9 Women’s Nutrition and Health

Minnie Mathew

Introduction

This module is designed for Master’s students of Women’s Development and Empowerment. This module will help the students to understand the role of nutrition and health for women and how good health is an important dimension of women’s empowerment. Frequent illness can have a strong negative impact on the role women can play in economic and social development. Therefore we are going to learn some basic nutrition and health facts and simple approaches to remain healthy.

Today when girls want to be equal to boys, girls need to grow up to their genetic potential and for this good nutrition and health play an important role.

Why is it important for girls and women to be healthy?

(a) it is important to achieve learning levels to the best of your capacity

(b) develop a good immune system which helps you to fight against illness (c) be physically active and work at an optimal level (d) good health from infancy through childhood can prevent non-communicable disease such as cardiovascular disease, diabetes etc., All this will contribute to healthy living through childhood, adolescence, adulthood and old age.

We need to have certain clear concepts before we proceed with the module.

What is nutritional status? The condition of the body influenced by the nutrients consumed through dietary intake and the ability of the body to utilize the nutrients for the functioning of the body.

What is health status? Health status is beyond the presence or absence of disease and includes aspects of body functioning which includes physical and mental well being of an individual. Dietary and health habits have a strong influence on the nutrition and health status of people.

What is malnutrition? It can be defined as a situation when the body has an imbalance of nutrients such as calories, proteins, vitamins and minerals including trace elements. This condition makes people vulnerable to diseases. Girls and women do not enjoy the same nutrition and health status as boys and men do. Wide prevalence of malnutrition can negatively influence the national productivity.

Learning Objectives

At the end of the lesson you will be able to know:

• The nutrition and health status of women in India.
• Micronutrient malnutrition among women in India especially anaemia and Iodine Deficiency Disorders (IDD)
• Maternal and Reproductive Health
• Common health problems among women in India

The nutrition and health status of women in India

Women are more likely to be malnourished since they have a menstrual cycle and a reproductive system with special demands on nutrition. The health and nutritional status of women if highly influenced by factors such as gender discrimination and also the lack of awareness of the right type and quantity of food to be consumed. Sustained inadequate food leads to malnutrition which can be mild or severe. Poor quality diets with inadequate fruits and vegetables results in silent hunger which is micronutrient malnutrition. Poor quality diets can also lead to morbidity. Social discrimination of adolescent girls can have serious implications since they are growing at a very fast rate comparable to their first year of life.

I would like you to understand the vicious circle of malnutrition. Is poor nutrition and health responsible for the poor socio-economic status? Or is it the poor socioeconomic status that results in poor nutrition and health status? Let us see how the vicious cycle perpetuates the poor nutrition and health status of girls and women (figure 1).

Figure 1

The vicious cycle of low status of women and poor nutrition and health status

                                              Parameters for understanding nutritional status:

In order to have a comprehensive understanding of nutritional status the following assessments would be important:

• Anthropometric measurements
• Body composition: reflects the distribution of body fat and lean mass. The Body Mass Index (BMI) is calculated as weight/height2 is a global index of nutritional status. This method has serious limitations in the sense that it cannot distinguish between fat and lean mass. The bioelectric impedance analysis (BIA) is also being used increasingly. The conventional single frequency method does not have much precision.
• Biochemical measurements for protein, micro nutrients, metabolic parameters
• Clinical assessments
• Measurements of dietary intake

Body Mass Index

Using Body Mass Index 1as an indicator to measure nutritional status of adults, more women had a BMI less than the normal BMI2 (figure 2).

Women who are underweight will be malnourished; will have weak bones, weak immune system, anaemia, dry skin, loss of hair, digestive disorders, irregular menstrual cycle and even infertility. Suboptimal BMI levels can reduce capacity to concentrate can cause memory impairment. They will have increased risk to infection and heart arrhythmia and respiratory disease. Low BMI before pregnancy can lead to pre-term and low birth weight of babies. Low BMI is also associated with pregnancy and labor complications such as diabetes, post partum hemorrhage. The gender implications are huge. Adolescents and young women invariably enter pregnancy in an undernourished condition and are at great risk to poor birth outcome. All this can lead to maternal and fetal morbidity and mortality.

