Malnutrition in india

Parveen. SK
III MDS,
Public Health Dentistry

• Introduction
• What is malnutrition and types of malnutrition
• Causes
• Clinical features
• Interventions
– Individual level
– Government programmes 3

• Global malnutrition
• Current scenario of India
• Current status of Andhra Pradesh
• Current status of Guntur district
• Effects of malnutrition on oral health
• Conclusion
• References
4

• India is one of the fastest growing countries in terms of
population and economics, growing at a population of 1.23 - 1.31
billion (2010-2015).
• India’s Gross Domestic Product growth (annual%) was decreased
from 10.3% (2010) to 7.6% (2015).
• The World Bank estimates that India is one of the highest ranking
countries in the world for the number of children suffering from
malnutrition.
• The 2015 Global Hunger Index (GHI) Report ranked India 20th
amongst leading countries with a serious hunger situation.
5http://databank.worldbank.org/data/reports.aspx?source=2&country=IND

• Malnutrition refers to the situation where there is an unbalanced
diet in which some nutrients are in excess, lacking or wrong
proportion.
• Despite India’s 50% increase in GDP since 1991, more than one
third of the world’s malnourished children live in India.
• Some of the major causes for malnutrition in India is Economic
inequality.
6
“The Indian exception”. The Economist. 31 March 2011. Retrieved 13 February 2012.

• Nutrition may be defined as the science of food and its
relationship to health. It is concerned primarily with the part
played by nutrients in body growth, development and
maintenance.(Park 2015)
• Malnutrition refers to the situation where there is an
unbalanced diet in which some nutrients are in excess, lacking or
wrong proportion.
– Types:
A. Under nutrition
 Protein Energy
 Micronutrient
B. Over nutrition
 Obesity
7https://en.wikipedia.org/wiki/Malnutrition_in_India?oldid=757036116

• Being below the optimum nutrient level for a healthy growth,
development and living is called undernourishment.
• Under nutrition results in:
8
Stunting-
•Stunted growth, also known as stunting and nutritional stunting, is a
reduced growth rate inhuman development.
•Stunted children may never regain the height lost as a result of
stunting, and most children will never gain
the corresponding body weight.
•Measured by height for age.
https://en.wikipedia.org/wiki/Malnutrition_in_India?oldid=757036116

Wasting:
• It is also known as wasting syndrome,
refers to the process which
causes muscle and fat tissue to
"waste" away.
• Measured by Weight-for-height (WFH).
10
https://en.wikipedia.org/wiki/Malnutrition_in_India?oldid=757036116 (accessed on 21-5-2017)

Low birth weight (LBW):
• It is defined as a birth weight of a live born infant of
less than 2,500 g (5 pounds 8 ounces) regardless of
gestational age.
• Their chance of survival is poor; they have less ability
to resist diseases, therefore, suffer from frequent
infection, inability to cope up thus they are Severely
Malnourished.

• Reduced ability to perform normal tasks / physical performance –
for example, not being able to walk fast .
• Altered mood – malnutrition can be associated with lethargy and
depression.
• Recurring illness : Recurrent or chronic infections
• Weak immune system
• Weight loss
• Tiredness
• Poor concentration

The Two forms of Under nutrition:
Protein-Energy Malnutrition (PEM)
• Protein Energy Malnutrition (PEM) is a major health and
nutrition problem in India.
• It occurs particularly in weaklings and children in the
first years of life.
• It is not only an important cause of childhood morbidity
and mortality, but leads to permanent impairment of
physical and mental growth of those who survive.
13
K. Park, Text book of preventive and social medicine -23rd edition, Jabalpur: Banarsidas
Bhanot 2015 pg no:10,27,832-848.

