Complementary foods associated diarrhea
http://www.100md.com
《美国医学杂志》
Department of Foods and Nutrition, Faculty of Home Science, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
Abstract
The World Health Organization regards illness due to contaminated food as one of the most widespread health problems in the contemporary world. Food safety especially in the weaning groups is one of the major concerns that have posed a threat to health of the children. Millions of children in the world die each year from diarrheal diseases; hundreds of millions suffer from frequent episodes of diarrhea and consequent impairment of nutritional status. Contaminated foods play a major role in the occurrence of diarrheal diseases. Apart from food contamination, transmission of infection occurs by direct contact, highly favored by the habits and customs of the people. Improper storage and handling of cooked food is equally responsible for food-borne illnesses, as during storage especially at ambient temperature (28-38 oC) there is the risks of multiplication of pathogenic organisms increase. Food safety education is a critical prerequisite and is an essential element in control and prevention of diarrheal diseases. However, no preventive measures can ever be successful without the acute involvement of the caretakers, other family members and the community. To sensitize the community in a catalytic manner, health workers, community leaders and community volunteers can act as effective change agent, to bring about a behavior that can lead to improvement in their real life practices, thereby reducing the prevalence of diarrheal episodes in young children. Food Safety Education Programs that involve volunteers are cost effective as they can be reached to a maximum number of people through limited health personnels, and by this, the community can be made responsible for its own health problems.
Keywords: Weaning/complementary; Food borne pathogens; Food safety education; Diarrheal diseases
Children constitute a major proportion of the global population today. It has been reported that 10 % of the 5.8 billion people living in the world are children under 5 years of age.[1] It is estimated that annually some 1.8 million children die from the direct effect of diarrheal diseases. However, many more are affected by the effects associated with diarrheal diseases and malnutrition. It is estimated that annually some 13 million children under 5 years die in developing countries, mostly from the associated effects of malnutrition and infections.[2]
In the early stages of prenatal life, breast-feeding is an important factor contributing to child's health and well- being. In the subsequent months, breast milk is supplemented with various other foods, and the term "weaning" is used to describe this stage in a child's life. The introduction of these complementary foods represents the next critical stage in the child's nutritional progress, and it is then that the greatest incidence of diarrhea occurs because they are exposed to food-borne pathogens. Poor Environmental Sanitation and poor personal hygiene of caretakers continue to remain a leading etiological factor for diarrhea.
In spite of the constant increase in the prevention of food-borne illnesses, the Global importance of food safety is neither fully appreciated by many of the public health authorities[3] nor by the food handlers. Therefore, preventive strategies that can bring about a sustainable behavioral change in the caretaker of the young children are the need of the present time.
Complementary Foods Associated Hazards And Risk
In developed countries, the industrially prepared alternatives to home-based supplements are preferred as they are convenient, hygienic and often recommended by health workers due to their proper food value. However, in developing countries, like India, the solid and semi- solid foods prepared at home are the usual sources of nourishment for the child, as the cost of infant foods available in the market becomes unaffordable[4]. These include buttermilk, curd, dal, chapatti, rice, khichdi, mashed potato, kheer, porridge, bread, biscuits, boiled egg yolk, banana, pudding , sago, sheera , green vegetables etc.[5],[6] The incidence of diarrheal diseases especially high after weaning is initiated, because food is the medium for microbial growth; the introduction of unhygienically prepared weaning foods exposes the child to enteropathogens.
Morbidity And Mortality Related To Diarrhea
Infant Mortality Rate (IMR) and Under 5 Mortality Rate (U5MR) are regarded as a reliable and sensitive index of the total health status of a community and often used as an indicator to gauge the level of socio-economic development of a country. Diarrhea is one of the causes of morbidity and mortality among children in the developing world. For children under 5 years in developing areas and countries, there was a median of 3.2 episodes of diarrhea per child - year[7].
Pathogens associated with diarrhea
Diarrheal diseases are most commonly encountered of all the major food-borne infections table1, although enteric fevers, Brucellosis More Details, poliomyelitis, helminthic infections and other diseases are also of concern.[3] In urban slum of Baroda, several raw as well as cooked fresh and leftover weaning foods showed the presence of pathogenic organisms such as Staphylococcus aureus, Bacillus cereus, Clostridium perfringens and total Coliforms[8].
