1. 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

2. 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.

3. 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

4. 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.

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

6. 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.

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

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

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. THANK YOU

23. Knock Knees