Sreeprasad T G Chairperson IAP Kerala Nutrition chapter 10

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE I have immense pleasure to be part of the 12th Annual State Conference of the IAP Nutrition Chapter (Pediatric and Ped nutricon 2022 Adolescent Nutrition Society), hosted by IAP Kottayam Branch. It is good to know that this physical meeting is having blessings of National PAN Society, Kerala State IAP and IYCF Chapter. The Theme of the Conference ‘Mal-Nutrition to Mall- Nutrition’, has been carefully chosen and also the topics and faculty. This academic meet shall take us through the intricacies of underweight to overweight / obesity and micronutrient malnutrition. Underweight, Overweight and Micronutrient malnutrition leads to morbidity, mortality and quality of survival. The ‘Nutrition Transition’ that happend in Kerala, much ahead of all other states, has pushed our future citizens into different clinical types of malnutrition, which can soon jeopardize their wellbeing and buy adulthood diseases for them at a much younger age than our ancestors. I hope that this meet shall create awareness about the importance of healthy eating at all age to ensure normal growth and development. I wish all success for the conference and hope that all the participants shall become champions of ‘Early Childhood Development & Nutrition (ECDN)’. Jai Hind Jai IAP Dr Elizabeth K E D MD, DCH, FIAP, FRCPCH (UK) UNICEF Consultant, Kerala Former Prof. & HOD Pediatrics, SAT Hospital Govt. Medical College, Thiruvananthapuram, India President, IAP IYCF Kerala Chapter, 2022 & Former President, IAP Kerala State, 2016 Former President, IAP National Nutrition Chapter, 2017-2018 Former President, IAP State Nutrition Chapter 11

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Ped nutricon 2022 Dear all I congratulate Nutrition Chapter of IAP Kerala for hosting Pednutricon of Kerala State in this month. PAN Society (Nutrition Chapter of IAP) is a unique body which conducts various programs nationally and internationally related to pediatric nutrition. After the Pandemic we are now knowing that beside infectious diseases practice now Pediatric Nutrition and Developmental Pediatrics are most valuable branches to survive in practice and important in day to day life also. I thank Dr K E Elizabeth and Dr Sreeprasad T G, President Nutrition Chapter IAP Kerala, for giving this opportunity to write my thoughts for this souvenir. Dr Elizabeth is backbone of not only Nutrition Chapter but also nutrition field in paediatrics. I hope this conference will update the knowledge of all pediatricians in Kerala state related to pediatric nutrition. Best wishes to the chapter for a successful conference. Thank you, Dr Parag Gaikwad National Secretary, Nutrition Chapter Central IAP President, Pune IAP 12

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE Ped nutricon 2022 I am extremely delighted to learn that IAP Kottayam Branch is hosting the 12th Annual subspecialty State Conference of the Nutrition chapter of IAP Kerala \"Ped Nutricon2022\"on the 10th of July. I am also glad that a Souvenir is being released on this occasion which would definitely benefit the practicisingPediatricians for future reference. I appreciate the sincere and dedicated effort of team IAP Kottayam and the Nutrition chapter of our State Branch to come out with this excellent souvenir under the able guidance of Dr K.P Jayaprakash Sir . IAP Kottayam has always excelled in its academic CME s and I take this opportunity to congratulate the organisers and the scientific committee for the meticulous selection of topics as well as faculty for this conference .I extend my warm greetings and best wishes for the success of the conference. Warm Regards, Dr Johnny Sebastian Secretary, IAP Kerala 13

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Dear Colleagues and Friends, Ped nutricon 2022 It gives me great pleasure to know that the Nutrition Chapter,Kerala is organising the 12thAnnual State Conference PEDNUTRICON 2022 on 10th of July at the IMA Hall in Kottayam. Nutritional well-being is a prerequisite for the achievement of the full social, mental, and physical potential of any population so that all people can lead full, productive lives and contribute to the development of the community and the nation with dignity. Nutrition is an integral part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and above all longevity. Healthy children learn better. People with adequate nutrition are more productive and can create opportunities to gradually break the cycles of poverty and hunger. Malnutrition, in every form, presents significant threats to human health. Today, the world faces a double burden of malnutrition that includes both undernutrition and overweight, especially in low- and middle-income countries. The Topics chosen for the Conference are very apt and the COVID epidemic has brought to light the reality of this problem. I thank the organisers for the academic feast, and I wish all success to this PEDNUTRICON 2022. Dr Kristin Indumathi Secretary Kerala IYCF Chapter 2022 14

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE Ped nutricon 2022 Dear Delegates, The Occasion of publishing the Souvenir Nutricare, as a part of the 12th Annual State Pediatric Nutrition Conference of IAP Kerala is proud movement of IAP Kottayam. It is also an occasion to recall the glorious achievements of IAP Kottayam since its inception. It gives me immense pleasure and gratitude to write few welcome notes. I am really happy that in this conference many subject of importance in nutrition will be discussed by well learned experts in this field, especially about Mall nutrition to Mal nutrition. I appreciate the sincere and dedicated efforts of all involved in the souvenir. I extend my best wishes for the grand success of the nutricare conference. Thanking you all Dr Joseph Abraham Pattani President, IAP Kottayam 15

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Ped nutricon 2022 Respected seniors and friends, It is a real pleasure for IAP Kottayam to host the 12th Annual State conference of IAP Kerala Nutrition chapter. After two years of inactivity due to the Covid pandemic, things have not been the same for us as well as the kids. A total change in food habits and life style has altered the nutrition and health of majority of the children. The topics have been chosen by the Scientific committee led by chairperson Dr Veerendra Kumar keeping in mind of this change in food habits and I believe all the pediatricians and post graduates attending this conference will have an excellent academic feast about nutrition and its challenges. I congratulate the Organizing team and committee members led by Dr Darly S Mammen and Dr Nisha V Krishnan for their dedication and hard work to make this conference a successful event. Wishing all the best for grand success of PEDNUTRICON 2022. Dr Preeja S Secretary IAP Kottayam 16

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 MESSAGE Ped nutricon 2022 The members of the organising committee and my- self are very proud to present the 12th Annual Confer- ence of IAP Kerala Nutrition Chapter - PED NUTRICON 2022 under the theme \" NUTRICARE : Mal - Nutrition to Mall - Nutrition \" on 10th July 2022 at IMA Hall, Kottayam. Proper maternal, infant, young child and adolescent is essential for the growth, development and event free survival of the child. Nutritional care has got effects on epigenetics, immunity, life style illnesses and also on eco- nomic survival of the world. The scientific sessions are scheduled to fulfill the theme of the conference. The hard work and dedication of all the members of the organising team during the preparation for the con- ference is highly appreciated. Without them the event would not have been possible. Thanks and acknowledgement are due to each and everyone in the PED NUTRICON 2022 team. I wish and hope that the deliberations of the conference will take the attendees to a new level of Nutritional care for children. My personal respect and greetings goes out to all of you. Enjoy the nutritious and delicious PED NUTRICON 2022! Dr Darly S Mammen Org Chairperson 17

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala MESSAGE Ped nutricon 2022 Dear colleagues, The impact of nutrition on health has been identified from the times of Hippocrates, as evidenced by his famous quote, “let food be thy medicine and medicine be thy food;” and it still holds true in the 21st century. Under nutrition used to be the crux of paediatric nutrition related problems, but in the current scenario of globalisation, junk foods contribute to juvenile onset of lifestyle diseases. Pednutricon 2022 is an update on both ends of this malnutrition spectrum. On behalf of the Scientific Committee, I wish the program all success. Dr Veeerendrakumar M Chairperson Scientific Committee. Ped Nutricon 2022 18

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 EDITORIAL Dear colleagues, We embark on a journey to nurturing care for children.Parents and caregivers are the center of providing nurturing care.In our efforts to sensitise,everyone involved in care of children we wish to con- duct events like this,which will keep the impetus on track. This conference is envisaged to raise awareness among our colleagues and as well spread the importance of nutritious ,healthy and stable environment right from planning a child to developing to the opti- mal potential one can have. We wish this is a humble beginning which is a starter,might go a long way in achieving real potential for children. Dr Jayaprakash K P Editor, Pednutricon Souvenir 19

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala CONTENTS SECRETARY REPORT ............................................................................21 Mal- Nutrition to Mall- Nutrition & ‘Mission Mazhavil’ .....................22 Dr Elizabeth K E What You Wanted To Know About Childhood Dyslipidemia .............25 Dr M Zulfikar Ahamed 1000 DAY NUTRITION .........................................................................29 Prof Dr Savida P NATIONAL NUTRITION PROGRAMS ....................................................31 Dr Shanavas A Dietary Management of Inborn Errors of Metabolism ......................36 Prof Dr Mohandas Nair Nutritional Ketosis ..............................................................................38 Dr Sheeja Sugunan GROWTH CHARTS IN NUTRITION .......................................................40 Dr Jayaprakash K P ADOLESCENT FOOD HABITS AND FOOD FADS ...................................41 Dr Kristin Indumathi IYCF practices in India & Kerala- Where do we stand? .......................45 Dr Priya Sreenivasan GOOD NUTRITION: A Talk To Adolescents ..........................................48 Dr Newton Luiz Pediatric obesity- evaluation and management ................................53 Dr Thomas P Varghese Medical Nutrition Therapy in Type 1 Diabetes Mellitus .....................55 Dr Riaz I 20