A study carried out a clinical evaluation of 211 infants and young children admitted in Santa Cruz General Hospital, Bolivia, for various types of diarrhea during 1991-1992. A peak cluster was observed in children aged 1 year, of which 80% were acute diarrhea and the remaining 20% were prolonged or chronic diarrhea. The major bacterial pathogen was enteropathogenic Escherichia More Details coli . Other bacterial pathogens such as klebsiella, Shigella, Vibro cholerae, Ancylostoma were also detected[9].
In another study the age-specific distribution of enteropathogens in young children suffering from diarrheal diseases in a hospital of urban Bangladesh was determined. A 5% systematic sample was used to examine 1207 rectal swab specimens of children aged 1-35 months with acute watery diarrhea. Variation in isolation rates of enteropathogens was observed in different age groups. Overall, Rotavirus (26%) and Campylobacter (26%) were the most common pathogens followed by enterotoxigenic E . coli (15%), Vibrio cholerae 01 (7%), other Vibrios (9%), Shigella (4%) and Salmonella More Details (<1%)[10].
Sources of food contamination and microbial proliferation
Many pathogens that cause diarrhea in humans, including V. cholerae, Shigella spp., Campylobacter, E. coli, Poliovirus, Entamoeba histolytica , can be recovered from flies and many pathogens can survive on the integument of flies for a period of 10 days. Pathogens can also be carried in the food by flies and deposited on food when they regurgitate or deposit excreta. Thus flies are a potent source of contamination in foods and water[11].
In another study it was shown that flies could transmit fecal organisms from latrines to the food contributing to the increased risk of persistent diarrhea in Burmese children.[12] In a study carried out it was shown that personal hygiene practices of mothers were significantly related to high levels of bacterial contamination of drinking water and weaning foods.[13]
Behaviors such as the child defecating on the floor, water or rags being used to cleanse the child after defecating, and mother not washing the child's hand or her hand with soap and water after defecation, or cleansing the child's perinum were directly related to higher risks of persistent diarrhea.[12]
The potential risk factors leading to diarrhea in young children were feeding leftover and overnight foods, not washing hands prior to cooking and feeding, consumption of the spilled food from the floor, use of dirty cloth for wiping hands and utensils and the use of unsterilized and dirty feeding bottles for the children.Figure1 shows the various causes of diarrhea which can lead to death in young children[8].
Strategies to reduce diarrheal morbidity and mortality
To address these diarrheal problems, well-designed programs for health education in food safety of caregivers through health workers is fundamental. The design of such programs should focus on critical control measures during food preparation and should take into consideration the sociocultural and socioeconomic factors leading to food-borne diseases. To this end, the food preparation habits of caregivers should be studied using the Hazard Analysis Critical Control Point system (HACCP) as a methodology. Furthermore, the impact and efficacy of health education interventions need to be evaluated and, if needed, be improved.[2]
Improved feeding practices, along with avoidance of animal feces and improved personal and domestic hygiene, should be considered important interventions in reducing the high incidence of diarrhea in infants in developing countries[14]. However, no preventive measures can ever be successful without the active involvement of an individual, a family and the community. In order to change a behavior in the community, a desire for a change should be created by imparting knowledge so as to develop the correct attitudes towards the health of children and thereafter bring about positive changes in behavior.
It has been found that villages show the greatest improvement in their hygiene behavior after the intervention tended to have a stronger sense of community than others and had more people actively involved in the intervention.[15] Mothers must receive nutritional counseling from the health care providers that is practical and take into account family views and realities and also include clear instructions on the frequency of meals, the amount to be fed in each meal and solutions to the problems of individual child and family.[16]
The community programs must be planned and undertaken by and with the community, initiated to deal with the expressed 'felt needs' of the people and within their fullest possible involvement, participation, organization and action. All efforts should be made to assist people in informing themselves of their problems and resources and in generating their own solutions.[17]
Food safety education imparted to mothers through change agents can be successfully used to bring down the prevalence of diarrhea in small children residing in urban slums along with improvements in knowledge, attitude and practices of their mothers regarding environmental sanitation, personal hygiene and feeding practices.[18]
Food Safety Education intervention imparted through change agents resulted in reduction in the prevalence of diarrhea. Improvements were found in the knowledge and practice of mothers related to etiology of diarrhea, hand washing practices, preparation and feeding of ORS. Significant impact of education was found in the fully educated mothers, which can be a result of enhanced training of mothers by the volunteers as well as the portable information offered by the leaflets and calendars.[8] After imparting food safety education for a period of about one month consisting of 5 sessions, there was a 33% reduction in diarrhea in children below 2 years of age.[19]
The community can be taught how to alter its existing practices to reduce diarrheal episodes. It has also been said that, "Showing people how to do things for themselves may take a little time but it is relatively inexpensive, sustainable and long lasting. Moreover, people are strengthened by it".[20]