• The two clinical forms of PEM are- Kwashiorkor and
marasmus
14
Bhanot 2015 pg no:10,27,832-848

K. Park, Text book of preventive and social medicine -23rd edition, Jabalpur: Banarsidas Bhanot 2015 pg
no:10,27,832-848

Bhanot 2015 pg no:10,27,832-848

• Micronutrient deficiency is a lack of essential vitamins and
minerals required in small amounts by the body for proper growth
and development.
17

18
Calcium-
•Calcium is important for maintaining strong bones and controlling
muscle and nerve function.

Vitamin D-
•This vitamin is also critical for bone health.
•Symptoms of vitamin D deficiency can be vague, fatigue
and muscle aches or weakness.
•“If it goes on long term, a vitamin D deficiency can lead
to softening of the bones.
Potassium-
Symptoms of potassium deficiency include weight loss,
muscle weakness, constipation, and in severe cases, an
abnormal heart rhythm.
http://www.everydayhealth.com/hs/guide-to-essential-nutrients/common-nutrient-
deficiencies/ (assessed on 25/05/2017)
19

Iron-
• Iron helps in production of red blood cells. When iron levels get
too low, your body can’t effectively carry oxygen. The resulting
anemia can cause fatigue and might also notice pale skin and
dull, thin, sparse hair.
• 2 billion people – over 30% of the world’s population – are
anaemic, many due to iron deficiency, and in resource-poor areas,
this is frequently exacerbated by infectious diseases.
• In developing countries every second pregnant woman and about
40% of preschool children are estimated to be anaemic.
20
http://www.everydayhealth.com/hs/guide-to-essential-nutrients/common-nutrient-deficiencies/
(assessed on 25/05/2017)
http://www.who.int/nutrition/en/ (assessed on 25/05/2017)

• In many developing countries, iron deficiency anaemia is aggravated by
worm infections, malaria and other infectious diseases such as HIV and
tuberculosis.
• The major health consequences include
– poor pregnancy outcome,
– impaired physical and cognitive development,
– increased risk of morbidity in children and
– reduced work productivity in adults.
• Anaemia contributes to 20% of all maternal deaths.
21
Global nutrition report-2015

Vitamin B12-
B12 deficiency include-
• numbness in the legs, hands, or feet
• problem with walking and balance
• anemia
• fatigue
• weakness
• a swollen, inflamed tongue
• memory loss and
• hallucinations.
22

Vitamin A Deficiency:
• Approximately one third of the world’s preschool-age population is
estimated to be vitamin A deficient; with highest prevalence (44-50%) being
reported in regions of Africa and South-East Asia.
• Vitamin A deficiency continues to be a major public health nutritional
problem in India. The prevalence of Bitot’s spot, the objective sign of
clinical VAD (0.8%) was higher than the figures recommended by the WHO
(≥0.5%), indicating the public health significance in rural pre-school
children of India.
• While in case of blood vitamin A deficiency (<20μg/dL), the prevalence
(61%) was a severe public health problem in all NNMB states, ranging from
52% in Maharashtra to 88% in Madhya Pradesh.
• The proportion of severe blood VAD (<10μg/dL) was (21.5%) indicating
severe public health problem in all the National Nutrition Monitoring
Bureau (NNMB) states.
23
N ARLAPPA. Vitamin A Deficiency is Still a Public Health Problem in India.
INDIAN PEDIATRICS,2011, VOLUME 48,853-54.

• Obesity is a medical condition in which excess body fat has
accumulated to the extent that it may have a negative effect on
health.
• People are generally considered obese when their body mass
index (BMI), a measurement obtained by dividing a person's
weight by the square of the person's height, is over 30 kg/m2, with
the range 25–30 kg/m2
• Obesity in India has reached epidemic proportions in the 21st
century, with morbid obesity affecting 5% of the country's
population.
https://en.wikipedia.org/wiki/Obesity accessed on 20-6-2017
25

