Prevention of Anemia by reduction of High Fluoride consumption Dr.Pradeep Saxena, Additional DDG, Dte.General of Health Services, M/o Health &F.W.,New Delhi

Contents Background Sources of Fluoride Clinical manifestations of Fluorosis. Changes in GI Tract due to high Fluoride. Preventive Measures. Steps to be followed in Ante Natal Clinic. Role of Diet Editing . Brief introduction about NPPCF.

Background Fluorosis is a Public Health problem caused by excess intake of Fluoride mainly through drinking water or food products/drugs/ industrial pollutants over a long period of time. It leads to health disorders like Dental Fluorosis, Skeletal Fluorosis and Non-Skeletal Fluorosis. Desirable limit for Fluoride in drinking water, as per BIS standards, is 1.0 mg / Litre (1PPM). Permissible limit is 1.5 mg/ Litre (1.5PPM). Fluorosis impacts growth, development, economy and human resource development of the country

Sources of Fluoride Natural - Leaching of Fluoride from geological crust into drinking water. Food and Beverages - Black tea, black salt, supari. Drugs- Some anesthetic agents, antibiotics, antidepressants, fluoride toothpaste. Pollution - Dust from fluoride containing soil, from Mining, Industrial emissions.

Fluorosis Manifestations Fluorosis manifests as Dental, Skeletal and/or Non- Skeletal Fluorosis :- Dental Fluorosis: Chalky white teeth   Transverse yellow brown/dark brown bands

Fluorosis Manifestations Skeletal Fluorosis : Severe pain and stiffness in neck and back bone. Severe pain and stiffness in joints. Severe pain and rigidity in the hip region (pelvic girdle). Inability to squat. Ugly gait and posture. Increased girth, thickening and density of bone by X-ray. Knock knees/ Bow legs.

Non skeletal Fluorosis Anemia and malnutrition. Gastro - intestinal problems: Consistent abdominal pain, intermittent diarrohea/ constipation, blood in stool  Neurological manifestations: Nervousness & depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinate frequently (Polydypsia and polyurea) Muscular manifestations: Muscle weakness & stiffness, pain in the muscle and loss of muscle power.

Other Effects of Excess Fluoride Fluoride has multiple role in deranging metabolic activities, besides the well defined symptoms of Dental Fluorosis, Skeletal Fluorosis and Non-Skeletal Fluorosis.Its other adverse effects on the body are:- (i) Damage to G.I. Mucosa. (ii) Injury to RBCs. Both the above effects lead to Anaemia / Malnutrition. Consequences are maternal mortality, infant mortality, low birth weight babies. Elimination of Fluoride from the body leads to remarkable improvement.

100% Absorption of Nutrients Showing Scanning Electronmicrograph (SEM) of the Intestinal lining (Duodenal region) of a normal volunteer 100% Absorption of Nutrients F¯ <1.0 mg/l Normal Mucosa NORMAL HUMAN INTESTINE

Absorption of Nutrients Showing Scanning Electronmicrograph (SEM) of the Intestinal lining (Duodenal region) of volunteer consuming fluoride contaminated ground water Absorption of Nutrients F¯ 1.2 mg/l 20 % DAMAGED INTESTINE

Upon withdrawal of F¯, microvilli regenerates in few days Showing Scanning Electronmicrograph (SEM) of the Intestinal lining (Duodenal region) of volunteer consuming fluoride contaminated ground water Absorption of Nutrients F¯ 3.2 mg/l 3 % Upon withdrawal of F¯, microvilli regenerates in few days SEVERELY DAMAGED

Preventive Measures:- (1) SAFE DRINKING WATER (2) DIET EDITING FOODS TO TAKE Milk, Yoghurt, Green leafy vegetables, fruits, Lemon, AMLA,orange, tomato, guava, papaya. FOODS NOT TO TAKE Black salt, betel nut, tobacco chewing, (3) Avoid use of Fluoride tooth paste. (4) Calcium,Magnesium,Vitamin Supplements (C,D3,E) (5) Behaviour change.