A study conducted by the National Institute of Nutrition (NIN) covering nine states of India in 2010 showed that the intake of all nutrients by non pregnant and non lactating women from rural and tribal areas was lower than the levels recommended by the Indian Council of Medical Research (ICMR). The deficiency of energy and protein intake was greater among pregnant and lactating women.

Therefore in order to maintain a normal BMI range, it is important to consume a healthy balanced diet. Increase your calorie intake. Eat nutrient dense foods instead of empty calories. Do not allow an imbalance of the food you eat by eating junk foods. Regular exercise is important.

Micronutrient malnutrition among women in India

Indian diets are deficient in micronutrients. Those micronutrient deficiencies which have public health significance are, vitamin A deficiency, iron deficiency anaemia and iodine deficiency disorders. Others are Zinc and vitamin B deficiencies.

Anaemia

Anaemia is a condition when there is a deficiency of Haemoglobin in the blood which results in pallor and tiredness. This condition occurs mostly due to deficiency of iron in the body. Since haemoglobin carries oxygen, when there is a deficiency of haemoglobin, the body cells will not get enough oxygen à fatigue and poor work output.

Anaemia is a very common condition in the world and is highly prevalent in India especially among children, women and men. It is higher among children and women when compared to men. You will observe from the chart below that a large proportion of children are anaemic. Women when compared to men are more anaemic and pregnant women are more anaemic that non-pregnant women (figure 3).

The major cause for anaemia includes iron deficiency, hookworm infestation, vitamin A deficiency, Malaria, chronic diseases such as TB and HIV.

The consequences of anaemia include fatigue and cognitive loss resulting in reduced work output and earning capacity. This leads to productivity loss and a loss to GNP.

Anaemia can cause irregular heart beat because it pumps more blood to make up for the reduced oxygen that is being transported to the blood. Maternal anaemia leads to increased blood loss during delivery which can lead to maternal mortality. The probability of anemic women delivering premature and low birth weight babies is very high. Anaemia affects the immune system which can make a person ill more frequently.

Anaemia through adolescence can delay the age of menarche. Anaemia can cause neurological problems such as headache, irritability and muscle weakness.

What do you do if you are anaemic? Reduce the intake of refined foods such as sugar, refined flour. Of-course an iron rich diet will be helpful but never forget to have a balanced diet since proteins, vitamins and minerals are important to have proper iron absorption. Enabling nutrients include copper, folic acid, vitamin B12, ascorbic acid. Fresh fruits and vegetables should be an important part of your diet.

Vitamin A deficiency:

Vitamin A is important for maintaining normal growth and has an important role for maintaining good vision and epithelial tissues. Even today in many Indian districts there are persons with clinical signs of Vitamin A deficiency such as Bitot’s Spots.

There is high prevalence of Vitamin A deficiency among children and pregnant women in their third women belonging to low socio economic groups.

A good diet including carrots, dark green vegetables, sweet potatoes, capsicum, green chillies, fish, melon, mango etc., would be very helpful. Since Vitamin A deficiency is a public health problem in India, the government has a National Prophylaxis Programme though which massive doses of vitamin A are provided to children in the age group of 6 to 59 months.

Iodine Deficiency Disorders (IDD)

IDD can cause brain damage and therefore a serious problem. IDD includes a range of issues such as cretinism, mental retardation, learning disabilities, goiter, hypothyroidism, abortion and still birth. A large number of Indian children have iodine deficiency. Pregnant women and newborn infants are highly prone to IDD.

IDD has public health significance and the entire country is prone to IDD. The reason is environmental degradation. The solution to this problem is consumption of iodized salt. India has adopted universal salt iodization.

Maternal and Reproductive Health

The health of a woman is very important for a successful full term pregnancy and a healthy birth outcome. Successful motherhood depends on the social, physical and emotional well being. Although maternal deaths have come down in India, from 212 deaths per 100,000 live births in 2007-09 to 178 in 2010-12, we continue to have an unacceptable level of maternal mortality.

What are the reasons?

