UNIT 19 OTHER NUTRFIIONAL PROBLEMS

Structure

19.1 Introduction 19.2 B-Complex Deficiencies (Nature, clinical features, causes, treatment and prevention) 19.2.1 Ariboflavinosis (Riboflavin deficiency) 19.2.2 Pellagra (Niacin deficiency) 19.2.3 Beriberi (Thiamine ddiciency) 19.3 Vitamin D deficiency-Rickets and Osteomalacia (Nature, clinical features, causes, treatment and prevention) 19.4 Vitamin C deficiency-Scurvy (Nature, clinical.features, causes, treatment and prevention) 19.5 Fluorosis 19.6 Lathyrism 19.7 Let Us Sum Up 19.8 Glossary 19.9 Answers to Check Your Progress Exercises

19.1 INTRODUCTION

Units 17 and 18 of this block discussed sofi,e of the most important deficiency diseases which are not only widely prevalent but, more importantly, lead to complications and death as well. There are also other deficiencies which may occur in a large number of people. Some may cause irreversible changes in the body while others may not cause irreversible complications. Yet, these can interfere with the normal functions of the body. Some vitamin deficiencies are important examples. In this unit, we will discuss vitamin deficiencies like ariboflavinosis, beriberi, scurvy. You will also learn about fluorosis and lathyrism. The latter two diseases are not deficiency diseases. Lathyrism is caused by a toxin present in a foodstuff. On the other hand, fluorosis occurs because of excessive consumption of in water and foods. Objectives After studying this unit, you will be able to : describe vitamin deficiencies like ariboflavinosis, beriberi, scurvy, rickets and pellagra discuss the major features of fluorosis and lathyrism caused by consumption of excessive amounts of a nutrient (fluoride) or a toxin and enumerate the measures taken to treat and prevent, these disorders.

19.2 B-COMPLEX DEFICIENCIES

You have learnt that vitamins like thiamine, riboflavin, niacin, folic acid and B12 are the vitamins of the Bcomplex group. In this section, you will learn about what happens when there is a deficiency of these vitamins in the body. Let us begin with ariboflavinosis or riboflavin deficiency.

19.2.1 Ariboflavinosis (Riboflavin deficiency) This is a nutritional deficiency occuring due to reduced intakes of riboflavin through 30 the diet. Riboflavin deficiency is one of the most common amdng the Ecomplex deficiencies. How can we make out that a person is suffering from this Other Nutritional Disorders deficiency? As in the case of other deficiency diseases you have studied about, this disease is also associated with certain obvious clinical features.

Clinical Features : The major clinical features of ariboflavinosis include:

a) Angular : One of the clinical signs of ariboflavinosis is ,angular stomatitis. The subjects develop cracks on both the sides (angles of upper and lower ) of the mouth (Fig 19.1). This is a very common sign noticed among children, and as high as 30-35% of the children exhibit angular stomatitis. There is usually not much of discomfort and because of this, children and adults ignore it.

Fig. 19.1 Angular Stomatitis (Photo Courtesy : National Institute of Nutrltlon, Hyderabad)

b) :This is particularly common among women, especially during pregnancy. The tongue becomes raw and red. There will be a burning sensation whenever foods which are hot and rich in spices are consumed. The tip of the tongue is affected first. In severe deficiency, the tongue may develop cracks as well. c) Cheilosis :The lips develop cracks and become red. The subjects may also lose appetite.

Causes : Ariboflavinosis is due to dietary inadequacy of riboflavin. You already know that green leafy vegetables, milk, organ meats are good sources of riboflavin. Whole grain cereals, and pulses, nuts provide riboflavin in moderate amounts. As we have already discussed, in the families of poor rural communities, diets contain negligible amounts of pulses and milk. Meat is consumed, but very rarely. As a result, riboflavin deficiency is very common in our country. In fact, the requirements of riboflavin are directly associated with the amount of food energy consumed. Higher the amount of food energy consumed, higher will be the requirements of riboflavin. Turn back to dnit 6 of Block 2 for more information. You have learnt that Indian diets are mainly cereal-based. Cereals are not good sources of riboflavin. Therefore, our diets tend to be deficient in riboflavin.