• There were 20 million obese women in India in 2014
• Percentage of obese and severely obese men and women is still a
low in India, the numbers are growing.
26
Year 1975 women 2014 women 1975 men 2014 men
India 1.6 8.2 1.3 3.7
China 2.8 18.5 2.3 23.7
U.S. 35.2 30.6 57.2 43.5

• Worldwide, the number of obese people rose to 641
million in 2014 from 105 million in 1975.
• Still, India saw a more significant rise in obesity from
its 19th position for both men and women in 1975 to
rankings 5th and 3rd respectively in 2014, reflecting
increasing obesity rates among women worldwide
http://blogs.wsj.com/indiarealtime/2016/05/04/india-has-a-growing-obesity-problem
study-shows/ accessed on 24/05/2017
28

 Poverty:
• Poverty is the root cause of malnutrition in India. The poor people
cannot have nutritious food. Due to low income they cannot buy
enough amount of food of the desired quality for meeting their
children’s and family nutritional requirements
 Growing population-
• Population growth is the biggest major cause of malnutrition in
India.
• Due to maximum population growth there is no improved
agriculture production and this had led to uneven distribution of
food and rapid succession of pregnancies adversely affects the
nutritional status of mother.
29
Dr. Sangya Tripathi, Child Malnutrition in India: Causes and Intervention Programmes,
International Journal of Multidisciplinary Approach and Studies, Volume 03, No.2, Mar - Apr 2016

 Feeding habits-
• Breast feeding is very nutritious for infant. Lack of exclusive
feeding for first 6 months makes child prone to early onset
malnutrition.
 Social factors-
• Repeated pregnancies, inadequate child spacing, food taboo,
broken homes and separation of child from her/his parents are
the important social factors that may play a part in causes of
malnutrition.
 High pressure advertising of baby foods-
• Often urban educated working women discontinue breast feeding
due to high pressure advertising of baby foods manufacturers
and social demands.
30
International Journal of Multidisciplinary Approach and Studies, Volume 03, No.2, Mar - Apr 2016.

31
Cristian TALESCO , Felix Sai Kit NG , David IP. DEVELOPMENT: WHAT NOW? Past, Present and Future Challenges in
International Development. Department of Applied Social Sciences. 2016.

• Hepatomegaly– The liver is enlarged with rounded lower
margin and soft consistency in about one third of cases.
• Change in hair- texture will change, would be thin, dry,
hypopigmented, straight, brittle, sparse.
32
International Journal of Multidisciplinary Approach and Studies, Volume 03, No.2, Mar
- Apr 2016

• Changes in skin- Skin would be look like old paint
flaking off the surface of the wood, hyperpigmented
patches can be appear in malnutrition.
• Infections- Unfortunately children with malnutrition are
prone to have infections like diarrhoea, respiratory and
skin infections.
33
International Journal of Multidisciplinary Approach and Studies, Volume 03, No.2, Mar
- Apr 2016

Pre-Natal and Post-Natal Care :
• Prenatal care is very important to keep child and
mother healthy.
• During pregnancy and lactation, nutrient requirements
increased and foetus/infant depends on mother to
meet this requirements.
• Adequate intake of iron and nutritional food can
reduce the chance of low birth rate.
34

• Antenatal check up, intake of folic Acid and iron
capsules, proper balance diet, tetanus injections,
delivery in health centre, and birth spacing post natal
care can prevent low birth and malnutrition.
• Post natal care of mother is very necessary and family
should give proper and adequate diet to mother for
first six months.
35

Exclusive breast feeding:
Breast feeding for six months-
• First milk protects and immunizes the neonate from
most of the bacteria and viruses. It contains colostrum
which is very rich and prevent neonatal and infant
mortality and morbidity.
• The antibody of colostrum provide safety from
infection and helps to boost immune system
• Breast milk is very hygienic source of nutrition for
neonate and infant for first six month.
36