• Age at pregnancy: Adolescent pregnancies, girls below the age of 19 can be problematic, since the adolescents themselves have not attained full growth. If they become pregnant, they will be competing with the fetus for the nutrition. This stress can negatively influence the mother and the birth outcome. The risk of maternal death is double than that of adult women. Adolescent marriage and pregnancy is a result of gender inequality. Pregnancy after 35 also poses risks such as miscarriage, premature delivery, still birth, excessive bleeding, gestational diabetes
• Health and nutritional status of the women before and during pregnancy. Normally during the pre-pregnancy situation women are quite healthy provided they eat a nutritious diet and are not anaemic.
• Health care during pregnancy. Prenatal care includes regular check up, good diet, access to iron and folic acid supplementation, immunization etc. When women do not consume adequate food, they do not gain enough weight and they use their own body stores for the foetal growth and place themselves at risk. At the same time obesity can also have a negative effect, sometimes leading to gestational diabetes. Due to gender discrimination, a woman sometimes does not receive these services. Sometimes, health services are far away and therefore, prenatal care is ignored. Lack of information is yet another important reason why women do not receive the services.
• Reproductive tract infections (RTI) can pose threat to fertility. While both men and women are at risk, it poses greater risk to women. RTI can result in fetal wastage, low birth weight of babies and infections at birth. It is a great problem for adolescent mothers
• Oral health has a strong bearing on the birth weight of babies. Good oral health has advantages to both mother and child. Poor oral health is related to several diseases and poor birth outcome.

What can be done?

• Regular medical check-up
• Consuming a balanced diet and additional food for the growing fetus.
•  Consuming nutritional supplements such as iron and folic acid
• Personal and oral hygiene.
• Regular exercise and rest

Health problems among women

While illness can affect women and men, there are some illnesses which are more prevalent among women and we will be discussing them here. Women have tendency not to reveal their illness, they lack awareness and when they do perceive and reveal, women do not receive adequate health care due to gender discrimination.

Urinary tract infection (UTI)

Women are more prone to UTI, perhaps due to anatomical differences. UTI is caused by bacteria moving from the bowels or the anus to the urinary tract including the kidneys, ureter, bladder and the urethra. One can develop UTI due to incomplete emptying of the bladder, through intercourse or because of reduced immunity.

Symptoms of UTI include a burning sensation while passing urine, a tendency to frequently urinate, cloudy and bad smelling urine, low abdominal pain and fever. When you have these symptoms, you need to consult a doctor.

You can prevent UTI by emptying the bladder regularly, drinking plenty of water and washing from front to back and not the other way around.

Breast Cancer:

Gender has a role. Women have a greater risk for breast cancer. In cancer one has malignancy (abnormal cells)

• Older women are more prone to develop breast cancer.
• Menstruation before 12 years and menopause after 55 increases the risk.
• Women not giving birth at all or giving birth after 35 increases the risk
• Overweight/obesity, lack of physical exercise are contributory factors.
• Genetic mutations and history of cancer in the family predisposes you more.
• Exposure to radiations
• Hormone therapy
• Environment

How do you recognize or suspect that you may have breast cancer? In the early stages, cancer being painless goes unnoticed. Therefore regular screening is important. Mammographic screening is controversial. However screening once in two years for women older than 55 has been recommended.

Self examination can be beneficial. One can check for the following: A person with breast cancer can develop lump in the breast, pain in the breast, discharge from the nipple, change in the shape of the breast, patch on the breast.

Early detection will have enormous advantages since it helps you to live longer.

Cervical Cancer:

Cervical cancer is very common in India. This is caused by a virus or sometimes a bacterial infection and is transmitted through sexual contact. Bad hygiene is a contributory factor. You can be at risk if you have multiple partners, do not use contraceptive protection, and too many pregnancies. Since it is caused by a viral infection, it is preventable. It can be detected through a PAP smear test

Osteoporosis:

The word means porous bones, where the bone density is reduced. This is a condition occurs more among older women because of reduced estrogen production. Early menopause can be responsible for onset of osteoporosis. Osteoporosis can cause fractures, therefore it is important to avoid falls. Persons with osteoporosis have reduced Vitamin D levels and increase parathyroid hormone production. Lack of exposure to sunlight can be a predisposing factor.

The causes of osteoporosis are malnutrition, low intake of dietary calcium, phosphorus, magnesium, Zinc, iron, fluoride, Vitamin A, K, E and C. High blood acidity can also contribute to the development of osteoporosis. Even if fats which are considered beneficial to the body (polyunsaturated fatty acids) are consumed, the balance between them can be a contributory factor, for example the imbalance of omega 6 (corn oil, sunflower and peanut oil i.e.,) and omega 3 (olive and fish oil). Soft drinks can place you at risk to osteoporosis since they contain phosphoric acid.