Treatment : Patients suffering from ariboflavinosis should be given one tablet of B-complex daily for about one week to ten days.

Prevention : Milk is a good source of riboflavin. However, poorer communities cannot afford milk in view of its high cost. We have to make sure that the communities include foods rich in riboflavin like green leafy vegetables, whole cereals and pulses and cheaper nuts in their every day diet to prevent ariboflavinosis. 3 1 Nutrition-Related Disorders Check Your Progress Exercise 1

1) List the clinical features of ariboflavinosis.

2) What dietary advice would you give to prevent ariboflavinosis? Answer in three sentences.

...... 3) Fill in the blanks : a) Milk is a ...... source of riboflavin. b) Higher the consumption of energy in food,...... will be the iequirement of riboflavin. c) The changes noticed in the tongue due to ariboflavinosis are'referred to as1 ......

19.2.2 Pellagra (Niacin deficiency) This is a nutritional disorder due to the deficiency of niacin, one of the B-complex group of vitamins in the diet. Though it is not as common a ariboflavinosis, pellagra is more frequently seen in the Telengana region of Andhra Pradesh and adjoining parts of Maharashtra and Karnataka.

Clinical features : Pellagra is characterized by typical skin changes (dermatosis), diarrhoea .and mental changes.

Dennatosis means changes in the skin. The patients suffering from pellagra exhibit typical skin changes. These changes are symmetrical and are evident only on the parts of the body exposed to the sun like forearms and legs, face and the exposed parts of the neck. The skin becomes dry and scaly (Fie;. 19.2).

Fig. 19.2 Pellagra (Photo courtesy : National Institute of Nutrition, Hyderbad)

Diarrhoea i.e. loose motions is also present. In some cases, of course, this may be absent.

Patients of pellagra have slight mental changes. These include irritability, forgetfulness and loss of orientation. We are using the word 'orientation' to mean the sense of being able to relate to time, place and events. There may be headache and sleeplessness, tremors of hands and legs and mental depression. Mental changes may be very noticeable when the patient suffers from severe niacin deficiency. It is- Nutritional Disorders estimated that a number of patients with pellagra go to mental hospitals for treatment because of these mental changes. Usually glossitis is also seen in individuals with pellagra.

Causes : Pellagra has been known to he common in countries where maize is a staple such as Mexico. The niacin in maize is in a bound form and is not available to the body. Hence, people who consume maize as the staple cereal have greater chances of developing pellagra. In India, however, the disease is common in areas where jowar is the staple cereal like in the Telengana region of Andhra Pradesh and the adjoining Maharashtra and Karnataka. This is because of the presence of excessive amounts of the amino acid leucine in jowar leadittg to an imbulance between leucine and isoleucine. You may wonder as to what is imbalance between amino acids. The human body, for normal functioning, has to maintain a balance between various amino acids. When this balance is affected and one amino acid is more than the other it is known as imbalance. You have already learnt that the body needs eight essential amino acids, leucine and isoleucine being two of these. Please refer to Unit 3 of Block 1.

Treatment : Nicotinamide is the drug of choice. It is a compound of which niacin is a part. Niacin as such is not given bebause when taken in large,doses, it produces some unpleasant effects like the face and body becoming hot and red, nausea and vomiting. Nicotinamide brings dramaticerelief to patients suffering from pellagra. Generally, a dose of 300 mg peryday is given. Along with it, B-complex tablets are

Prevention : You know that pellagra is a preventable disease. The important aspect of prevention is encouraging communities to consume mixed cereal diets so that adequate niacin is available in the diet. The communities should be educated to consume diets based not only on jowar but also rice or wheat. In addition, inclusion of pulses, even in small amounts, is useful in the prevention of pellagra. Nuts, oilseeds and organ meats are also good sources. YOUlearnt in Unit 4, Block 2 that milk contains high amounts of tryptophan which the body converts into niacin.