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 SECRETARY REPORT Dear seniors and friends, IAP Child India journal April is- sue also had many articles from The office bearers of Nutrition chapter, IAP Kerala 2022 PAN Kerala members. World Obe- were elected in EB meeting at IMA Kochi on 9 th January sity Day was also observed in a dis- 2022 with chairperson Dr Sreeprasad T G and Dr Nisha V tinguished manner by the district Krishnan as convenor. Childhood nutrition and IYCN were branches stressing on right nutrition from start of life to included in the Presidential action plan PROMISE 2022 prevent obesity. by IAP Kerala President Dr Vijayakumar M with Dr Kristin Indumathi as co-ordinator PAP. The activities kickstarted IAP Kerala IYCF chapter came into existence on June in January with ECDN workshops in various districts with 2022 with observance of complementary feeding day led support from UNICEF & IAP Kerala. PAN Kerala also con- by Chairperson Dr Elizabeth K E, Convenor Dr Kristin ducted various awareness sessions on the event of Na- Indumathi and treasurer Dr Priya Sreenivasan. tional Girl child day. We also had a few medical check up camps for anemia and malnutrition in various districts in The 12 th annual conference of IAP Kerala PAN chap- Kerala including the unprivileged classes of people in tribal ter is being organised at IMA Hall, Kottayam by IAP and hilly areas of Kerala and also health check ups in vari- Kottayam, IAP Kerala Nutrition chapter and IYCF Chap- ous orphanages. IAP branches Trivandrum,Thalassery and ters on 10 th July 2022 and the Theme is -NUTRICARE- Kozhikode also conducted academic sessions in Nutrition Malnutrition to Mall- Nutrition and the topics are chosen and parental awareness sessions on healthy eating. Dur- to cover the whole of pediatric nutrition with stresses on ing IAHW, also many awareness sessions on adolescent 1000 day nutrition and also nutrition in various organic nutrition and food habits was conducted in major districts disorders. I am extremely grateful to the scientific com- of Kerala. mittee, organising committee members and the office bearers of IAP Kerala and CIAP for extending their whole The Post COVID Times witnessed an impetus in MBFHI hearted support in this humble venture. certification activities in various hospitals distributed all over Kerala in association with PAP co-ordinators of The activities planned for future are: Intensive train- MBFHI revamping. Multiple scholarly articles were pub- ing sessions on pediatric nutrition during the National Nu- lished in dailies and journals by IAP Kerala President, Prof trition month- September,establishment of mother sup- Dr Elizabeth K E and others on the alarming rise in child port groups with HCW to roll out in various districts with obesity with COVID pandemic. Various media programs the help of IAP branches,school wise screening for mal- on healthy feeding of children were also done by experts nutrition -both extremes and association with other sub- in pediatric nutrition. specialty chapters and PAP co-ordinators to reach our goals-AHA,ECHG,NCD prevention,MBFHI revamping.. Dr Elizabeth K E, UNICEF consultant Kerala participated etc.. in National consultative meet and also published few books on nutrition including IAP- IYCF ‘Essentials of I feel that as responsible pediatricians ,we should be maternal,infant, young child and adolescent nutrition”, the voice for our future generations as their productivity, “Expanding Horizons of Nutrition” and “Nutrition and life style diseases and well-being are all established even Child development”. prior to the conception and nutrition plays an essential role in this. Multiple academic sessions on pediatric and adoles- cent nutrition and IYCF were conducted on Diap platform Jai Hind, Jai IAP.. and at CIAP conference at Noida by Dr Elizabeth K E, Dr Kristin Indumathi and Dr Priya. Post graduate training Dr Nisha V Krishnan sessions were also conducted on child nutrition and SAM. Elizabeth madam was honoured with the prestigious IYCF Convenor IAP Kerala Nutrition Chapter 2022 & award in recognition of her services in the field of child Org Secretary PedNutricon 2022 nutrition at PEDICON 22 at Noida. 21

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Mal- Nutrition to Mall- Nutrition & ‘Mission Mazhavil’ Dr Elizabeth K E Introduction MD, DCH, Ph. D, FIAP, FRCPCH (UK), The double burden of malnutrition is coming up as an important UNICEF Consultant public health issue. The greatest challenge that we face now is that Former Prof. & HOD Pediatrics, the proportion of normal children is decreasing and those with un- SAT Hospital, derweight and undernutrition as well as overweight and obesity are Govt. Medical College, increasing. In the book on ‘Expanding Horizons of Nutrition’, by the Trivandrum author, the determining factors and remedial measures of this situa- tion have been discussed. The changing profile of malnutrition and the nutrition transition turning away from healthy eating to overeat- ing and ‘JUNCS” are ringing the alarm to intervene on a war footing. We are sitting on a volcano of NCDs; that too at a much younger age- group. Are we still deaf to this? Mall- nutrition used to be the disease of the affluent and Mal-nu- trition that of the deprived. But currently, the scenario has changed. During COVID 19 pandemic, all the unhealthy cooking practices got free entry into our kitchens through YouTube and Post COVID unlock, these items reached our doorsteps through the ‘flying squads of the food chains and the Swiggys and the Jennies’. This transition happened all on a sudden and across all socio-economic sections. Healthy eating patterns fast disappeared, the difference between the ‘haves and the have-nots’ increased and suboptimal eating became the rule among the low-income groups, especially the parent-less and home-less chil- dren. Most of the Public health programmes came to a standstill, es- pecially the feeding and supplementary nutrition programmes.Mid- Day School meal programme is an important example. Thus, the double burden of malnutrition has become more prevalent affecting quality of life. A doable strategy is the Rainbow revolution or’Mission Mazhavil’ is all about healthy eating, in order to supply all essential nutrients including micronutrients and thereby buy back the health of our fu- ture citizens. Changing Profile of Malnutrition & Early Nutrition Programming leadingto Early Onset of Adulthood Diseases. 22

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Severe Acute Malnutrition (SAM)seems to be (3). Increased birth weight as in LGA babies, born decreasing, butModerate Acute Malnutrition to mothers with DM or Glucose intolerance, (MAM) is becoming a common diagnosis. However, continuing as childhood obesity. SAM among 0-6 months old babies is going unrec- The impact of Birth weight on future health and ognized among the NICU graduates and LBW ba- bies. This is a preventable cause of morbidity and diseases is a ‘U-shaped curve’ unlike the ‘J- shaped mortality, if growth monitoring is meticulously fol- curve’ of usual risk factors, which remains static lowed as part of the Early Childhood Development till a particular threshold and then suddenly the and Nutrition (ECDN) well baby visits. risk increases. Even though MAM is a frequent diagnosis, there Why Capitalize on the First 1000 Days of Life? is no effective programme for MAM at Community or Institutional level. Community Management of ‘Nutrition and Nurture’ during the first 1,000 MAM (CMAM) should address both SAM and days provides the building blocks for physical MAM, but still hospital care and or NRC care is re- growth and brain development. Healthy futures stricted to SAM and that too only above 6 months begin in the first 1,000 days, nourishing a strong of age.Identifying and treating MAM is the best start for all children. The first 1,000 days are a time strategy for curbing SAM and associated morbid- of tremendous potential and enormous vulner- ity and mortality. However, there is no action yet ability. in this regard. Will all windows close on Second Birthday? Micronutrient Malnutrition that cuts across all The rapid brain growth and myelination/wiring age groups and independent of weight and height, is another hurdle that negatively influence the of the neurons happen mostly till second birthday, physical and neurodevelopmental outcome. The but some neuroplasticity can persist beyond 2 story of iron supplementation programme for the years. Hence, it is a solace that there an extended last several decades without any substantial gain widow of opportunity at least till 3 years of age. so far is another major challenge. The micronutri- Thus, it is important to start with preconception ent gap leading to hidden hunger and overt micro- care, carry forward throughout pregnancy till three nutrient malnutrition needs immediate attention. years of age. Nature or Nurture? Weight for Age or Weight for Height? Most of the effects of the dual malnutrition have In a short population like ours, it is better to aim trans generational effects via epigenetics tags, weight for height, rather than weight for age. It is which may pass on to 1-60+ generations. It is now better to accept ‘Small, But Healthy’ seems to be understood that the role of Genetics/ Nature is the best for constitutionally small babies. There is only 20%, in contrast to environmental effects like no dictum that all should catch the Gaussian Mean. nutrition and stimulation/ Nurture, which is 80% in achieving one’s innate potential. Tracking BMI and Growth Charts as an Early In- tervention. Birth Weight and future Health Outcome. It is interesting to note that offspring of no other (1). The fuel mismatch -Fuel deficiency during fe- mammal is born clad with so much fat, being the tal life resulting LBW babies, followed by early highest creation. The BMI of a human baby is 13 at introduction of high energy obesogenic diet in birth, which shoots up to 17 at one year and then the postnatal period, especially the ‘JUNCS’ has to dip to a nadir of 15 by 5-6 years. Then slowly rise to 18.5 by adulthood. This is called ‘Adiposity (2). Rapid and Early postnatal growth during in- rebound’. No dip or early dip as seen now predicts fancy and early childhood due to the Nutrition future obesity and late dip denotes future thinness. transition with high purchasing power, afflu- So Tackling BMI is considered a practical interven- ence and urbanization. 23

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala tion to tackle obesity. supplements and non-nutritional interventions like Immunization, especially Rubella vaccina- How to break theIntergenerational cycle of tion, WASH, deworming etc. Chakravyuuham? This is very crucial as most of the Nutritional Cardiomyopathy due to deficiency effects are transgenerational. of Iron, Selenium, Thiamine are well known. Vi- tamin D deficiency is yet another, which is now Till now, we are making circles around these added to the list. circles and trying to attack from outside as in case of the Chravyuuham of the Mahabharata War. Do Early detection of deficiencies along with defects we have the know how to get inside and come out a birth and developmental delay and or disability victorious? It is not easy. Sad to quote that the and referral to the RBSK scheme like the ‘Mission young warrior Abhimanyu had only the know how Hridhyam program is a big boon. But it has to reach to get inside, but not how to come out. all beneficiaries including the underprivileged. The right nutrition during this 1,000-day win- Role of Public Private Participation and Conver- dow, now extended to 0-3 years can have an enor- gence? mous impact on a child’s ability to grow, learn, and rise out of poverty.Undernutrition, consisting of The PPP model in the ‘HridhyamProject’ under fetal growth restriction, stunting, wasting, and hid- RBSK in Kerala which has directly contributed to den/overt micronutrient malnutrition along with tackling the burden of congenital heart disease sub optimum breastfeeding adversely impacts child among children as an end game in the reduction survival. It is critical to break the inter-generational of IMR to single digit is commendable. cycle of malnutrition, otherwise under nourished girls will become under nourished women, who give birth to low-birth-weight infants. What are the Practical Steps for Intervention? Role of UNICEF in this regard? 1. Adolescent care- Ensure Pre-pregnancy stan- In Kerala, UNICEF is partnering with NHM, IAP, dards like minimum 45 kg weight, 145 cm height, NNF, KFOG, IMA in creating awareness and taking normal BMI with micronutrient sufficiency in- up proactive steps. UNICEF can support most of cluding adequate iron stores the early interventions to nip the risk in the bud by way of situation analysis, capacity building and 2. Maternal Care- Ensure a stress-free ‘Joyful Preg- documentation. nancy’& Responsive Parenthood. Ensure healthy eating and preventive steps like vaccination. Similar toMission Indra Dhanush for Catch up Vaccination, let us launch ‘Mission Mazhavil’ for 3. Essential immediate Newborn Care- Zero Sepa- reducing the burden of malnutrition. ration and Zero alternate feeding other than breast milk unless medically indicated. Anticipatory Age-appropriate Nutrition Guid- ance, Growth monitoring, Developmental surveil- 4. Optimum Neonatal Care of Healthy Newborns lance, Immunization, Disability detection and early including newborn screening, breastfeeding, intervention are to be systematically implemented warmth and minimum handling and monitored to ensure child survival and quality of survival. 5. Advanced Quality neonatal Care of the “Sick and the Small Newborn Babies” Let us pledge to become an ECDN Championand work for: 6. Optimum Care of Infants and Young Children, ensuring adequacy of breastfeeding, Comple- “A Universal health system that eliminates pre- mentary feeding & Toddler Feeding/ Family Pot ventable deaths of newborns and stillbirths; Feeding and preventing the double burden of malnutrition. And where Every pregnancy is wanted, where Every birth is celebrated, 7. Continuum of Care through Life Course Ap- proach Intergenerational Care with Nutri- where Women, Babies, and Children Survive, tional inputs like heathy eating and Nutritional Thrive, and reach their Full potential”. 24