Complementary food after six month-
• Nutritional supplement should be introduced in diet
after age of 6 months
• Soft and hand mashed food
• Fresh homemade food like the staple cereal of the
family should be used to make the first food for an
infant.
• Milk, meat, eggs, vegetables, fruits or foods whatever
family can afford.
• Ghee or oil is important to add in food of infant.
37

Complete and Timely immunization-
• Timely and complete immunization protect children
from several diseases .
• For every child it is necessary to receive all primary
immunization and booster doses.
• Vitamin A is very essential to make eyesight and
immunity strong. it is very necessary to give Vitamin A
rich food as well as vitamin A supplement.
• Food rich Iron, and iron supplement is necessary for
child growth. De-worming in twice a year prevent child
from infections.
38

Appropriated and Frequent feeding for children
during and after illness-
• Due to infections like diarrhoea, affects nutritional
status and losses body fluids and nutrients.
• So small digestive meal should be given
• It is very necessary to maintain hygiene to prevent
infections which can be maintained through adopting
hand washing habits and by accessing the safe
drinking water and Safe disposal of stool.
• Adequate fluid should be given to child.
39

Government programme to reduce
malnutrition in India
40

http://iap.healthphone.org/pdf/the-governments-efforts-to-fight-malnutrition.pdf
(accessed on 4/6/2017)

Methods of Nutritional Assessment
• Nutrition is assessed by two types of methods;
 Direct
 Indirect
• The direct methods deal with the individual and measure
objective criteria, while indirect methods use community health
indices that reflects nutritional influences
43

Direct Methods of Nutritional Assessment
 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods
44

Indirect Methods of Nutritional Assessment
These include three categories:
• Ecological variables including crop production
• Economic factors e.g. per capita income, population density &
social habits
• Vital health statistics particularly infant & under 5 mortality &
fertility index
45

Nutritional Indices in Adults
• The international standard for assessing body size in adults is the
body mass index (BMI).
• BMI is computed using the following formula:
BMI = Weight (kg)/ Height (m²)
• Evidence shows that high BMI (obesity level) is associated with
type 2 diabetes & high risk of cardiovascular morbidity &
mortality
46

Classification BMI(kg/m2)
Principal cut-off points
Underweight <18.50
Severe thinness <16.00
Moderate thinness 16.00 - 16.99
Mild thinness 17.00 - 18.49
Normal range 18.50 - 24.99
Overweight ≥25.00
Pre-obese 25.00 - 29.99
Obese ≥30.00
Obese class I 30.00 - 34.99
Obese class II 35.00 - 39.99
Obese class III ≥40.00
47
The International Classification of adult underweight,
overweight and obesity according to BMI

• The prevalence of chronic energy deficiency
(BMI<18.5) (adult nutritional status)
48
1997-98 2010-11
Adult men 45.5% 32%
Adult women 48% 33%

DIETARY ASSESSMENT
• Nutritional intake of humans is assessed by five
different methods.
• These are:
– 24 hours dietary recall
– Food frequency questionnaire
– Dietary history since early life
– Food dairy technique
– Observed food consumption
http://www.ake-nutrition.at/uploads/media/anthropometrics_bia.pdf
49

UNICEF/WHO/World Bank Group - Joint Child Malnutrition Estimates 2017 edition, accessed
on 02-09-2017 52

54
UNICEF/WHO/World Bank Group - Joint Child Malnutrition Estimates 2017 edition, accessed
on 02-09-2017

UNICEF/WHO/World Bank Group - Joint Child Malnutrition Estimates 2017 edition, accessed on 02-09-
2017

59
Globally, only three out of four households are consuming adequately iodized salt, putting
far too many children at risk
Percentage of
households
consuming
adequately
iodized salt,
2009─2013
Source: UNICEF global nutrition database, 2014, based on Multiple Indicator Cluster Surveys (MICS), Demographic and Health
Surveys (DHS) and other nationally representative household surveys, 2009─2013.