19.2.3 Beriberi (Thiamine deficiency) Beriberi is a nutritional deficiency disease caused by the deficiency of the vitamin thiamine in the diet. Thqdisease is rare in our country. Please refer to Unit 4 of Block 2 for more information on thiamine.

Clinical features : Beriberi is a disease of slow origin. Generally, the individual to . start with, experiences loss of appetite, weakness and heaviness in the legs. The person also becomes tired easily. The patient complains of the feeling of pins and needles and numbness in the legs. There may be loss of sensation i.e. loss of the feeling of touch over the legs. The disease occurs in two forms. It manifests itself either as wet beriberi or dry beriberi. Wet beriberi is characterized by accumulation of fluid in the body. This can ultimately lead to heart failure. The patient may complain of'palpitation (forcible and rapid hem beats felt by the patient) and sometimes of chest pain. There may also be pain in the leg muscles on application of pressure.

In the case of dry beriberi, the patient will feel a weakness in the legs progressively making the patient completely bedridden.

Causes : The disease is primarily due to the inadequacy of thiamine in the diet. The disease is very common in communities consuming rice which is highly polished. This is due to the fact that during polishing the thin outer layer of rice (which contains thiamine) is removed. Do you remember Highlight 1 in Block 2? Losses during refining were discussed in detail there. In parts of South India, beriberi was commonly seen when highly polished rice was being consumed. It is rare in our country now-adays, perhaps, because the diets are not based on highly polished rice. Also rice is rarely the only staple being consumed. Other cereals are also eaten in varying amounts. Even in South India, the communities consume diets consisting of wheat, millets and pulses, though in small amounts. These are good sources of 33 Nutrition-Related Disorders thiamine. In the communities subsisting on parboiled rice, beriberi is not seen. Can you explain why?

Treatment : In the case of both wet and dry beriberi, thiamine should be given by 'injection into the muscle atleast for three days. The patient should be advised complete rest. Thereafter, thiamine tablets can be given three times a day.

Prevention : The best way to prevent beriberi is to consume rice which is not highly polished. In fact, hand pounded rice is the best. We car1 also take steps to reduce polishing of rice while milling. This will help to prevent loss of thiamine. There are a number of modern rice mills where we can produce rice with less polishing. Increase in co?sumption of pulses and other thiamine-containing foods prevents beriberi. The richest dietary sources of thiamine are yeast and bran (outer layer) of wheat and millets as we mentioned earlier in Unit 4 (Block 2).

Check Your Progress Exercise 2

1) Match the items in Column A with those in Column B.

Column A Column B i) Pellagra cause a) Nicotinamide ii) Ariboflavinosis b) Tryptophan iii) Heart failure c) Leucine-isoleucine imbalance iv) Niacin d) Wet beriberi v) Highly polished rice e) Ariboflavinosis and Pellagra vi) Milk f) Leucine-lysine imbalance vii) Food energy g) Niacin deficiency viii) Skin changes on exposed h) B-complex deficiency parts of the body i) B-complex and protein ix) Glossitis deficiency X) Skin changes j) Dry beriberi k) B-complex requirements I) Cheilosis m) Low thiamine content 2) List the clinical features of beriberi......

19.3 VITAMIN D DEFICIENCY

Rickets is a disease of growing children in which the bones become softened and deformed due to the deficiency of vitamin D. Osteomalacia is the adult form of vitamin D deficiency. In the subsequent discussion we will explore the major features of these disorders as well as their treatment and prevention. We begin with the causes.

Causes : You have already learnt that vitamin D is one of the fat-soluble vitamins. In Unit 4 of Block 2 you discovered the amazing fact that vitamin D is synthesized (manufactured) in the skin after exposure to sunlight. We have plenty of sunlight in our country and hence the disease is not as common. However, the disease is more frequently seen when there is not enough exposure to sunlight.