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 What You Wanted To Know About Childhood Dyslipidemia And Were Eager To Ask. Dr M Zulfikar Ahamed 1. Which are the components of the ‘Quartet’ which lead to cardio- vascular disease? Senior Consultant in Pediatric Cardiology A: The ‘deadly quartet’ includes hypertension, dyslipidemia, obesity KIMS Health and diabetes. Thiruvanathapuram 2. Who described the atherosclerotic plaque as a fundamental le- sion of atherosclerosis? A: Rudolph Virchow, the famous pathologist from Vienna, Austria did, in 1856. 3. Who introduced the ‘Lipid Hypothesis’ in atherosclerosis? A: In 1912-1913 Nikolai Anichkov and Chalatov experimentally pro- duced atherosclerosis in rabbits by feeding them with pure cho- lesterol. This lead to ‘Lipid Hypothesis’. 4. How will we define dyslipidemia? A: You could say that there is a ‘Five Finger’ definition of Dyslipidemia. i. High total cholesterol ii. High LDL cholesterol iii. High non-HDL cholesterol iv. High Triglycerides v. Low HDL cholesterol 5. What are the usual causes of childhood dyslipidemia? A: It can be monogenic [Familial Hyper Cholesterolemia], polygenic or secondary 6. Which lesion is the sine qua non of atherosclerosis? When do they appear? A: Atherosclerotic plaques are considered the sine qua non of ath- erosclerosis. They start appearing in coronaries by 15 years. 25

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala 7. Is there a correlation between childhood are moderate / high risk for CAD which include dyslipidemia and future adult CVD? CKD, Kawasaki Disease with aneurism, neph- rotic syndrome and post transplant situation A: Yes, there is. Various epidemiological studies etc. like, Bogalusa heart study, PDAY and Muscatine study have demonstrated convincingly that 13. Is there is a scientific provision for universal there is a strong correlation. screening in children? 8. Can dyslipidemia in children and adolescents A: Possibly Yes. NHLBI 2011 (USA) recommends ‘track’ to adulthood, like hypertension and obe- universal screening, which is endorsed by AHA sity? and AAP. A: Yes it does track. Atherosclerosis is now con- 14. What is the methodology of universal screen- sidered to start in adolescence and acceleratein ing? adulthood, leading to CVD. A: 9. How can we define and categorize childhood 0 – 2 years : No screening dyslipidemia? 2 – 8 years : Selective screening A: Lipid values in childhood are categorized into, Acceptable, Borderline and Abnormal. 9 – 11 years : Universal screening This has been endorsed by AAP. 12-16 years : Selective Total Cholesterol LDL – Cholesterol 17-21 years : Second universal screening Acceptable <170 mg/dL < 110 mg/dL 15. Which lipid is screened? Borderline 170 – 199 mg ” 110-129 mg ” A: It can be fasting lipid profile, total cholesterol High > 200 “ > 130 “ or HDL – Cholesterol. Fasting Lipid profile is preferred for children with risk factors and Non And Abnormal HDL – HDL – Cholesterol for Low risk group. cholesterol < 35 mg/dL TG > 150 mg/dL 16. Is the recommendation for universal screening accepted by all medical boards? 10. Screening for childhood dyslipidemia; what are the modes? A: No. European and NICE guidelines (UK) do not support universal screening. A: It is usually individual based; either selective or universal. Selective screening is the usual 17. What are the two approaches to managing norm. dyslipidemia? 11. What is meant by selective or targeted screen- A: One is population approach and the other, in- ing? dividual (high risk) approach. A: Screening is done in selective high risk children. 18. Which are the four components of treating childhood dyslipidemia? 12. Who are ‘selectively’ screened? A: i. If Parent / Grandparent Aunt / Uncle Sib- A: The four components are diet, exercise, drugs ling have documented Angina, Myocardial inf- or a combination. arction, stroke, sudden cardiac death, CABG or PTCA before 55/65 years – [Female / male] 19. What action is taken for ‘borderline’ lipids? ii. If parent has dyslipidemia A: Institute a life style modification regimen in- cluding diet and exercise. iii. If child has hypertension, diabetes, obesity or is known to smoke. Repeat lipid values after one year. iv. If child has certain medical conditions which 26

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 20. If lipid values are abnormal initially, what do vii. Reduce sugar sweetened food or drink we do? 28. Can pharmacotherapy be used in children? A: You have to reconfirm the values and rule out secondary causes. A: Yes, we can. But with great care and caution. 21. What are the secondary reasons for childhood 29. Which are the drugs used in childhood dyslipidemia? dyslipidemia? A: They are hypothyroidism, CKD, PCOD, Neph- A: Statins and non statins. rotic syndrome, Collagen vascular disease and drugs. 30. Which are the statins approved for children? 22. What are the three steps taken initially in con- A: There are many. It can be Lovastatin, firmed dyslipidemia? Simvastatin, Atorvastatin or Rosuvastatin A: The measures includes diet therapy, exercise 31. Which are clear indications for statins in child- and weight reduction. hood? Dietary management involves both dietary A: Child above 10 years with failure to reach tar- modification and dietary supplementation. get LDL -C by lifestyle modifications in 6 months. 23. What are the factors to be modified in dietary modification? 32. What about children below 10 years? A: We have to modify diet contents like carbohy- A: No statin is prescribed unless there is a very drate, protein, fat, SFA, MCFA, PUFA and cho- high risk CVD, LDL- C level > 400 mg/dL and/or lesterol. TG > 500 mgm/dL 24. What are CHILD I and CHILD II diets? 33. Which are the factors to be considered before making a decision on statin therapy? A: They are two steps of ‘Cardiovascular Health Integrated Lifestyle Diet’ [CHILD] A: Age of the child, severity of dyslipidemia, other CVD risk factors and family preference all have 25. What is CHILD I diet? to be weighed in before starting statin therapy. A: It includes 30% of energy from fat, 7-10% from 34. What lipid values do we want to achieve? saturated fat, < 300 mg of cholesterol and zero trans fat. A: At least : LDL-C value < 130 mg/dL [Optimal : <110 mg/dL] 26. What is CHILD II diet? 35. Do we monitor children on statins? How? A: Here calories from fat is 25-30%, saturated fat <7%, cholesterol < 200mg with zero trans fat. A: We have to serially monitor lipids, creatine ki- nase, AST and ALT and HbA1C. at baseline, af- 27. What are the practical steps in CHILD diets? ter 4 and 8 weeks and every 6 months. A: 36. What are the potential adverse effects of statins? i. Use skimmed or low fat milk. A: Adverse reactions are rare. They include my- ii. Use vegetable oil low in saturated and trans opathy, abnormal liver function and new on- fat. set diabetes. iii. No or minimal animal fat 37. Which are the non statins used in childhood dyslipidemia? iv. Increased fish and legumes; decreased meat and poultry A: The drugs include Ezetemibe, bile acid sequestrants, fibric acid derivatives, Niacin v. Reduce egg yolk to < 2-3 / week and PCSKG inhibitors. vi. Encourage vegetables and fruits 27

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala 38. Can we translate our therapy and give a syn- 40. What did DISC study prove? thesis? A: This 3 year study proved that dyslipidemia in Yes. children between 8 and 10 years can be treated safely with low fat, limited cholesterol diet with DIET no adverse effects. The reduction of LDL-C was Child I 5-7%. Child II No Fat restriction 41. What did STRIP study convey? Fat restriction Statins+ A: It studied the long term impact of a low satu- Statins+ rated fat / low cholesterol diet on normal No Statin children.It lead to reduction of total cholesterol and LDL-C with HDL-C remaining same. And 01-2 yr 10 yr 21 yr that too by not affecting growth, puberty, BMI and menarche. 39. Are there major studies on diet therapy in child- hood dyslipidemia ? A: Yes. They areDISC study [1995 USA] and STRIP study (2007 Finland) Selected References: 1. Integrated Guidelines for Cardiovascular Health and Risk reduction in Children and Adoles- cents: Summary Report. NHLBI. Oct 2012 2. Guidelines for Screening Prevention, Diagnosis, and Treatment of Dyslipidemia in children and Adolescents Stephen Daniels. 2017 3. The Dietary Intervention Study in Children (DISC) J. Am Diet Assoc 1998 Jan; 98(1) : 31-4. 4. The STRIP study: Long term impact of a Low Saturated Fat / Low Cholesterol Diet. H.Ninikoski, V.Tapani, KatjaPahkalaJorma et al. Pediatrics: 27 September, 2014. 5. Dyslipidemia in children: Definition, Screening and diagnosis. S.D.Ferranti, JW NewburgerUPTODATE 2017. 6. Management of dyslipidemia in children S.Kalra, A. Gandhi B.Kalva et al. Diabetology and Metabolic syndrome 2009; 1:26. 28