60
The incidence of low birth weight is highest in South Asia
•Excludes China.
•Source: UNICEF global databases, 2014, based on Multiple Indicator Cluster Surveys (MICS),
Demographic and Health Surveys (DHS)

61
Effective vitamin A supplementation coverage has been achieved in many
countries with high child mortality rates
Percentage of children
aged 6─59 months that
received two high-dose
vitamin A supplements in
2014.
Source: UNICEF global nutrition database, 2015, based on administrative reports from countries for
the 2014 calendar year.

Source: UNICEF - country profiles/India/Nutrition IND/Annual Results Report 2016 Nutrition

• A gradual improvement in the Global Hunger Index (GHI) between
1990 (48.1%) and 2015 (29%), though it denotes that hunger is still
serious in India (Grebmer et al., 2015).
• NSSO consumption expenditure surveys (2009-2010) also
corroborate this with the observation that, between 1987-88 and
2009-10 there was a 10% reduction in food expenditure to total,
except for small increase in the lowest income group (NSSO,
2011).
K VIJAYARAGHAVAN, The Persistent Problem of Malnutrition in India, Proceedings of the Indian National Science
Academy, 2016,Vol 82, No 5 ,pg:1341-1350

66https://data.unicef.org/wp content/uploads/country profiles/India/Nutrition_IND.pdf

67
https://data.unicef.org/wp content/uploads/countryprofiles/India/Nutrition_IND.pdf

70https://data.unicef.org/wp content/uploads/countryprofiles/India/Nutrition_IND.pdf

79
National Institute of Nutrition. Annual Report 2012-13. Nutrition profile of Chenchu . A primitive tribe of
Andhra Pradesh

81
* Percentage not shown; based on fewer than 25 unweighted cases

• Nutrition represents a summation of intake,
absorption, storage and utilization of foods by the
tissues.
• Oral tissues are one of the most sensitive indicators of
nutritional state of the body.
• Nutritional deficiencies are associated with changes in
the integrity (health and appearance) of the oral
structures/ tissues and these changes are frequently
the first clinical signs of deficiency.
84
GA Agbelusi, Effects of nutrition on oral health, Nigerian Medical Journal, 2010,vol: 51(3),Pg: 128-130

• Nutrition affects oral health and oral health affects
nutrition.
• The effects of malnutrition can be seen in the oral
structures in all stages of human growth and
development from conception to old age.
• The consequence of certain oral diseases may
compromise the nutrition by affecting the intake and
mastication particularly in some vulnerable groups like
people with severe caries, severe oral ulceration,
advanced periodontal disease and the resulting
edentulousness.
85
GA Agbelusi, Effects of nutrition on oral health, Nigerian Medical Journal, 2010,vol: 51(3),Pg: 128-130

86
Psoter WJ, Reid BC, Katz RV. Malnutrition and Dental Caries: A Review of the
Literature. Caries Res. 2005 ; 39(6): 441–47.

87
Psoter WJ, Reid BC, Katz RV. Malnutrition and Dental Caries: A Review of the
Literature. Caries Res. 2005 ; 39(6): 441–47.

Effect of micronutrients on dental tissues-
• Optimal maternal nutrition is required for optimal
odontogenesis and calcification of the deciduous teeth
in the foetus.
• Ameloblasts are sensitive to nutritional deficiencies
and infections.
• Enamel hypoplasia/ hypocalcification may result from
neonatal infections in Vitamin A, D and calcium
deficiency.
88
GA Agbelusi, Effects of nutrition on oral health, Nigerian Medical Journal,
2010,vol: 51(3),Pg: 128-130

Nutrition and Dental Caries-
• Dental caries prevalence is increased in resource poor
countries due to the effect of urbanization, increased
availability and consumption of refined sugars and low
exposure to dietary fluorides.
• Refined sugars on the other hand are easily available,
cheap and are accessible even to the children of the
poor and the cheapest snack a child can buy.
Conclusion-
• There is a reciprocal relationship between nutrition
and oral health; adequate attention must be paid to
both in order to ensure a good balance between the
two to maintain good health.
89