In the subsequent discussion on clinical features, treatment and prevention we will have to talk about rickets and osteomalacia separately. Let us begin with rickets.

RICKETS: The young child in certain parts of our country frequently becomes a victim of rickets. Rickets is character~sedby a range of specific clinical features as you will 34 Bee in the following discussion. Clinical features : In the initial stages of the disease, children become restless. The Other Nutritional Disordrrr muscles lose their firmness and become flabby. When the abdominal muscles lose their firmness, the abdomen gets distended. You know that a normal baby's teeth erupt at a particular age. The baby sits and crawls at a particular age. These are known as developmental milestones. In the case of rickets, there is a delay in these milestones. For exampte, teeth erupt late in children with rickets. There is also considerable delay in the age at which the child can sit and crawl. The child is too weak and is unable to walk in some cases.

The most important changes caused by this disorder are seen in the bones. The growing ends (epiphyses) of the long bones (like those of the forearm) get extended and widened. For example, there will be a swelling of the forearm bones at the wrist. There may also be swelling at the ends of the ribs which gives an appearance of "beading" of ribs or rachitic rosary. In other words, the enlargements on the ribs on the chest of the child give an appearance of a rosary (chain of beads). In normal children the anterior fontanelle-an opening between the skull bones-closes by t about 18 months of age. In rickets the closure of the anterior fontanelle is delayed. In view of the softening of the bones, the children develop what is known as craniotabes 1 on the skull. As a result, the skull bones instead of being hard give a feeling of yielding when pressure is applied on them.

The child ultimately develops various deformities of the bones. Deformities of the chest with the breast bone becoming prominent are common. This protruding of the breast bone is usually known as pigeon chest. The typical deformities seen in children who have recovered from rickets are due to the'child's weight bearing down on the legs before complete recovery takes place. At this time the bones are still soft and cannot stand the weight of the child. As a result, the children may have "bow legs" (bent like a bow) or "knock kneeswewhenboth the knees will be tauching each other, unlike in normal children. Some children may have bossing (prominence or jutting out) of frontal (front) and parietal (side) bones of the skull. Deformities of the backbone also may develop if the disease continues beyond the age of 2 years (Fig. 19.3).

Fig. 19.3 Rkkets (Photo courtesy : National Institute of Nutrition, Hyderabad) Nutrition-Related Disorders Treatment : Vitamin D and adequate intake of calcium are the important requirements for treating rickets. Several preparations of vitamin D are available. These also provide vitamin A. Generally, cure results with dailitreatment of vitamin D for about 4 weeks. The treatment should be supplemented with calcirlm.

Prevention : Adequate exposure to sunlight is the most important factor in protecting the child from rickets. Dietary sources are few and the vitamin is found chiefly in fish liver oils and egg yolk. Milk is not a good source of the vitamin. Inclusion of these foodstuffs in daily diets prevents rickets. Supplementation with vitamin D is generally not required in India. However, where required, particularly among families confined to the indoors, cod liver oil is of Rnown value in the prevention of the disease.

OSTEOMALACIA : As you have already learnt, osteomalacia is the adult form of rickets. We come across osteomalacia commonly in women of reproddctive age (1545 years of age). This is more common among women who have had multiple (many) pregnancies. The 'disease is frequently seen among wemen belonging to low socio-economic groups depending on poor diets and who are confined to the house. In India, osteomalacia is not that common. Osteomalacia can also be caused by some digestive disorders which may interfere with absorption of vitamin D.

Clinical features : Pain in ribs, hip bone, iower back and legs is the most common complaint. There is mrlscular weakness and the woman usually finds it difficult to climb stairs. 'There will be pain on application of pressure on the bones like the hip bone. Sometimes there may be fractures of the bones. Deformities of the back bone are common.

Treatment : Daily.vitamin D is the drug of choice. Very rarely, once a week or fatnightly injectlon of vitamin D into the muscles may be necessary. Supplements of calcium should be given as well. Generally symptoms subside within four to eight weeks.