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 1000 DAY NUTRITION Prof Dr Savida P The 1st 1000 days refers to the period that begins with the day of conception to completed two years of life. Each day this journey is Prof & HOD special and influence the way baby develops, grows and learns not Mount Zion medical college just now, but for the entire life. In India 48% of children are stunted by Adoor 2 years of age and it is not reversible; 18% of babies are low birth Former Prof and weight babies. 7 out of 10 children are anemic and 6 out of 10 children Superintendent, ICH Kottayam are deficient in zinc. Iodine deficiency is also common. All this problems has got trans generational effects. So in order to improve the growth and development of futurechildren, we have to have plans and preparation to solve. It starts from the pre pregnancy period, then throughout pregnancy and labor and to complete two years of age. The first step is -one has to plan the time of pregnancy ;how many children they want; have a holistic checkup before pregnancy and correct iron deficiency, improve the weight if underweight and take folic acid 3 months prior to pregnancy to prevent neural tube defects. Eat healthy food which satisfy the optimum nutritional requirements. Take adequate protein, carbohydrates, fat, minerals and vitamins. Ensure adequate intake of Omega 3 fatty acids and Omega 6 fatty acids during pregnancy. Additional 300 calories, 60 gram of protein, Iron 220 microgram, Iodine, Calcium 1gram, and folic acid 400microgram, Vitamin D – 400IU. Right nutrition taken by mother has a long lasting impact on health during and beyond the first 1000 days of a baby. During the 1st 3 years the brain grows and develop; significant pattern of thinking and responding are established. During this period brain is thrice active as an adult brain. As a parent they get very special opportunity to help your baby socially, physically and cognitively. Mothers are mother – any mother; human/animal always nurture, protect and teaches her young one to function and survive in this world. A child needs to feel special, loved, valued, and needs to feel safe. Human brain is the most developed organ on the planet. The story starts from the womb. The structure is made in the womb but the 29

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala wiring between the neurons is not completed. And supplement additional 200 kilo calories, 300 kilo the 1st 2 years of life is crucial for the wiring of brain calories for 9 months to 12 months and 550 kilo which shapes us as adults. For this nature (genetics) calories for 12 to 20 months old babies. And the should be normal and the nurture should be diet should be adequate in protein, minerals and optimum. At birth only 25% of the brain is formed. vitamins. To prevent iron deficiency, provide iron 75% of the brain develops in the 1st 2 years of age. rich food from 6 month of age onward. Give iron This is catalyzed by the environmental stimuli which drops 1 mg per kg per day. For preterm and low is in the hands of care giver. birth baby, give iron from 1 month of age onwards. Supplement Iodine through iodized salt. Provide The nutrition during the 1st 2 years- exclusive food which is rich in Omega 3 fatty acids. The breast feeding is enough for the 1st 6 months of minimum meal frequency of a child two times per life,and continue for a minimum of 2 years. And day in 6-8 months age group and 9-24 months 3 start the complementary feeding when the baby is times per day. Continue frequent on demand ready – means when the baby is developmentally feeding until 2 years of age or beyond. And food fit – able to sit up, able to hold the head steady, should have proper consistency. opens the mouth on seeing the food and keeps the tongue low and flat to receive the food, closes the The 1000 days are a period of rapid physical lip over a spoon, scrapes the food off while the growth accelerated mental development and offers spoon is removed from the mouth; keeps the food a unique window of opportunity to build lifelong in the mouth, swallows it rather than pushing it health and intelligence.Let the dream- all children back out. The major pillars of complementary grow well,all become geniuses, all love this world feeding are start at right time and age appropriate and this planet will become a paradise- comes true. food, diversity of food, responsive feeding and food hygiene. For infants 6 months to 8 months 30

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 NATIONAL NUTRITION PROGRAMS Dr Shanavas A 1st 1000 days 270 days in utero to 730 days postnatal identified as critical win- Professor Pediatrics dow period for nutritional programming TDMCH ALAPPUZHA Targeting the 1000 day period – One of the best investments to MBBS and MD Paediatrics improve health, nutrition and economic outcomes from GMC Trivandrum. Poor nutrition during this window – Lead to newborn and child Special interest in morbidity, mortality, poor fetalgrowth and stunting Immunology and Damage from poor nutrition during this period often irreversible Hematology Therefore nutrition specific interventions during this window will be most impactful Developmental plasticity – Our capacity to adapt to different social and physical environments is Greatest in the first 1000 days Neuroplasticity – Biological capacity of the CNS to change structur- ally and functionally in response to experience and adapt to the envi- ronment Patterns of abnormal neuroplasticity identified in CP, intellectual disability, ASD, ADHD 31

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala NEED FOR NUTRIONAL PROGRAMS e) Emphasis on geriatric nutrition Every infant and child has the right to good nu- f) Production of 250 million tons of grains annu- trition (“ Convention on the Rights of the Child”) ally 7.7% of children are severely wasted, 19.3% are g) Promoting appropriate diet and healthy life wasted and 35.5% are stunted* style Average calorie intake among 1-5 year old chil- LONG TERM GOALS dren was around 810kcal/day Improving food production Requirement for 1-3 year old is 1010kcal and Improvement of dietary pattern through pro- 1360 kcal for 4-6 year old# duction of nutritionally rich foods Strengthening PDS • In the 2019 Global hunger index(GHI), India Implementing land reforms ranks 102nd out of 117 countries with a score Monitoring of nutrition programs of 30.3- India has a level of hunger that is seri- Promoting research ous NATIONAL FOOD SECURITY ACT, 2013 NATIONAL NUTRITION POLICY Adopted by Government of India in 1993 Also called Right to food act Under the Department of Women and Child Aims to provide subsidized food grains to 2/3rd of Indian population Development Came to effect on 12th September 2013 Includes Mid day Meal scheme, ICDS( Integrated GOALS OF NNP, 1993 Child Development Service) and PDS(Public Distri- a) Reduction in incidence of MAM, SAM and bution System) Under the PDS–5kg/person/month of cereals at stunted growth by half b) Reduction of incidence of LBW babies to <10% a) Rice at rupees 2/kg c) Elimination of blindness due to vitamin A de- b) Wheat at rupees 2/kg ficiency d) Reduction in iron deficiency anemia among c) Coarse grains(millets) at rupees 1/kg pregnant women to 25% Pregnant and lactating mothers, eligible children e) Universal use of salt for reduction of iodine – provided with daily free cereals deficiency disorders to less than 10% VARIOUS NATIONAL PROGRAMS Programs and Schemes Sl.No Target groups 1. Pregnant and lactating mother -National nutritional anemia prophylaxis program -Special nutrition program 2. 0-3years -ICDS 3. 3-6years -National nutritional anemia prophylaxis program -ICDS 4. School going children -Vitamin A prophylaxis program 5. Adolescent girls(11-18years) -National nutritional anemia prophylaxis program -ICDS -Balwadi Nutrition program -Applied Nutrition program -Mid day meal scheme -National nutritional anemia prophylaxis program -National nutritional anemia prophylaxis program -SABLA(ICDS) -Kishori Shakti Yojana(ICDS) 32

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 INTEGRATED CHILD DEVELOPMENT SCHEME(ICDS) SUPPLEMENTARY NUTRITION PROGRAM Launched on Oct 2nd 1975 under ministry of Primarily designed to bridge gap between rec- social welfare ommended daily intake (FDA) and average daily One of the world’s largest programme to pro- intake of vulnerable groups in a community vide an integrated package of services for the en- Target group:- tire development of the child - Children 6 months to 6 years - Pregnant and lactating mother Centrally funded scheme executed by State govt. Service delivered through ICDS scheme and union territories • The beneficiaries:- Children <3 years Children 3-6 years Pregnant women and lactating mothers Adolescent girls Women in reproductive age group (15-45 yrs) • The ICDS Scheme offers a package of six services ? Supplementary Nutrition ? Pre-school non-formal education ? Nutrition & health education ? Immunization ? Health check-up ? Referral services ? Objectives:- 1. To improve the nutritional and health status of children in the age group 0-6 years. 2. To lay the foundation for proper psychological, physical and social development of the child. 3. To reduce the incidence of mortality, morbidity, malnutrition and school dropout. 4. To achieve effective coordination of policy and implementation among the various depart- ments to promote child development 5. To enhances the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education. The service are delivered through anganwadicentre(AWC) 1 AWC for 400-800 population 33

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala AMRUTHAM-NUTRI MIX Malappuram, Palakkad , Kollam and Idukki • ICDS provide supplementary nutrition for chil- • MID-DAY MEAL SCHEME dren in the age group of 6 months to 3 years in • Initially Tamil Nadu started a mid day meal the form of take home rations(THR) programme(a.k.a school lunch programme) in • Amrutham-nutri mix is a serial based powder 1961 under Ministry of education - to provide mix developed by CPCRI (central plantation at least one nourishing meal to school going crops research institute),Kasargod, Kerala children per day • From 2006 onwards, Kudumbasree collaborate • MDM program launched in Kerala in 1984 with social welfare dept of Kerala for the sup- • Later Govt. of India launched a centrally spon- ply of THR in the Anganwadies in the state sored scheme on 15th august 1995 as MDM • Fortification of Nutri mix under progress with scheme support of WFP in Wayanad and need to be ex- • National program to support primary educa- panded to all district after feasibility analysis tion –class I-V • Aim- To Increase school enrollment, retention • Currently each children is provided with 3.5kg and attendance of students and improves nu- Amrutham-Nutri mix a month at the rate of trition 135gm per day for 25 days • In 2007 the scheme extended to cover children • Price per kg- 56 rupees ; given free of cost in upper primary class (VI-VIII) • ADOLESCENT GIRL SCHEMES- ICDS • Kishori Shakthi Yojana(KSY) – 11- 18 yr Aim -Self development, nutrition and health status, lit- eracy, and numerical skills, vocational skills Service provided • VITAMIN A PROPHYLAXIS PROGRAM -Non formal education-physical , developmental • Launched in 1970 by MoHFW • Objectives to reduce the disease and prevent- and sex education Basic health supplement- Iron & folic acid , dew- ing blindness due to vit A deficiency • Target group -9 months to 3 year orming tablet • Mega dose of vitamin A given at 6 months in- Nutrition provision was 9.5 rupees/day terval- total 5 doses -600 calories, 18-20 gm protein & micronutrients Prophylactic vit A given as per dosage schedule :- per day • 100000 U at 9 months with MR vaccine • 200000 U at 16-18 months with DPT booster • Nutrition program for adolescent girls(NPAG) • 200000 U every 6 months up to 3 year -Target group- 11-19 yrs • NATIONAL NUTRITIONAL ANEMIA PROPHY- -6 kg free food for malnourished adolescent girls LAXIS PROGRAM • Launched in 1970 by MoHFW • SABLA – Rajiv Gandhi Scheme for Empower- • Aim- prevention of nutritional anaemia in ment of adolescent girls(RGSEAG) -supplementary nutrition -600 calories, 18-20 mothers and children gram protein and micronutrients per day for • In 1991 renamed as national nutritional 300 days in a year -IFA supplementation, health checkups, refer- anaemia control programme ral services, health education, life skill educa- tion, vocational training -SABLA address the multi-dimentional prob- lems of adolescent girls • SABLA will replace KSY & NPAG in 200 selected districts in India • KSY will continued in remaining district • In Kerala district covered under SABLA are – 34