References
1. World Health Organisation (WHO). The World Health Report 1998 -Life in 21st Century, A vision for all. WHO. Geneva.
2. Moterjemi Y. Research Priorities on Safety of Complementary Feeding 2000; 106: 1304-1305.
3. Kaferstein F, Abdussalam M. Food Safety in the 21st Century. Bull WHO 1999; 77(4) : 347-351.
4. Kaul M, Kaur S, Wedhwa S, Chhibber S. Microbial contamination of weaning foods. Indian J Pediatr 1996; 63(1): 79-85.
5. Kumar V, Kumar L, Diwedi P. Morbidity related to feeding pattern in privileged rural infants. Indian Pediatrics 1981; 18 (10): 743-749.
6. Singh R, Kumar OA, Rana RS. Breast feeding and weaning practices among urban muslims of District Lucknow. Indian J Pediatr 1992; 29 (2): 217-219.
7. Margaret Kosek, Caryn Bern and Richard L. Guerrant. The global burden of diarrheal disease, as estimated from studies published between 1992 and 2000. Bulletin of World Health Organization 2003; 81(3).
8. Sheth M. and Arora S. Impact of an educational intervention for the mothers of children less than 3 years of age on diarrhea prevention and its management.
Abstracts of Scientific Presentations, 9th Asian Conference on Diarrheal Diseases & Nutrition. All India Institute of Medical Sciences and the Indian Council of Medical Research. September 28-30, 2001; 84.
9. Ise T, Tanable Y, Sakuma F, Jordan U, Serrate E, Pena H. Clinical evaluation and bacterial survey in infants and young children with diarrhea in the Santa Cruz General Hospital, Bolivia. J Trop Pediat 1994; 40(6) : 369-374.
10. Hoque BA, Juncker T, Sack RB, Ali M, Aziz KMA Sustainability of water, sanitation and hygiene education project in rural Bangladesh a 5-year follow up. Bull WHO 1996; 74(4) : 431-437.
11. Motarjeni Y, Kaferstein F, Moy G, Guevedo F. Contaminated weaning food: a major risk factor for diarrhea and associated malnutrition. Bull WHO 1993; 71 (1): 79-92.
12. Khing- Maung- (U), Moy- Khin, Nyunt - Nyunt-Wai, Nyi-Win -Hman, Thein -Thein Myint and Butler T. C. Risk factors for persistent diarrhea and malnutrition in Burmese Children 11, Behavior related to feeding and hand washing. J Trop Pediatrics 1994; 40(1) : 44-46.
13. Imong SM, Rungruengthankit K, Ruangyuttikam C, Wongsawasdi L, Jackson DA, Drewett RF. The bacterial content of infant weaning foods and water in rural northern Thailand. J Trop Pediat 1989; 35: 14-17.
14. Black RE, Lopez de Romana G, Brown KH, Bazalar OG, Kanashirao HC. The incidence and aetiology of infantile diarrhea and major routes of transmission in Huascar, Peru. American Journal of Epidemiology 1989; 129(4): 189, 785-799.
15. Pinfold JV, Horan NJ. Measuring the effect of a hygiene behavior intervention by indicators of behavior and diarrhoeal disease. Transactions of the Royal Society of Tropical Medicine and Hygiene 1996; 90 (4): 366-371.
16. Bhan MK, Bhatnagar S, Behl R. Persistent diarrhea and associated malnutrition in children. Bulletin of Nutrition Foundation of India 1996; 17 (2): 1-4.