Prevention : Free access to sunlight is the best way to prevent osteomalacia. Once the deformities occur we cannot correct them. Vitamin D supplements in pregnant women can be undertaken in susceptible cases like in the case of people who are generally confined indoors and in women who had multiple pregnancies.

Check Your Progress ~xircise3

1) Fill in the blanks : a) Rickets and osteomalacia are due to the deficiency of ...... in children and ...... :...... respectively. b) The changes noticed on the ribs due to rickets appear like a ...... c) Exposure to ...... is the best way of meeting vitamin D needs. d) In rickets ...... ends of the bones get extended and widened. e) For the prevention of rickets ...... oil is of known value. 2) What is required for the synthesis of vitamin D by the body and where is it synthesized?

......

19.4 VITAMIN C DEFICIENCY-SCURVY

Scurvy is a nutritional disorder due to inadequate intake of vitamin C. It is observed when people subsist for prolonged periods on diets devoidof.frsh fruits and vegetables. It is not a commr>nly observed nutritional deficiency in India. Other Nutritional Disorders Clinical features : The most important clinical sign of scurvy is spongy, bleeding . The gums are swollen, particularly in the region between the teeth. They bleed even on slight touch. Infection of gums is also usually present. in^ spots may be seen on the skin above the knees and on the lower parts of the thighs due to bleeding. There may also be anaemia due to associated iron or folic acid deficiency. Untreated, the deficiency can lead to death due to internal bleeding.

Causes : Scurvy is due to consumption of diets which do not contain fresh fruits and vegetables for very long periods. This leads to deficiency of vitamin C or ascorbic acid. You know thaf vitamin C is destroyed by heat i.e. by cooking. Hence even if the diet may appear to contain adequate amounts of vitamin C, it may still cause scurvy due to destruction of vitamin C during cooking.

Treatment .: Vitamin C tablets should be given to the patients. Vitamin C by mouth is most often adequate. In acute cases vitamin C injections into the veins will be necessary. It should be followed by administration of vitamin C by mouth i continuously. Prevention : Amla, guava, citrus fruits (lime, orange), are rich sources of vitamin C. Amla is, in fact, the richest source of vitamin C. Similarly sprouted (germinated) pulses like whole bengal gram are good sources of vitamin C. Communities should be educated to include one of these foods in the diet regularly.

19.5 FLUOROSIS

Fluorosis is a disease caused by consumption of excessive amounts of the mineral for longperiods. Fluoiine is essential for the development and maintenance of normal bones and teeth. However, if it is consumed in excessive amounts it leads to fluorosis. Research has also indicated that low fluoride intake can lead to dental caries (cavities) in teeth. Fluorosis is an important health problem in some districts in the States of Andhra Pradesh, Punjab, Karnataka, Tamil Nadu and Rajasthan.

Causes : The main source of fluoride for us in India is drinking water. Drinking water should contain less than 1 mg per litre of fluoride. In areas where fluorosis is common, the fluoride content of water is as high as 3-12 mgAitre. In these areas the population depends on wells for their drinking water. Normally fluoride content in flowing rivers is not high. In our country, due to the hot climate we generally consume more water and thus take in higher amounts of fluoride. The foods do not, however, contribute much of fluoride. The daily diets, however, may provide about 0.25 mg of fluorine. Only foods such.as sea fish, tea and cheese are rich in fluorine.

Ciinical features : Fluorosis is manifested as changes in the teeth (dental fluorosis) and in bones (). In other words, the clinical manifestations will be seen in teeth and bones.

Dental Fluorosis :In children living in areas where fluorosis is common the disease ! i affects only the teeth. The teeth lose their shine and chalky, white patches appear on . them. This is known as motrling of teeth. Mottling is considered as an early sign of fluorosis. Later, these white patches become yellowish. In severe cases of fluorosis the hard, glistening substance covering the of the teeth (enamel) gets eroded ultimately leading to depressions on the teeth (Fig. 19.4). This is known as pitting. 1 Mottled enamel is best seen on the upper cutting teeth known as incisors. You do not see mottling in the teeth of children below the age of 5'years.