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 • This programme is revised and expanded to • 2. Use of technology (ICT) for real time growth include beneficiaries from all age groups under monitoring and tracking of women and children NIPI programme • 3. Intensified health and nutrition services for • Target group:- the first 1000 days • Infants 6-59 months • 4. Jan andolan- peoples movement around • School children 5-10 years malnutrition through awareness programme • Adolescents 11-19 years • POSHAN Maah- september • Pregnant and lactating women • POSHAN week- sept 1-7 • Women in reproductive age group(15-45 years) • SAMPUSHTA KERALAM • POSHAN Abhiyaan in kerala • It is under WCD department • Aim – to prevent and reduce stunting, under nutrition, reduce prevalence of anaemia and re- duction of LBW • Target group :– • Children <6 years • Adolescents • Pregnant and lactating mother • THENAMRUTH • Recently Kerala govt. launched a Nutrition bar • NATIONAL IODINE DEFICIENCY DISEASES CON- with an aim to provide supplementary nutri- TROL PROGRAM tion to children with severe underweight across • Govt. of India launched national goitre control the state program in 1962 • Nutrition bar has been created jointly by WCD • Later it was renamed as NIDDCP dept. and KAU • It is implemented in all states/UTs for entire • This supplement is developed as a part of SampushtaKeralam(Nutrient rich Kerala) population • Aim – to minimise the commonness of IDD</ project =5% and ensure 100% consumption of ad- • Bar is made with over 12 ingredients like; rice, equately iodised salt(15ppm) at the domestic corn, wheat, ragi, soya flour, bengal gram, level ground nut, sesame, jaggery and liquid glucose • POSHAN ABHIYAN (NATIONAL NUTRITION • Rich in nutrients such as iron, calcium and pro- tein MISSION) • Launched on 8thmarch 2018 in Rajasthan • 100gm bar comes with:- • POSHAN- Prime Minister ’s Over arching • 439.65 calories Scheme for Holistic Approach • 15 gm protein • It work as ICDS system strengthening and nu- • 13 gm fat trition improvement project(ISSNIP) • 5.23 mg iron • Aim – to improve nutritional outcomes for chil- • 238.7 mg calcium dren, pregnant and lactating mothers by • Target group- children between 3-6 years utilisation of key Anganwadi services • Each under nourished child will be given 1 nu- • It is a multiministral convergence mission with trition bar per day the vision to ensure attainment of malnutrition • Each nutrition bar will cater to 1/3rd of the daily free India by 2022 nutrient and calorie requirement of children • For implementation of POSHAN Abhiyaan the • It complies with the dietary requirement of a 4 point strategy/pillars of the mission are:- child as recommended by MoHFW&WHO • 1. Inter-sectoral convergence for better service delivery 35

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Dietary Management of Inborn Errors of Metabolism Prof Dr Mohandas Nair Inborn errors of metabolism are a group of conditions which are inherited in which because of mutation in certain genes, certain en- HOD Pediatrics zymes are either absent or deficient. The substrate of that particular GMC Idukki step accumulates and the product becomes deficient. The accumu- Genetics specialist lated substrate may be converted to another product. The manifesta- President IAP Kozhikode tions could be due to deficiency of the product or due to the toxic effects of either the substrate or its byproducts. Severity of the condi- 36 tion depends on the level or quality of the particular enzyme. Certain modifications in diet along with proper monitoring will help in controlling the symptoms and will help the patient to achieve near normal growth and development and to reduce organ damage. In this session, we will consider few conditions 1. Phenyl Ketonuria (PKU) 2. MSUD 3. Glutaricacidemia Type I (GA I) 4. Urea Cycle defects (UCD) 5. Galactosemia 6. Glycogen Storage Disease Type I PKU: In PKU, conversion of phenyl alanine to Tyrosine is compro- mised. Brain is the organ maximally affected. Phenyl alanine level has to be maintained below a particular level so that the child will attain near normal growth and development. Special medical diets are avail- able which do not contain phenyl alanine. Phenyl alanine being an essential amino acid, if this alone is given, the child will not grow and also will suffer from deficiency of various proteins. So the diet the child receive should be balanced in such a way that it contains ad- equate quantity of all essential aminoacids to ensure growth, at the same time, low in phenyl alanine to ensure its blood level not exceed- ing the recommended range (120-360 micromols/ litre) and contains adequate energy to prevent protein catabolism. Normal proteins are allowed which provide 40-50 mg/kg/day of Phenyl alanine. Breast milk contains 46mg and infantformula, 60 mg per 100ml. Rest of the pro- tein requirement should come from phenyl alanine free formula. Then, calculate the energy contained in the above diets and ensure rest of energy from non-protein sources and enough fluid requirements. Phe-

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 nyl alanine containing foods should be evenly dis- hyperammonemia is mainstay of treatment. For tributed over 24 hours to ensure protein synthesis that, the dietary protein need to be restricted. At round the clock. Monitor growth and development the same time, prevent catabolism by providing clinically and plasma aminoacid levels periodically sufficient calories. Medications that remove nitro- to see that phenyl alanine and tyrosine levelsare gen to be given regularly. Outcome is guarded. Liver with in permitted range. With this, majority of chil- transplantation- in severe cases. dren with PKU can attain almost normal growth and lead a near normal life. Goal for protein intake, fraction as normal pro- tein are fraction as medical food (EAA) are assessed. MSUD: Goal of dietary management is to keep Calculate amount of medical food, amount of nor- plasma leucine concentration between 100 -200 mal protein (breast milk/ formula). Calculate en- micromols /litre for <5 years, 100-300 for >5 years. ergy requirement, rest of energy from protein free Medical foods devoid of branched chain source. Fluid needs to be met with. Amount of aminoacids are commercially available for this. Di- supplemental citrulline or arginine to be identified. etary leucine restriction along with supplementa- tion of valine and isoleucine to be done. At the Galactosemia: Restrict lactose and galactose. same time ensure that the child receives adequate For this, two types of medical formulas are avail- energy, protein, vitamins, minerals and fluids as per able. One is soy based formula which do contain requirements. small amount of galactose. This is less costly and sufficient for most of the situations. Other is el- Diet planning is just like that described in PKU. emental formulas containing L-aminoacids. This Establish intake goals based on clinical status of the does not contain galactose at all. This is more suit- child and bloodLeucine levels. Find out the amount able for preterm for preterm babies with galac- of breast milk or formula to meet leucine need. tosemia. This is costlier. Supplement calcium and Rest of the protein requirement should come from vit. D will be essential as the diet is restricted of BCAA free formula. Determine energy from the various dairy products. Endogenous production of protein sources mentioned above. Rest of calories galacose is an issue. Galactose in fruits and should come from BCAA free medical food or non- vegitables- only very small quantity.So can be al- protein sources. Plasma aminoacid levels should lowed in the diet. Monitor Gal-1-P in RBCs, be periodically monitored to assess leucine, isoleu- Galactitol in urine, DXA and 25-OH- Vit D levels. cine and valine levels. Growth monitoring along with developmental and neurologic assessment Glycogen Storage Disease Type I: The patients should be done regularly. are prone for hypoglycemia even with fasting for a short duration. So frequent meals during day time Glutaricacidemia Type I (GA I): Restriction of is very important. Continuous Ryle’s tube feeds lysine and tryptophan along with supplementation during night or middle of night feeding to be en- of Carnitine and riboflavin is the mainstay of sured. After 9 months of age, uncooked corn-starch therapy. The patient should receive Protein 1.6-3.5 (in younger age, it is not tolerated). Avoid galac- gm/kg/day (higher end of range for infants), Lysine tose, fructose, sucrose and lactose (fructose and 40-100mg/kg (More for infants) and Tryptophan galactose cannot be converted to glucose in GSD I 7-20 mg/kg (more for infants) . Calculate amount patients). Fat limited diet is advised due to the risk of breast milk or infant formula based on lysine of hypertriglyceridemia. Allopurinol is to be given needs. Determine protein intake as whole protein, if there is hyperuricemia. In uncooked form, corn based on this. Rest of the protein need- from spe- starch is digested slowly, which act as a sustained cial medical food for GA I which is commercially source of glucose. Start with 0.4gm/kg every 4 hour, available. Lysine: arginine ratio to be looked in to, can be increased to 1.6g/kg in young children, upto supplement arginine if needed. Rest of the calo- 2.5gm/kg in childhood. Initially 3-4 hourly, in child- ries from protein free food items. Ensure adequate hood, 4-6 hourly and post puberty, at bed time only. fluid intake. Monitor blood lysine and tryptophan It should not be added to acidic beverages. Can be periodically along with growth, development and mixed with infant formula.Use immediately after neurologic assessment. mixing into a liquid. Opened packet to be used with in 2 weeks Urea Cycle defects (UCD): Correcting 37

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Nutritional Ketosis Dr Sheeja Sugunan Nutritional ketosis is the intentional restriction of dietary carbohydrate intake to accelerate production of ketones, which then acts as the primary Associate Professor and source of fuel for the body. It has been used in the treatment of refractory Pediatric Intensivist, seizure and also as a part of various weight management regimens. SAT Hospital, Government Medical College Mechanism of action Thiruvananthapuram Nutritional ketosis increases the serum free fatty acid levels, reduces 38 glucose fluctuations, and activates ATP sensitive potassium channels. This in turn is associated with increased mitochondrial biogenesis, increased oxidative phosphorylation,enhanced GABA levels, reduced neuronal excitability and firing.It also stabilizes the synaptic function. By stabilising the blood sugar and decreasing insulin release, nutritional ketosis also mitigates the downstream anabolic and tumorogenic effects of longstanding insulin resistance Indications Conditions associated with >50%seizure reduction in >70% patients include Angelman syndrome, Complex 1 mitochondrial disorders, Dravet syndrome, Epilepsy with myoclonic–atonic seizures (Doose syndrome), Glucose transporter protein deficiency syndrome,Febrile infection–related epilepsy syndrome (FIRES), Infantile spasms, Otahara syndrome, Pyruvate dehydrogenase deficiency, Super refractory status epilepticus, Tuberous sclerosis complex. It is the treatment of first choice in glucose transporter protein deficiency and pyruvate dehydrogenase deficiency(PDHD). In glucose transporter protein deficiency, glucose cannot cross blood brain barrier and leads to seizure, developmental delay and movement disorders. While in PDHD, pyruvate cannot be metabolised to Acetyl COA leading to severe lactic acidosis , encephalopathy and seizures. Seizure freedom is unlikely in patients with focal seizures. There is insufficient evidence for its use in Autism spectrum disorder, Alzheimer Disease, Migraine, brain tumors and traumatic Brain Injury.