• P Lopez-Jornet et al. (2012) done a cross-sectional
study on 465 participants aged 65 years or older to
determine the risk of malnutrition in both
institutionalized and noninstitutionalized elderly
people of the region of Murcia in Spain.
• The risk of malnutrition was 49%. A greater prevalence
was recorded in the older and in the institutionalized
participants.
90
P Lopez-Jornet et al. Effect of oral health dental state and risk of
malnutrition in elderly people, Japan Geriatrics Society, 2013
Jan;13(1):43-9.

• There were no significant differences in terms of
malnutrition or the risk of malnutrition between the
participants with or without dentures or between the
dentate or edentulous participants.
91

• Nutrition is of basic importance in the maintenance of
dental and periodontal tissues. Mouth is frequently a
sensitive indicator of nutritional maladjustment.
• Restriction of the amount of carbohydrate or type of
carbohydrate has a favorable influence on dental
caries.
• The formation of enamel stops and the production of
dentin is defective when the vitamin A in the diet is not
adequate.
92
Harris et al.,Nutrition in Dental and Oral Health, Journal of American
dental association,1941,Vol. 28, pg: 424-430.

• Vitamin C has a definite effect on the formation of
dentin. A deficiency in ascorbic acid interrupts the
activity of the osteoblasts, odontoblasts and
ameloblasts.
• Vitamin D deficiency causes rickets which leads to
enamel hypoplasia of tooth which is more susceptible
to decay
93

• A prospective, four-year longitudinal study of 209
Peruvian children was conducted to evaluate the effect
of a single malnutrition episode occurring at infancy
(i.e., < 1 year of age) on dental caries in the primary
teeth.
• Children were recruited into the study at age 6-11
months after they had suffered from a malnutrition
episode and were thus classified as either:
(1) Normal
(2) Wasted (low weight for height)
(3) Stunted (low height for age)
(4) Stunted and Wasted (S and W)
94
ALVAREZ et al. A Longitudinal Study of Dental Caries in the Primary
Teeth of Children who Suffered from Infant Malnutrition, Journal of dental
research, 1993,vol:72 (12), pg: 1573-76.

• Number of teeth were analyzed at ages 1 year, 1.5
years, 2 years, 2.5 years, 3 years, and 4 years.
• Eruption of the primary teeth was significantly delayed
in all malnourished children;
• However, the effect of stunting (retarded linear growth)
was more pronounced and lasted longer than that of
wasting or acute malnutrition (i.e., 2.5 vs. 1.5 years,
respectively).
95

• By age 4 years, children from group 4 (S and W)
showed a significantly higher caries experience in the
primary teeth than did those in any of the other three
groups.
• Conclusion: A single, moderate malnutrition episode
occurring in infancy (< 1 year of age) resulted in
increased dental caries later in life, possibly as a
consequence of a deleterious effect on the formation
of tooth enamel early in life.
96

• Malnutrition may alter the homeostasis, which can lead
to disease progression of the oral cavity, reduce the
resistance to the microbial biofilm and reduce the
capacity of tissue healing.
• Studies have suggested that enamel hypoplasia,
salivary gland hypofunction and saliva compositional
changes may be the mechanisms through which the
malnutrition is associated with caries.
97
Aparna Sheetal et al., Malnutrition and Its Oral Outcome – A Review, Journal of
Clinical and Diagnostic Research. 2013 January, Vol-7(1): 178-180

• Saliva has an important role in ensuring adequate
nutrition and in protecting from oral diseases.
• At the same time, nutritional deficiencies compromise
salivary gland function, thus increasing susceptibility
to dental caries and oral infections and reducing
quality of life.
98
Lingstrom and Moynihan, Nutrition, Saliva, and Oral Health, NUTRITION AND
ORAL HEALTH, 2003, vol:19 (6), 567–569.