Skeletal Fluorosis : In older individuals, fluorosis leads to changes in the bones because of consumption of excess of fluoride for prolonged periods. Initially, the individual will have pain in the neck and stiffness of the back. This progressively leads to difficulty in the movement of the neck and back. We can see the changes in bones only when X-rays are taken in early cases of skeletal fluorosis. In severe skeletal fluorosis the patient will be so incapacitated as to be completely bed-ridden. Recently, in some areas of Andhra Pradesh and Tamil Nadu, a new form of fluorosis has been recognised. In such a case we see changes in legs which look like a severe I Nutrition-Related Disorders

Fig. 19.4 Dental fluorosis (Photo courtesy : National Institute of Nutrition, Hyderabad)

form of knock knees. This new form of fluorosis seen in Andhra Pradesh and Tamil Nadu is called genu valgum. What causesgenu valgum? We are still not sure hut trace element imbalances appear to be the reason along with high intakes of fluoride.

Prevention : Fluorosis can be prevented hut cannot be cured. The hest method to prevent fluorosis is to consume water which has less than 1 mg per litre of fluoride. In other words, steps should be taken to supply drinking water with safe levels of fluoride to the communities to prevent fluorosis. Where this is not possible defluoridation (removal of excess fluorine) of water is the only alternative. This can be done at the household level. A simple method is to first add lime powder to the pot of drinking water. Then alum is added. It is stirred for about 10 minutes. The water is then decanted off and stored in clean vessels. Such water will have fluoride in safer levels. Large scale defluoridation using costly modem instruments is not possible. Intensive education of the community is necessary to encourage domestic defluoridation.

Check Your Progress Exercise 4

1) Fill in the blanks : a) Fluorosis is due to ...... consumption of ...... b) Normal drinking water should contain less than ...... of fluoride. c) Fluoride in inadequate amounts in the diet can cause ...... of teeth d) Changes in bones due to excessive consumption of fluoride is known as...... fluorosis.

2) The following is a list of symptoms of nutritional deficiency disorders. Tick the ones specific to scurvy.

i) Mental changes ii) Glossitis iii) Cracks on lips iv) Spongy, bleeding gums v) Rashes cn skin vi) Pale conjunctiva vii) Spoon shaped nails viii) Tiny spots below skin ix) Bleeding on touch 3) How can you remove excess fluoride from water at the domestic level? 0thNrtritioRnl ~imrdm ......

19.6 LATHYRISM

Larhyrism is a disease of the nervous system caused by consumption of a pulse,.... kesari grown.

Causes : Kesari dal (Lathyrus sativus) contains a toxin which affects the -~rvous system (neurotoxin). The toxin causes damage !o the nervous system. The disease is common among landless agricultural labourers in Madhya Pradesh, Bihar and Uttar Pradesh. Particularly during drought seasons, the agricultural labourers depend solely on kesari dal. In fact, kesari dal is a hardy crop which can survive even in severe droughts when much of the wheat crop is damaged. The agriculturai labourers in these areas receive the dal from the landlords as wages. They prepare rotis using the dal and consume the same.

Clinical features : This is a disease of the nervous system as we have already mentioned. In the initial stages, when the individual is subjected to physical stress (exercise) he exhibits a gait (walking style) which looks awkward. At this stage, if the dal is withdrawn further progress of the disease can be controlled.

The progress of the established disease is typical and one can observe four clear stages. In the first stage, the patient will walk with .i=rky movements without the aid of a stick. This is called the no stick stage.

As the disease progresses, the patient can walk only with the support of a stick. This is called the one stick stage. During this stage, the patient walks on his toes with the support of a stick with the knees slightly bent. While walking, there is the crossing of legs one over the other.

When the symptoms are more severe, the patient can walk only with the support of two'sticks (two stick stage). The gait is slow and clumsy. There'is crossing gait i.e. the legs cross one over the other while walking and the knees are markedly bent. The patient gets tired easily on walking even short distances.