Sexually transmitted Diseases among Women:

As the name implies, these diseases are contracted from one person to another through sexual contact. These include both bacterial and viral infections although the bacterial infections are declining and viral infections are increasing. Some of the sexually transmitted diseases are:

•  Human Papilloma Virus (HPV), which occurs in the mouth, throat, cervix and anus. There are several types of HPV. There are vaccines available.
• Herpes is also caused by a virus, Herpes Simplex Virus. It affects the cervix and genitals and the skin. It creates a chronic situation.
• Others include Condyloma acuminate, gonorrhea, chancroid, syphilis, hepatitis B and C, HIV.

   We will discuss HIV separately. These infections can lead to fertility and pregnancy problems, premature births. Infants can also develop eye infection and damage. Some of the STIs can be treated with the help of antibiotics, but may develop resistance due to frequent infections. Precautions: have a single partner and practicing safe sex.

Human Immunodeficiency Virus (HIV):

In this condition, the immune system fails to fight against the infections. It is life threatening and without treatment one may survive for approximately 10 years. This infection is transferred through body fluids such as semen, blood, vaginal fluid or breast milk. It is usually spread if one has an intercourse with a person having HIV, without the use of a condom; sharing needles with a person with HIV, blood transfusion when the blood is infected; contact with an open wound with HIV infected blood. Pregnant women can transmit the infection to their babies.

HIV enters the white blood cells and CD4+ T cells and starts to spread from cell to cell and cell free spread. CD 4 cells play an important role to play in protecting the body from infections. When a person is infected with HIV, the virus starts destroying the CD4 cells. When the CD4 count is a parameter to diagnose HIV since the CD4 count comes down drastically when infected with HIV. When the CD 4 count drops below 200 cells/mm3, it will lead to Acquired Immuno- deficiency Syndrome (AIDS) which is an advanced stage of HIV. Figure 4 depicts the mechanism of HIV infection.

Figure 4

Mechanism of HIV Transmission

While some start experiencing symptoms such as flu after being HIV infected. Others do not experience any symptom for years, even a decade. The symptoms of HIV include frequent infections, like diarrhea, thrush, tiredness, headache, fever, dry cough, weight loss etc. HIV patients very commonly develop Tuberculosis. The best way to know if one is infected with HIV is to go for a test.

While there is no cure, treatments are available to improve the immune system and live longer. The drugs have side effects and after some period the patient may develop drug resistance. It is therefore immensely important to adopt safety measures so that one is not exposed to the infection. Good food which will improve the immune system is very important.

Conclusion

We have so far discussed the important nutritional problems, prevalence of low BMI, anaemia, vitamin A deficiency and Iodine deficiency disorders. We discussed the reproductive health concerns and the common health problems such as urinary tract infection, breast cancer, cervical cancer, osteoporosis, sexually transmitted diseases and HIV. We also learnt how these problems can be prevented and treated. I would like to conclude by saying that a healthy balanced diet combined with exercise, personal hygiene, having a single partner and adopting safe sex practices are very important.

RECOMMENDED READING:

1. Chellan Ramesh., Paul, Lopamudra, 2010, Prevalence of iron deficiency anaemia in India: Results from a large nation-wide survey. Journal of Population and Social Studies. Volume 19, No.1
2. Elizabeth, I., Ransom. Leslie K Elder, 2003, Nutrition of women and adolescent girls: why it matters. Population Reference Bureau.
3. Government of India, 2013, SRS Statistical Report
4. Mallikharjuna Rao, K., Balakrishna, N.,Arlappa, N., Laxmaiah, A., Brahmam, G.N.V. (2010). Diet and Nutritional Status of Women in India. J Hum Ecol, 29(3):165-170.
5. International Institute for Population Sciences, 1992-93, 1998-99, 2005-06, 2014-15. National Family Health Survey I,II,II and IV.
6. Sheila, CV, 2011, Public Health Nutrition in Developing Countries. Woodhead Publishing India Pvt. Ltd.
7. World Health Organization., 2014. Saving mother’s lives