• A cross-sectional study was done based on a cohort of
1,160 children, 4-5 years of age (mean = 4.5 0.5 years),
who had been followed longitudinally from the age of 4
months to determine the association between obesity
and caries.
• There was a significant association between at-risk
overweight children (P < 0.001), overweight children (P
< 0.001), and caries in the primary dentition.
99
F. Vázquez-Nava et al,Association between obesity and dental caries in a group
of preschool children in Mexico, Journal of Public Health Dentistry, 2010, Vol: 70
issue 2, pg: 124-30

• Malnutrition is one of the biggest problems of contemporary
India.
• Substantial increases in economic growth experienced over the
past two decades did not translate into a similar substantial
reduction in under-nutrition, perhaps due to unequal economic
growth excluding the poor.
• Nutrition-sensitive interventions and programmes in agriculture,
social safety nets, early child development, education, women’s
empowerment and access to safe drinking water and sanitation
have enormous potential to scale-up and enhance the
effectiveness of nutrition-specific interventions
100

• http://databank.worldbank.org/data/reports.aspx?source=2&count
ry=IND
• “The Indian exception”. The Economist. 31 March 2011. Retrieved
13 February 2012.
• https://en.wikipedia.org/wiki/Malnutrition_in_India?oldid=7570361
16
• K. Park, Text book of preventive and social medicine -23rd edition,
Jabalpur: Banarsidas Bhanot 2015 pg no:10,27,832-848.
• Dr. Sangya Tripathi, Child Malnutrition in India: Causes and
Intervention Programmes, International Journal of
Multidisciplinary Approach and Studies, Volume 03, No.2, Mar -
Apr 2016.
101

• http://iap.healthphone.org/pdf/the-governments efforts-to-fight-
malnutrition.pdf
• https://data.unicef.org/wpcontent/uploads/countryprofiles/India/N
utrition_IND.pdf
• National Family Health Survey – 4, 2015 -16, India fact sheet.
• National Family Health Survey – 4, 2015 -16, Telangana fact sheet.
• K VIJAYARAGHAVAN, The Persistent Problem of Malnutrition in
India, Proceedings of the Indian National Science Academy,
2016,Vol 82, No 5 ,pg:1341-1350
• GA Agbelusi, Effects of nutrition on oral health, Nigerian Medical
Journal, 2010,vol: 51(3),Pg: 128-130
102

• Psoter WJ, Reid BC, Katz RV. Malnutrition and Dental Caries: A
Review of the Literature. Caries Res. 2005 ; 39(6): 441–47.
• P Lopez-Jornet et al. Effect of oral health dental state and risk of
malnutrition in elderly people, Japan Geriatrics Society, 2013
Jan;13(1):43-9.
• Harris et al.,Nutrition in Dental and Oral Health, Journal of American
dental association,1941,Vol. 28, pg: 424-430.
• ALVAREZ et al. A Longitudinal Study of Dental Caries in the Primary
Teeth of Children who Suffered from Infant Malnutrition, Journal of
dental research, 1993,vol:72 (12), pg: 1573-76.
• Aparna Sheetal et al., Malnutrition and Its Oral Outcome – A Review,
Journal of Clinical and Diagnostic Research. 2013 January, Vol-7(1):
178-180.
• Lingstrom and Moynihan, Nutrition, Saliva, and Oral Health,
NUTRITION AND ORAL HEALTH, 2003, vol:19 (6), 567–569.
103

• http://blogs.wsj.com/indiarealtime/2016/04/04/india-has-a-growing-
obesity-problem-study-shows/
• http://www.akenutrition.at/uploads/media/anthropometrics_bia.pd
f
• https://en.wikipedia.org/wiki/Obesity
• http://www.everydayhealth.com/hs/guide-to-essential
nutrients/common-nutrient-deficiencies/
104

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