17. Jelliffe B, Derrick and Jelliffe Patrice EF. Community Action - Family Nutrition Programmes. Proceedings of a joint IUNS/ UNICEF/ICMR working conference held at the National Institute of Nutrition 1977; Hyderabad, India.
18. Sheth M, Obrah M. Diarrhoea prevention through food safety education. Indian J of Pediatr 2004; 71 : 879-882.
19. Sheth M. and Mehrotra S. Food Safety Education: A sustainable way to reduce diarrheal incidences.
Abstracts of Scientific Presentations. September 28- 30, 2001. 9th Asian Conference on Diarrheal Diseases & Nutrition. Organized by All India Institute of Medical Sciences and the Indian Council of Medical Research, New Delhi. 92-93.
20. Oshaung A, Benbouzed D, Guilbert JJ. Education Handbook for Nutrition trainers. WHO Publication 1993.(Sheth Mini, Dwivedi Reeta)
Abstract
The World Health Organization regards illness due to contaminated food as one of the most widespread health problems in the contemporary world. Food safety especially in the weaning groups is one of the major concerns that have posed a threat to health of the children. Millions of children in the world die each year from diarrheal diseases; hundreds of millions suffer from frequent episodes of diarrhea and consequent impairment of nutritional status. Contaminated foods play a major role in the occurrence of diarrheal diseases. Apart from food contamination, transmission of infection occurs by direct contact, highly favored by the habits and customs of the people. Improper storage and handling of cooked food is equally responsible for food-borne illnesses, as during storage especially at ambient temperature (28-38 oC) there is the risks of multiplication of pathogenic organisms increase. Food safety education is a critical prerequisite and is an essential element in control and prevention of diarrheal diseases. However, no preventive measures can ever be successful without the acute involvement of the caretakers, other family members and the community. To sensitize the community in a catalytic manner, health workers, community leaders and community volunteers can act as effective change agent, to bring about a behavior that can lead to improvement in their real life practices, thereby reducing the prevalence of diarrheal episodes in young children. Food Safety Education Programs that involve volunteers are cost effective as they can be reached to a maximum number of people through limited health personnels, and by this, the community can be made responsible for its own health problems.
Keywords: Weaning/complementary; Food borne pathogens; Food safety education; Diarrheal diseases
Children constitute a major proportion of the global population today. It has been reported that 10 % of the 5.8 billion people living in the world are children under 5 years of age.[1] It is estimated that annually some 1.8 million children die from the direct effect of diarrheal diseases. However, many more are affected by the effects associated with diarrheal diseases and malnutrition. It is estimated that annually some 13 million children under 5 years die in developing countries, mostly from the associated effects of malnutrition and infections.[2]
In the early stages of prenatal life, breast-feeding is an important factor contributing to child's health and well- being. In the subsequent months, breast milk is supplemented with various other foods, and the term "weaning" is used to describe this stage in a child's life. The introduction of these complementary foods represents the next critical stage in the child's nutritional progress, and it is then that the greatest incidence of diarrhea occurs because they are exposed to food-borne pathogens. Poor Environmental Sanitation and poor personal hygiene of caretakers continue to remain a leading etiological factor for diarrhea.
In spite of the constant increase in the prevention of food-borne illnesses, the Global importance of food safety is neither fully appreciated by many of the public health authorities[3] nor by the food handlers. Therefore, preventive strategies that can bring about a sustainable behavioral change in the caretaker of the young children are the need of the present time.
Complementary Foods Associated Hazards And Risk
In developed countries, the industrially prepared alternatives to home-based supplements are preferred as they are convenient, hygienic and often recommended by health workers due to their proper food value. However, in developing countries, like India, the solid and semi- solid foods prepared at home are the usual sources of nourishment for the child, as the cost of infant foods available in the market becomes unaffordable[4]. These include buttermilk, curd, dal, chapatti, rice, khichdi, mashed potato, kheer, porridge, bread, biscuits, boiled egg yolk, banana, pudding , sago, sheera , green vegetables etc.[5],[6] The incidence of diarrheal diseases especially high after weaning is initiated, because food is the medium for microbial growth; the introduction of unhygienically prepared weaning foods exposes the child to enteropathogens.