Suggested Steps for Pregnant women in Antenatal Clinic Step 1: Test Hb using portable Hemoglobinometer Step 2: Test – Urine Fluoride level. if > 1.0 mg/L Step 3: Test Water for Fluoride Step 4: Introduce Diet Editing + Diet counselling Step 5: On every visit to ANC = Retrieve UFL  & Hb (iron + folic acid, hospital to supply) Step 6: Record birth weight + other details from Labour room register

Diet Editing + Diet Counselling + Iron & Folic acid supplementation Pregnancy outcome Iron + Folic acid supplementation does not have the desired impact due to non-absorption of nutrients ; If excess Fluoride is eliminated , leads to better absorption of nutrients & correction of malnutrition / undernutrition Diet Editing + Diet Counselling + Iron & Folic acid supplementation Diet Counselling + Iron & Folic acid supplementation

The Secret Behind Fluorosis Reinforce Diet Editing Prevention Reinforce Diet Editing & Diet Counseling

National Programme for Prevention and Control of Fluorosis (NPPCF) Goal :- To Prevent and Control Fluorosis in the country. Objectives :- To collect, assess and use baseline survey data of fluoride levels from Ministry of Drinking Water and Sanitation for starting the project. Comprehensive management of Fluorosis in the selected areas. Capacity building for prevention , diagnosis and management of Fluorosis cases.

NPPCF: Strategy Surveillance of Fluorosis in the community. Capacity Building at District level:- Consultant(1), Lab.Technician (1) & Field Investigators (3) for six months. Establishment of diagnostic facilities through labs. in the affected Districts. Management of Fluorosis cases including treatment, surgery, reconstruction & rehabilitation. Health Education for prevention and control of Fluorosis.

States/Districts under NPPCF S.No. State Total districts in the State No. of districts under NPPCF Names of Districts under NPPCF 1. Andhra Pradesh 13 9 Nellore, Guntur, Prakasam, Ananthapur, Kurnool, Krishna, Chittoor, Visakhapatnam, Srikakulam 2 Assam 27 6 Nagaon, Kamrup, Karbi Anglong, Dhubri, Nalbari, Karimganj 3. Bihar 38 11 Nawada, Banka, Aurangabad, Bhagalpur, Gaya, Jammui, Nalanda, Shekhpura, Kaimur, Munger, Rohtas 4. Chhattisgarh 5 Durg ( now shifted to Balod) , Kanker, Kondagaon, Korba, Mahasamund 5. Gujarat 33 4 Jamnagar, Sabarkantha, Vadodara, Banaskantha, 6. Haryana 21 Mehendragarh, Mewat 7. J & K. 22 1 Doda 8 Jharkhand 24 Palamu, Garhwa, Chatra, Hazaribagh, Ranchi, Pakur, Sahebgann, Ramgarh, Jamtara, Simdega, Dhanbad, Giridih, Godda

Nanded, Chandrapur, Latur, Washim, Yavatmal. Beed, Nagpur Sl. No. State Total districts in the State No. of districts under NPPCF Names of Districts under NPPCF 9. Karnataka 31 19 Bellary, Mysore, Chikballapur, Koppal, Davangere, Tumkur, Bagalkote, Bengaluru (U), Bengaluru (R), Bijapur, Raichur, Chitradurga,Gadag,Gulbarga, Hassan, Kolar, Mandya, Ramanagara, Shimoga 10 Kerala 14 2 Palakkad, Alapuzha 11 Madhya Pradesh 51 15 Ujjain,Chindwada, Mandla, Dhar, Seoni, Betul, Jhabua, Raigarh, Sehore, Alirajpur,Dindori, Khargoan, Raisen, Shajapur, Ratlam 12 Maharashtra 34 7 Nanded, Chandrapur, Latur, Washim, Yavatmal. Beed, Nagpur 13. Rajasthan 33 30 Nagaur, Ajmer, Bhilwara,Churu (Ratangarh) Dausa, Dungarpur, Rajsamand, Tonk, Bikaner, Jalore, Jaisalmer, Jodhpur, Jaipur, Pali, Sikar Udaipur, Swaimadhopur, Banswara, Karauli, Chittaurgarh, Ganganagar, Jhalawar, Jhunjhunu, Barmer, Alwar, Bharatpur, Kota, Sirohi, Bundi, Pratapgarh

TOTAL 156 Sangrur, Firozepur, Patiala Dharmapuri S.No. State Total districts in the State No. of districts under NPPCF Names of Districts under NPPCF 14 Odisha 30 3 Nayagarh, Angul, Nuapada 15 Punjab 22 Sangrur, Firozepur, Patiala 16 Tamil Nadu 31 1 Dharmapuri 17 Telangana 9 Mehboobnagar, Nalgonda, Karimnagar, Jagityal, Sircilla,Suryapet, Yadagiri, Wernaparthy, Nagarkurnool 18 Uttar Pradesh 75 10 Unnao, Rae Bareli, Pratapgarh, Firozabad, Mathura, Sonbhadhra, Ghazipur, Jhansi, Varanasi, Agra 19 West Bengal 6 Bankura, Purlia, Birbhum, D. Dinajpur, Maldha, Uttar Dinajpur . TOTAL 156

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Knock Knees