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Contraindications offered especially in malnourished children and children on valproate. Carnitine deficiency, fatty acid oxidation defects, pyruvate carboxylase deficiency and porphyria. Baseline investigations CBC with platelet count, organ functions RFT, LFT, Classic Keto Diet It consists of a diet with ratio of 4 gm fat to 1gm of fasting lipid profile, Serum electrolytes, calcium, magnesium, phosphorous, bicarbonate, Acyl carnitine protein plus carbohydrate. 90% of calories is provided profile and urine analysis with calcium creatinine ratio. from fat. In infants usually diet is started with 3:1 ratio. Rule out inborn errors of metabolism when suspected. There is no restriction of calorie and fluids. It is preferred in infants and pre school children. Follow up Patients may be advised to monitor urine ketones Modified Atkins Diet In this diet, daily carbohydrate consumption is at home at different times of the day. Blood glucose needs to be monitored especially during illness and restricted to 10 -15gm (adults 15-20gm). There is no excessive lethargy. Follow up visits should be planned limitation on protein, fluid or calorie intake. Intake of after 1 month then 3 monthly for 1 year and then 6 fat is encouraged. Usually 1:1 or 2:1 ratio is achieved. monthly. During follow up do anthropometric It’s ideal for low resource setting with a paucity of assessment, assess compliance with keto diet and trained dietician. It is preferred in school age children review vitamin and mineral supplementation. Look for and adolescents. side effects of keto diet and also assess efficacy and optimise AED. Low Glycemic Index Treatment In this carbohydrate intake is restricted to 40 – Investigations at follow up CBC with platelets, Electrolytes including serum 60gm/day. Carbohydrate should be evenly distributed to prevent fluctuation in blood sugar. Only food groups bicarbonate, calcium, LFT, RFT, Vitamin D level 3 with low glycemic index (<50) should be used. Carbs monthly, Fasting lipid profile, Urinalysis, urine calcium should be taken along with protein and fat. It is creatinine ratio. Monitor for metabolic acidosis specifically recommended in Angelman syndrome. It especially in patients taking carbonic anhydrase can be initiated as outpatient treatment. inhibitors like topiramate, zonisamide. Adverse effects of ketogenic diet Duration of ketogenic diet Common adverse effects include gastrointestinal Stop keto diet if no effect in 3 months.Children who symptoms like diarrhea, constipation, nausea, vomiting, respond to keto diet , re - evaluate after 1-2 years .Slow and exacerbation of gastroesophageal reflux.25% of wean over 2-3 months reducing fat to protein + CBH patients may develop hypoglycemiaespecially during ratio .80% of those who discontinue KDT after 2 years the first week of initiation. Carnitine deficiency (20%), of seizure freedom will continue to remain seizure-free Selenium deficiency (50%), Bone disease like Osteopenia, osteoporosis, and bone fractures, Management of excessive ketosis (>6mmol/l) Nephrolithiasis (7%), Mild neutropenia, Hyperuricemia, Suspect excessive ketosis in children with increased hypoproteinemia, hypomagnesemia, hyponatremia, hepatitis, and metabolic acidosis are some of the other lethargy , altered sensorium, vomiting or acidotic adverse effects reported. breathing especially during illness or after fasting. Check blood glucose and serum ketones. Administer orally 30 Supplements ml D10 or fruit juice. Retest serum ketones using finger Children on ketogenic diet should be offered daily prick 15 minutes after administration. If no clinical improvement or persistence of high ketones repeat 30 multivitamin, calcium and vitamn D supplements. ml D 10 / fruit juice orally. If no improvement give IV Additional supplements which may be offered include glucosebolus followed by maintenance. Serum ketones selenium, magnesium, zinc, phosphorus, iron and need to be monitored 6 hourly , while ketone levels copper .Empiric oral citrates have been found to be are high or unstable. Aim for blood glucose >45mg/dl. associated with decrease in incidence of renal stones. Carnitine levels needs to be monitored and supplement 39

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala GROWTH CHARTS IN NUTRITION Dr Jayaprakash K P Growth monitoring is an invaluable tool in assessing child well-be- Assoc Professor & ing. We had different approaches in assessing growth. Many used, Superintendent ICH formula,percentage,percentile and standard deviation score to assess Kottayam growth. Most meaningful effort in growth parameter assessment is to use standard deviationscore. If we use percentile,we depict it as arrange- ment of 100 measurements. The other means of percentage and for- mula have a low representation value. The WHO growth charts reflect growth in six continents. It is the best chart available for under five children.IAP recommends WHO growth charts should be used for all children <2 yrs. IAP endorses WHO growth charts for children below 5 yrs.IAP has data for children 5-18 yrs and has best charts for children in that age group. The Intergrowth 21 chart gives the ideal path for preterm/term growth. Growth charts are best utilized ,when applied over a period of time than as a point of time measurement. The apps of IAP and WHO are very useful to bring out data customized for individual children. The weight velocity chart,height velocity chart and head circum- ference velocity chart are very useful for monitoring over a long pe- riod of time. The customized charts of khadilkar charts for SGA,malnutrition and easy to use charts should be consistently used by every pediatrician. We wish our own country specific growth charts will evolve over period of time. This will generate good data as well as digitalized for- mat for use. 40

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 ADOLESCENT FOOD HABITS AND FOOD FADS Dr Kristin Indumathi India is home to 253 million adolescents – 120 million girls and 133 million boys, the largest numbers of adolescents in any country, glo- Senior Consultant bally and India’s economic growth is dependent on its adolescents . Neonatology & Pediatrics SUT Hospital, Pattom Adolescence -the period of critical growth Trivandrum Adolescence is defined as the period between childhood and adult- hood and has been recognized as a critical time for physical, mental, and behavioral development, creating a foundation for the rest of an individual's life. The age of adolescence is divided into early and late phases, from 10 to 14 years and 15 to 19 years. Ten to 14 years are critical years for both girls and boys as they achieve their maximum growth spurt. Annual height and weight gains may be as high as 9 cm and 8 to 10 kg, respectively. Early adolescence is also an opportune time to catch-up on height and weight deficits suffered in childhood. The growth spurt continues into late adolescence (15 to 19 years), especially for boys. It is well recognized that nutrient needs are high during the rapid growth and development of adolescence. It is there- fore important that adolescents have reliable nutrition information and develop dietary patterns that will serve them well at that time and for the future. In the late adolescence phase, some girls in India do enter preg- nancy and with low height, weight and hemoglobin levels, and will not be able to properly support healthy fetal growth or themselves. In a vicious cycle, babies born to adolescent girls are at an increased risk of being born too early or with a low birthweight. Those who conceive later with compromised nutritional status will face similar birth out- comes. Children of malnourished adolescent mothers are more at risk to suffer growth failure during the first 1,000 days (from conception to age two). Food habits of Adolescence The nutritional behaviour in adolescents is oftenless than ideal and due to their busy schedules, peer pressure, independent nature and self-identitysearching, adolescents may sometimes skip a meal, eat only snacks, try unconventional meals orconsume excessive amounts 41

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala of fast food, soft drinks and/or alcohol, and diet to and joint problems. Long-term risks include the extreme. In today’s lifestyle, and particularly heart disease and some cancers. in adolescence, snacks have become an important part of the daily food intake. Snacks are reported • When teenagers go on fad or crash diets they to provide up to one quarter of an adolescent’s can be at risk of not eating enough and not get- daily intake of energy but are generally high in fat ting the nutrients they need for healthy growth and sugar but low in iron, calcium, vitamins A, C and development. and folate • Severe dieting can lead to health and other Adolescent eating is conceptualized as a func- problems like fatigue, poor concentration and tion of individual andenvironmental influences. loss of muscle mass and bone density. Four levels of influence are described: • Some children develop eating disorders like an- orexia, bulimia and avoidant restrictive food in- • Individual or intrapersonal [psychosocial, bio- take disorder. Some signs and symptoms of an logical]; eating disorder include constant or repetitive dieting, binge eating, excessive exercise, food • social environmental or interpersonal [e.g., fam- avoidance, repeated weighing and dizziness. ily and peer]; • The child doesn’t need to restrict foods like dairy • physical environmental or communitysettings foods or foods with gluten unless they have a [e.g., schools, fast food outlets] food allergy or food intolerance that has been diagnosed by a health professional. • macro system or societal [e.g., mass media, marketing and advertising, social and cultural • If the child is eating a restricted diet that isn’t norms] . well-planned and/or supervised by a GP or di- etitian, it could lead to nutritional deficiencies The search for identity, the struggle for inde- and other health problems. pendence and acceptance, and concern about ap- pearance, tend to have a great impact on lifestyle, • For example, a dairy-free diet over an extended eating patterns and food intake among adolescents period of time might mean the child isn’t get- ting enough calcium, vitamin D, energy and pro- A study in Nepaleseschoolchildren showed that tein for bone health and peak bone mass. fast foods (ready to eat snacks, chips etc) werepreferred by more than two-third of adoles- • A poorly planned long-term vegetarian diet can cents. Advertising, probablyTV and magazines, in- result in the child not getting enough nutrients, fluenced preferences in 80% of these especially iron and vitamin B12. This is a par- Nepaleseadolescents . ticular risk for girls who have started having pe- riods. Both factors increase the risk of iron defi- Similar studies in Singapore and Malaysia ciency and anaemia. showed that a significant number of adolescents had food from the canteen at schools or at the The CNNS— 2019 hawkers for dinner .97.6% of Singaporean adoles- cents and 95.3% of Malaysians consumesweetened ComprehensiveNational Nutrition Survey( 2016- drinks, including soft drinks, fruit drinks,packet 18)released in 2019– birth to adolescence data- drinks, cordials, yoghurt-based drinks andcultured setprovides unparalleled new insights into alltypes milk drinks.32.5% consumethese 7 times a week . of macronutrient and micronutrientmalnutrition, dietary habits, life skill behaviours, access to ser- Problems arising out of Improper diet in Adoles- vices (school, health andnutrition) and physical cence activity throughout adolescence 10-19 years and for both boysand girls. • Eating too much food, particularly unhealthy food, puts the child at risk of overweight and The CNNS survey data comes at an obesity. opportunetime, two years after the launch of the National • An overweight or obese child is at an increased risk of type-2 diabetes, sleep apnoea and hip Nutrition Mission (POSHAN Abhiyaan) whichcan 42