Ultimately the knees are bent completely and the patient can only crawl. This is called the crawling stage. Young agricultural labourers are affected by the disease. Ultimately these youths end up as beggars due to this disabling paralysis.

Prevention : There is no specific treatment for the disease. Appropriate steps should be taken to prevent the disease.

,Banning of the crop is the surest way of preventing the disease. In fact, under the Prevention of Food Adulteration Act of Government of India, kesari dal is banned in all forms i.e. whole dal and'flour. Unfortunately, it is not being effectively operated in States like Madhya Pradesh and Bihar where the problem of lathyrism is common.

There are other methods of prevention. If only we can remove the toxin in the dal. we can still use the dal (Highlight 3). Nutrition-Related Disorders ~tkr~rrrYk..lDm- In the long run, the food habits of the communities require to be changed so that I they do not solely depend on kesari &I. Large scale nutrition education efforts are required for the purpose.

Check Your Progress Exercise 5

1) Fill in the blanks : a) Lathyrism is caused by a ...... present in ...... b) The toxin present in kesari dal affects the ...... system. c) The surest way of prevention of lathyrism in the country is ...... of the crop. d) At the domestic level the toxin in kesari dal can be removed by ...... method.

2) The following alternatives (a)...... f e) describe symptoms typical of a particular . nutritional problem. Identify the problem in each case. a) Cracks on angles of lips, raw and red tongue, cracks on lips, sensitivity of eyes to light. Problem : ...... b) Gum problem, internal bleeding on touch, associated anaemia. Problem : :...... c) Symmetrical skin rashes on exposed body parts, loose motions, loss of orientation. Proble'm : ...... d) Tiredness, palpitation. loss of sensation, padin leg muscles, accumulation of fluid. Problem : ...... t$ Delayed developmental milestones in young children, beading of ribs, delayed closure of anterior fontanelle, bow legs. Problem : ......

19.7 LET US SUM UP

Inthis unit you have learnt about some more vitamin defxiencics and problems arising due to excess intake of fluorine and kesari &I. You have ?ad that ariboflavinosis is due to the dietary deficiency of riboflavin, one of the B-complex vitamins. The main clinical featurm are angular stomatitis and glossitis. It can be - prevented by addition to the daily diets of pulses/nuts/milk/green leafy vegetables. Pellagra is due to the deficiency of niacin, one of the B-complex group of vitamins. It is characterized by skin changes, mental changes, diarrhoea. It is common in populations solely subsisting on maize and jowar. The disease can be prevented by consuming mixed cereal diets. Beriberi is due to the deficiency of thiamine, one of the Bcomplex vitamins. It was common h populations consuming highly polished rice. The disease is rare nowadays. Wet beriberi manifests with swelling of legs and face. Dry beriberi presents as weakness in limbs. There may be palpitation (rapid heart beats), chest paifi, feeling of pins and needles and numbness.. The disease can be prevented by consuming hand pounded rice or rice which is not highly polished. Rickets is due to vitamin D deficiency in children and osteomalacia is its adult counterpart. Vitamin D is synthesized in the skin on exposure to the ultraviolet rays of the sun. It is common in India in individuals who are not exposed to- the suh and remain confined indoors. The growing ends of long bones become widened and the muscles kome weak in rickets. Developmental mi!estones like the age at sitting and crawling are delayed in the disease. When the disease heals, bow legs, knock knees, pigeon chest, frontal bossing etc. may develop. Spinal deformities are also common. Vitamin D is given for treatment and prevention is by exposure to the sun and inclusion of good food sources if possible.

Deficiency of vitamin C in the diet causes scurvy. In India it is relatively uncommon. It is characterized by spongy bleeding gums where gums start bleediag even on slight touch. Tiny bleeding spots also may be seen around the knees and lower thighs. It canbe prevented by the consumption of diets which contain foods rich in vitamin C such as citrus fruits (orange, lime), guava, amla andsprouted pulses like chana or bengal gram.