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 provide valuable insights to support healthy boys. Co-existence of anemia and thinness is growth throughout childhood andadolescence. higher among girls and 15-19 year olds Highlights of the CNNS • Malnutrition in several forms is higher and/ or peaks in early adolescence • Every second Indian adolescent is either too short or too thin or overweight/obese. • Almost all adolescents fail to meet the daily re- quirements of physical activity for their age • Girlsare shorter than boys, but boys are thinner than girls. Thinness is highest in 10-12 year olds, • Almost all adolescents have “unhealthy” diets with vast in-state variations among 10-14 year olds and 15-19 year olds • School-based services (noon meal, IFA supple- mentation, deworming and biannual health • One in two adolescents suffer from at least two checkups) co-coverage is low and variable across of the six micronutrient deficiencies states. (iron, folate, vitamin B12, vitamin D, vitamin A and The analysis presented in this report is zinc) criticalevidence to plan for holistic programming for improving nutritionalstatus of adolescent girls • Diabetes and cardiovascular diseases risk and and boys, especially through schools. Campaigns hypertension among adolescents is increasing. on healthy foodchoices should be centered around At least 1 in 2 adolescents affected by at least promotionof a variety of items in appropriate one of these risks. proportionsin the food plate. • Anemia affects 40% adolescent girls and 18% 43

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Adolescence is a period where nutrition depri- sugar. Fruit juice can have a lot of calories, so vation is one of the major problem . the above limit your adolescent's intake. Whole fruit is al- tables in CNNS data show that the foods consumed ways a better choice. by adolescents were not according to Dietary guide- lines. • Eat balanced meals. Psychologically, adolescents develop their inde- • When cooking for your adolescent, try to bake pendence, and try and fit into their social circle. or broil instead of fry. Peer pressure may cause them to choose soft • Make sure your adolescent watches (and de- drinks instead of milk and to skip lunch to “hang creases, if necessary) his or her sugar intake. around” with their peers. Adolescents want to de- velop independence and make choices for them- • Eat fruit or vegetables for a snack. selves. They choose what and where to eat and drink. The following eating behaviours as common • Decrease the use of butter and heavy gravies. in adolescents, such as missing meals, eating snacks and confectionery, consuming high levels of fast • Eat more chicken and fish. Limit red meat in- food, consuming unconventional meals, drinking take, and choose lean cuts when possible. high amounts of alcohol and/or soft drinks, gener- ally consuming low levels of minor nutrients (empty • The MyPlate icon is a guideline to help you and calories) and often “being on a diet” your adolescent eat a healthy diet. MyPlate can help you and your adolescent eat a variety of foods while encouraging the right amount of calories and fat. How to help the Adolescent to EAT RIGHT • Parents can help being a healthy eating role model ,creating a healthy food environment at The following are some helpful considerations home and talking about healthy eating in posi- as mother’s prepare meals for their adolescent: tive ways. • Arrange for teens to find out about nutrition for It can be well affirmed that the behavioral themselves by providing teen-oriented maga- changes in adolescence affect their food intake and zines or books with food articles and by encour- they should be counseled and sustained motiva- aging them and supporting their interest in tion is required. It is appropriate to intervene at health, cooking, or nutrition. this age because the food habits once learnt per- sist into adulthood and the harmful effects are in- • Take their suggestions, when possible, regard- surmountable. An opportunity exists in adoles- ing foods to prepare at home. cence through nutritional intervention, which may if implemented can extend beyond the adolescent • Experiment with foods outside your own cul- growth spurt. Public health nutrition is to be given ture. more emphasis since promotion and prevention are deemed more critical to adolescent nutritional • Have several nutritious snack foods readily avail- health in India as it has one of the youngest gen- able. Often, teenagers will eat whatever is con- erations among the world countries. Adolescents venient. can and should take responsibility for their nutri- tion and the long-term repercussions on health. • If there are foods that you do not want your teens to eat, avoid bringing them into the home. • Discuss the following healthy eating recommen- Further Reading dations with your adolescent to ensure he or she is following a healthy eating plan: Adolescents, Diets and Nutrition,Growing Well in a Changing World • Eat 3 meals a day, with healthy snacks. • Increase fiber in the diet and decrease the use The CNNS Thematic Reports, Issue 1, 2019 of salt. • Drink water. Try to avoid drinks that are high in 44

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 IYCF practices in India & Kerala- Where do we stand? Dr Priya Sreenivasan Poor-quality diets in inappropriate quantity pose one of the great- est obstacles to childhood survival, growth, development and learn- MD, DCH, MPhil ing. The stakes are highest in the first two years of life. Around the (Clinical Epidemiology) world, 8,20,000 lives could be saved every year among under-fives, if Associate Professor of all children0–23 months were optimally breastfed1.Globally, under- Pediatrics, Government nutrition is estimated to be associated with 2.7 million child deaths Medical College, annually (45% of all child deaths)1.Optimal infant and young child feed- Thiruvananthapuram ing practices has been identified as the most cost-effective measures to reduce under-five mortality. IYCF indicators- old and new Eight core and seven optional indicators were published by WHO (2008)to help in data collection and reporting on IYCF practices throughout the world. The new WHO recommendations (2021) in- clude 17 population-level indicators without distinction as core or optional2. Breastfeeding indicators (expressed as percentages)include Ever breastfed, Early initiation of breastfeeding within one hour, Ex- clusively breastfed for the first two days after birth (new),Exclusive breastfeeding under six months, Mixed milk feeding under six months (new) and Continued breastfeeding 12–23 months (earlier, 12-15 months). Complementary feeding indicators (expressed as percent- ages) include Introduction of solid, semisolid or soft foods 6–8 months, Minimum dietary diversity (5 out of 8, breastmilk included as one food group), Minimum meal frequency, Minimum acceptable diet, Mini- mum milk feeding frequency for non-breastfed children 6–23 months, Egg and/or flesh foodconsumption the previous day 6–23 months (new), Sweet beverage consumption the previous day 6–23 months (new), Unhealthy food consumption the previous day 6–23 months (new), Zero vegetable or fruit consumption the previous day 6–23 months (new), Bottle feeding the previous day 0–23 months and In- fant feeding area graphs (new).Consumption of iron-rich/fortified foods as an indicator has been deleted as it was foundhard to operationalize in household surveys. 45

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala INDIA Breastfeeding indicators- According to NFHS-5 (2019-21), 41.8% of children below 3 years who were interviewed as part of the survey received early initiation of breastfeeding within one hour of birth3. Similarly, 63.7% received exclusive breastfeeding till 6 months. Complementary feeding indicators- According to NFHS-5, infants aged 6-8 months who received solid or semi-solid food along with breastmilk were 45.9%. Breastfedbabies aged 6-23 months who receivedan adequate diet (~ Minimum Acceptable Diet)was only 11.1%. Comprehensive National Nutritional Survey (CNNS)2016-18 is the largest micronutrient survey con- ducted in India till date with a sample size of 1,12,316 children and adolescents4. Their survey showed that in India, 82.5% infants continued breastfeeding at 12-15 months of age. While 41.9% of babies aged 6 to 23 months got the Minimum Meal Frequency, only 21% got the Minimum Dietary Diversity of four of more food groups on a daily basis. Dietary diversity differed between breastfed and non-breastfed babies, with a higher proportion of non-breastfed childrenaged 6 to 23 months receiving an adequately diverse diet (36%), compared to breastfed children (18%). A reverse pattern was observed for meal frequency, with a higher proportion of breastfed children being fed the minimum number of times for their age compared to children who were not breastfed (50% vs 42%). Minimum Acceptable Diet, a composite index of Minimum Dietary Diversity and Minimum Meal Frequency was 6.4%. As per UNICEF Flagship Child Nutrition Report 2021, ‘Fed to Fail?- The crisis of children’s diets in early life’, the percentage of children 6–23 months of age who consumed egg and/or flesh food during theprevious day is 15% in India5. Zero vegetable or fruit consumption (percentage of children 6–23months of age who did notconsume any vegetables or fruitsduring the previous day) is 55%. Micronutrient Status- According to NFHS-5, antenatals who consumed iron-folic acid tablets for 100 days or more were 44.1% and for 180 days were 26%. Babies aged 6-59 months who were anemic (<11.0 g/dl) were 67.1%. Only 8.6% of babies aged 6-23 months received iron-rich food (non- veg source) as per CNNS 16-18.Cov- erage of weekly Iron-Folic acid supplementation amongbabies aged 6-59 months (2020-21 April)as per Anemia Mukt Bharath score card is 9.9%6. Children aged 9-35 months who received a vitamin A dose in the last 6 months was 71.2% (NFHS-5). Under-fives with diarrhea in the 2 weeks preceding the survey who received zinc was 30.5%. Table 1- Biochemically proven micronutrient deficiencies in India (CNNS 2016-18) Age Vitamin A Vitamin D Zinc Vitamin B12 Folate 23% 1-4 years 18% 14% 19% 14% Malnutrition in India (NFHS-5) U5 underweight 32.1%, stunting 35.5%, wasting 19.3%, severe wasting 7.7%, overweight 3.4% KERALA Breastfeeding indicators- According to NFHS-5 (2019-21), 66.7% of children below 3 years who were interviewed as part of the survey received early initiation of breastfeeding within one hour of birth7. Only55.5% received exclu- sive breastfeedingtill 6 monthswhich is low when compared to the national percentage of 63.7. 46

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Complementary feeding indicators- According to NFHS-5, infants aged 6-8 months who received solid or semi-solid food along with breastmilk were 71.3%. Breastfed babies aged 6-23 months who received an adequate diet (~ Minimum Acceptable Diet) was 23.6%. Comprehensive National Nutritional Survey (CNNS) 2016-18 had a sample size of 2647 children and adolescents from Kerala. While 65.9% of babies aged 6 to 23 months got the Minimum Meal Frequency, only 52.8% got the Minimum Dietary Diversity of four of more food groups on a daily basis. Minimum Acceptable Diet, the composite index was 32.6% (Rank 2 among all states). Micronutrient Status- According to NFHS-5, antenatals who consumed iron-folic acid tablets for 100 days or more were 80% and for 180 days were 67%. Babies aged 6-59 months who are anemic (<11.0 g/dl) were 39.4%. 37.4% of babies aged 6-23 months received iron-rich food (non- veg source) as per CNNS 16-18. Cover- age of weekly Iron-Folic acid supplementation among babies aged 6-59 months (2020-21 April) as per Anemia Mukt Bharath score card is 0.5% (Haryana ranks first with a coverage of 44.2%). Children age 9-35 months who received a vitamin A dose in the last 6 months was 84.1% (NFHS-5). Under-fives with diarrhea in the 2 weeks preceding the survey who received zinc was 22.4%. Table 2- Biochemically proven micronutrient deficiencies in Kerala (CNNS 2016-18) Age group Vitamin A Vitamin D Zinc Vitamin B12 Folate 1-4 yrs 17.1% 11.8% 9% 3.4% 18.4% Malnutrition in Kerala (NFHS-5) U5 underweight 19.7%, stunting 23.4%, wasting 15.3%, severe wasting 5.8%, overweight 4% We need to act fast.While more than half of our young childrenget breastmilk, they do not get enoughanimal source foods, fruits, legumes or vegetables and rely too heavily on grains. The concept of ‘nutritional milestones’ with emphasis on quality, quantity, frequency and consistency of complemen- tary feeds should reach grassroot HCWs and caregivers of young children. The concept of ‘responsive feeding’ is still unknown to HCWs and caregivers. Optimal feedingdepends not only on what is fed, but also on how, when, where, and by whom the child is fed.No indicator has been devised to ‘measure’responsive feeding or the psychosocial aspect that is involved in IYCF practices. References 1. World Health Organization. Infant and Young Child Feeding. Available from: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child- feeding [accessed on 14.06.22] 2. World Health Organization and the United Nations Children’s Fund (UNICEF), 2021. Indicators for assessing infant and young child feeding practices: definitions and measurement methods. 2021. Available from: https://data.unicef.org/resources/indicators-for-assessing-infant-and-young-child-feed- ing-practices/ [accessed on 14.06.22] 3. Ministry of Health and Family Welfare, Government of India.National Family Health Survey 5 (2019-21). Compendium of Fact Sheets. Key Indicators. India and 14 States/UTs (Phase-11). 2021.Available from: http://rchiips.org/nfhs/NFHS- 5_FCTS/Final%20Compendium%20of%20fact%20sheets_ India%20and%2014%20States_UTs%20(Phase-II).pdf [accessed on 14.06.22] 4. Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. Comprehensive National Nutrition Survey (CNNS).National Report.2019. Available from: https://nhm.gov.in/WriteReadData/l892s/1405796031571201348.pdf [accessed on 14.06.22] 5. United Nations Children’s Fund (UNICEF). Child Nutrition Report 2021. Data Tables. Fed to Fail?. The Crisis of Children’s Diet in Early Life. 2021. Available from: https://data.unicef.org/resources/fed-to-fail-2021-child-nutrition-report/[accessed on 14.06.22] 6. National Health Mission. Anemia Mukt Bharat. Available from:https://anemiamuktbharat.info/amb-ranking-monthly/ [accessed on 14.06.22] 7. Ministry of Health and Family Welfare, Government of India. National Family Health Survey 5 (2019-20). Fact Sheets. Key Indicators. 22 States/UTs from Phase 1. 2021. Available from: http://rchiips.org/nfhs/NFHS-5_FCTS/COMPENDIUM/NFHS-5%20State%20Factsheet%20Compendium_Phase-I.pdf [ac- cessed on 14.06.22] 47

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala GOOD NUTRITION: A Talk To Adolescents Why It Is Important Eat wisely: it will make you taller, make you look smarter, and give you a rosier complexion. It will also improve your performance in stud- ies – and in sports. Dr Newton Luiz How much food to eat? Senior consultant Pediatrician At 10-12 years of age a boy needs 2200 calories and a girl 2000 and adolescent specialist calories. That is as much as their parents need, if they are office work- Dhanya Mission Hospital, ers: 2300 and 1900 calories respectively! Potta PO, Thrissur District Guess what, the average boy and girl at 16-18 years of age needs much more than his parents – 3000 calories for boys and 2400 calo- ries for girls. Are you under-nourished? Start eating! Adolescence is the last chance to gain height. It is dur- ing adolescence that you put on 25% of your height. And you need to grow strong bones too. Boys, do remember that 50% of your muscle mass comes in ado- lescence. Girls, do note that if you weigh <45 kg or your height is <145 cm at marriage, it is not only you who will suffer – you are going to have small babies in the future, and the next generation too will have to pay the price. Are you too short? If your parents are short, you may be genetically prone to be shorter. But don’t worry too much: your generation is on average 2 inches taller than your parents’ generation. Most boys are 2 inches taller than their fathers, and girls are 2 inches taller than their mothers. Look around at your cousins. If your weight is OK for your age, wait patiently. Some are a bit slow in putting on height. 48

12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Sorry, you cannot increase your height by doing Lots of adolescents who were quite slim 2 years pull-ups, or any particular exercise. And don’t ago have suddenly burgeoned out quite generously worry, you will not become shorter if you do gym in the last two years. The Covid virus does not in- workouts. Exercise is very good for your health, but crease your appetite, but sitting at home without there is no exercise that can affect your height. playing, and that too in front of the TV, and snack- ing heavily while watching TV, has resulted in many Horlicks, Boost and Pediasure do not increase adolescents gaining 15-20 kg in two years flat! Lack your height, your intelligence or your energy lev- of exercise and an excess of food is a powerful com- els. All they do is slim your purses and fatten those bination. of the companies. A specific problem with watching TV while eat- Are you overweight? ing is that the mind is distracted by TV, and you do not pay attention to the fact that you have already Wondering whether you are overweight, or even eaten as much as you normally do, nor do you no- obese? No weighing machine at home? Just look tice the stomach signals that it has had enough. in the mirror, and if you are honest you will know You end up eating twice as much as you intended at once whether you weigh too much or too little to. or you are just right. Weight by itself is not an adequate measure, as A few tips to avoid obesity it increases if you are taller. ‘Height – 100 = Suit- • Drink more water, before and during meals. able Weight’ is an OK formula to follow. At 12-16 years many adolescents are always • Eat with family members or friends. If you chat hungry, yet thin as a skeleton – that is because they while eating you eat more slowly, and your stom- are growing up fast. So long as you are growing ach has time to inform you that it is satisfied. upwards, eat as much as you want. But when you start growing forwards or sideways, it is time to • Use smaller plates; the brain is satisfied only control your food intake. when it sees that you have eaten a full plate of food. Why Am I Obese? • Avoid eating while watching TV; you mostly eat Because you are eating too much! Don’t com- snacks that are rich in calories. pare your food intake to that of others. If you are gaining weight, it means that you are eating more • Avoid watching TV while eating. than YOUR body is capable of utilizing. The only answer is to cut down your food intake by 20% at • Choose seasonal fruits and vegetables; they are every meal. nutritious and low in calories. Don’t say its genetic. Look at the photos of over- Water weight people, and you will find that 50% of them were quite slim at age 15. If it is genetic, it should We should drink plenty of water daily. At least 8 have been visible right from the toddler stage. glasses a day. Unfortunately, we get into the habit of drinking less, from a young age, because clean Don’t say it is genetic. Overweight runs in fami- drinking water is not always freely available, be- lies because families don’t run. cause bathrooms are not always accessible, and because we do not like to sweat. We should drink Overweight runs in families because some fami- only a glass at a time, but frequently. lies are too fond of bakery stuff. Also, some fami- lies use twice as much oil in their cooking, and twice We do not recognize thirst when it is mild. Next as much sugar. That is why even the newly married time you take a bus trip of half an hour, e.g. when woman, who came into the family 5 years ago, has going to school, try drinking a glass of water im- gained weight like everyone else, and she is obvi- mediately after the journey, and you will realize ously not genetically related to her husband and that you immediately feel less tired. his parents. 49

Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Eat Breakfast! Sugar: Like oil, it is just empty calories without any essential nutrients. Like oil, it enhances the Lots of adolescents skip breakfast. The first rea- taste of whatever it is added to. We cannot avoid it son is that they are in such a hurry to go to school – what is life without an occasional laddu or peda? that there is no time. But if you haven’t had break- – but we should certainly restrict its use. fast your blood sugar will decrease, and you will not be able to concentrate properly in the class. When you are at a wedding feast, don’t eat till School students should never miss breakfast; 10 your stomach is fit to burst. Take minimal rice or minutes is all you need. roti, so that there will be enough place in your plate for all those lovely curries. (Instead of eating lots Some people deliberately skip breakfast in the of rice with a little curry, eat all the curries with hope of losing weight. They are shocked when told very little rice). Also make sure that there is a little that this always results, over 6 months, in weight space remaining for the dessert that is to follow. gain! This is because the body rebels when it is forced to starve for long, and at every subsequent When eating dessert, remember that the first meal during the day it compensates by deliberately two ounces of payasam will go down your throat consuming more than necessary. Also, the person deliciously, the next two ounces are tasty, and any develops an unconscious and uncontrollable ten- more may even cause nausea. Take the first two dency to put every available snack into your mouth. ounces, and then stop when your mind is still ask- ing for more. Junk Food Salt: We take too much of it. The recommenda- Junk Food = is basically any food that has too tion is 3.8 grams per day, which works out to just much oil/sugar/salt, and too little proteins/vita- half a kg per month for a family of four – but the mins/ minerals. It is rich in calories and low in es- average Indian family takes 10-15 gm per day, or sential nutrients. Basically, most anything you get THREE TIMES the recommended amount. And re- from the bakery: Coca Cola, Lays, chocolates, cream member that most junk food, not just chips, have biscuits – and also traditional ones like payasam, an excess of salt. laddu, peda. Balanced Diet Oil: It is 100% calories and 0% everything else. When added to food it makes it very tasty, but not A balanced diet is one in which you get adequate so healthy. Ask your parents to restrict your home quantities of all essential nutrients – proteins, vi- use of oil + ghee to ½ kg/month/person (2 kg a tamins, and minerals like iron and calcium – when month for a family of four). This presumes that you you consume adequate calories. This food pyramid do not visit the bakery much, and do not eat out in tells you what to eat: restaurants frequently. a. The foundation of the food we eat is cereals. If there is too much oil in your food, there will be too much in your bloodstream. It gets stored in b. Above this comes fruits and vegetables, and we the walls of the blood vessels, causing them to are encouraged to consume them in plenty. narrow down, and gradually the blood flow is seri- ously compromised. One fine day a blood vessel c. Eggs, fish, chicken and other meats are all highly gets blocked, and you end up with a heart attack nutritious. While non-veg is good, note that the or a stroke. veg column is larger. Diabetes results in a similar phenomenon; so d. It is good to take some milk and/or curds every too smoking and hypertension. High blood sugar, day. the toxins in the smoke, and high BP all damage the blood vessel wall and make the person prone e. At the top is a small column for oils and fats and to this. Imagine the situation if a person is obese sweets. Have them, but in small quantities. and also has Diabetes and Hypertension and is a smoker! f. Right at the bottom, we have also a reminder that it is important to take plenty of fluids, 2 50