Fluorosis is a disease caused by excessive consumption of fluoride. It is an important health problem in some districts of Andhra Pradesh, Karnataka, Punjab, Rajasthan and Tamil Nadu. In children, it manifests as dental fluorosis which is characterized by mottling and pitting of-teeth. In the case of older individuals, skeletal fluorosis develops. It is characterized by changes in the bones which can be seen only in X-rays. The patient develops pain and stiffness of the neck and back. Defluoridation of water can be done at the domestic level to remove excess fluorine. This would help to prevent fluorosis.

Lathyrism is a disease of the nervous system seen in landless labourers in the States of Madhya Pradesh, Bihar and Uttar Pradesh due to consumption of kesari dal for prolonged periods. It leads to paralysis of the lower extremities affecting mainly youth who end up as beggars. The toxin in the dal can be removed by parboiling of the dal on a large scale or steeping it in hot water. Education of the communities in the areas to avoid dependence on the dal or banning of the crop can help in the control of the disease.

19.8 GLOSSARY

Pins and needles : A feeling of pricking by sharp pins or needles. Enamel : The hard, glistening substance covering the. crown of a tooth i.e. its top part. Muscle tone : Firmness of muscle Incisors : Cutting teeth, four in number in each jaw Anterior fontanelle : A diamond shaped opening on the scalp between frontal and parietal skull bones. Microgram (Crg) : 1/1000th of a milligram . Dental fluorosis : Changes in the teeth due to fluorosis Mottling of teeth : A sign of dental fluorosis in which chalky white or yellowish patches appear on the teeth. Bow legs : A deformity when legs are bent like a bow. Knock knees : A deformity in which both the knees touch each other. Alum : A chemical compound containing a double sulphate of aluminium. It helps in settling of physical impurities of water. I Gait : Walking style Prevention of Food An act formulated by the Government of India to prevent Adulteration Act : adulteration of foods with harmful substances.

Frontal bone : The single skull bone forming the forehead. Parietal bones : The bones, two in number, forming part of the upper and each Qheck Your Progress Exercise 1

1) Angular stomatitis. glossitis, cheilosis. 2) To include in the diets one or more of the following: Green leafy vegetables, pulses, nuts, milk. 3) a) good b) greater or higher C) glossitis Check Your Progress Exercise 2 1) (i),-(c), (19-(I), (iii)-(dl, (iv)-(a), (v)-im), (vi)-(b), (vii)-(k), (viii)-(g), (ix)= (e), (XI-(i). 2) List symptoms of wet and dry beriberi separately,

Check Your Progress Exercise 3 1) a) Vitamin D; adult women

2) Sunlight is required for synthesis of vitamin D by the body. Vitamin D is synthesized under the skin. I Check Your Progress Exercise 4 1) a) Excessive, fluoride/fluorine b) 1 mg per litre C) Caries d) Skeletal i 2) (iv), (viii), (ix)

Check Your Progress Exercise 5 I 1) a) Neurotoxin, kesari dal b) Nervous c) Banning d) Steeping 2) (a) Ariboflavinosis (b) Scurvy (c) Pellagra (d) Wet beriberi (e) Rickets. 1 CAN YOU JDENTJFY THESE DISORDERS ?

Slides Courtesy : Voluntary Health Association of India in collaboration with Dr. David Morley, Institute of Child Health, London CAN YOU IDENTIFY THESE DISORDERS ?

Slides Courtesy : Voluntary Health Association of India in I collaboration with Dr. David Morley,-Institute. of 1 Child Health, London CAN YOU IDENTIFY THESE DISORDERS ?

Slides Courtesy : Voluntary Health Association of India in collaboration with Dr. David Morley, Institute of Child Health, London CAN YOU IDENTIFY THESE DISORDERS ?

Slides Courtesy : Voluntary Health Association of India in collaboration with Dr. David Morley, Institute of Child Heglth, London 47