Morbidity And Mortality Related To Diarrhea
Infant Mortality Rate (IMR) and Under 5 Mortality Rate (U5MR) are regarded as a reliable and sensitive index of the total health status of a community and often used as an indicator to gauge the level of socio-economic development of a country. Diarrhea is one of the causes of morbidity and mortality among children in the developing world. For children under 5 years in developing areas and countries, there was a median of 3.2 episodes of diarrhea per child - year[7].
Pathogens associated with diarrhea
Diarrheal diseases are most commonly encountered of all the major food-borne infections table1, although enteric fevers, Brucellosis More Details, poliomyelitis, helminthic infections and other diseases are also of concern.[3] In urban slum of Baroda, several raw as well as cooked fresh and leftover weaning foods showed the presence of pathogenic organisms such as Staphylococcus aureus, Bacillus cereus, Clostridium perfringens and total Coliforms[8].
A study carried out a clinical evaluation of 211 infants and young children admitted in Santa Cruz General Hospital, Bolivia, for various types of diarrhea during 1991-1992. A peak cluster was observed in children aged 1 year, of which 80% were acute diarrhea and the remaining 20% were prolonged or chronic diarrhea. The major bacterial pathogen was enteropathogenic Escherichia More Details coli . Other bacterial pathogens such as klebsiella, Shigella, Vibro cholerae, Ancylostoma were also detected[9].
In another study the age-specific distribution of enteropathogens in young children suffering from diarrheal diseases in a hospital of urban Bangladesh was determined. A 5% systematic sample was used to examine 1207 rectal swab specimens of children aged 1-35 months with acute watery diarrhea. Variation in isolation rates of enteropathogens was observed in different age groups. Overall, Rotavirus (26%) and Campylobacter (26%) were the most common pathogens followed by enterotoxigenic E . coli (15%), Vibrio cholerae 01 (7%), other Vibrios (9%), Shigella (4%) and Salmonella More Details (<1%)[10].
Sources of food contamination and microbial proliferation
Many pathogens that cause diarrhea in humans, including V. cholerae, Shigella spp., Campylobacter, E. coli, Poliovirus, Entamoeba histolytica , can be recovered from flies and many pathogens can survive on the integument of flies for a period of 10 days. Pathogens can also be carried in the food by flies and deposited on food when they regurgitate or deposit excreta. Thus flies are a potent source of contamination in foods and water[11].
In another study it was shown that flies could transmit fecal organisms from latrines to the food contributing to the increased risk of persistent diarrhea in Burmese children.[12] In a study carried out it was shown that personal hygiene practices of mothers were significantly related to high levels of bacterial contamination of drinking water and weaning foods.[13]
Behaviors such as the child defecating on the floor, water or rags being used to cleanse the child after defecating, and mother not washing the child's hand or her hand with soap and water after defecation, or cleansing the child's perinum were directly related to higher risks of persistent diarrhea.[12]
The potential risk factors leading to diarrhea in young children were feeding leftover and overnight foods, not washing hands prior to cooking and feeding, consumption of the spilled food from the floor, use of dirty cloth for wiping hands and utensils and the use of unsterilized and dirty feeding bottles for the children.Figure1 shows the various causes of diarrhea which can lead to death in young children[8].
Strategies to reduce diarrheal morbidity and mortality
To address these diarrheal problems, well-designed programs for health education in food safety of caregivers through health workers is fundamental. The design of such programs should focus on critical control measures during food preparation and should take into consideration the sociocultural and socioeconomic factors leading to food-borne diseases. To this end, the food preparation habits of caregivers should be studied using the Hazard Analysis Critical Control Point system (HACCP) as a methodology. Furthermore, the impact and efficacy of health education interventions need to be evaluated and, if needed, be improved.[2]
Improved feeding practices, along with avoidance of animal feces and improved personal and domestic hygiene, should be considered important interventions in reducing the high incidence of diarrhea in infants in developing countries[14]. However, no preventive measures can ever be successful without the active involvement of an individual, a family and the community. In order to change a behavior in the community, a desire for a change should be created by imparting knowledge so as to develop the correct attitudes towards the health of children and thereafter bring about positive changes in behavior.
It has been found that villages show the greatest improvement in their hygiene behavior after the intervention tended to have a stronger sense of community than others and had more people actively involved in the intervention.[15] Mothers must receive nutritional counseling from the health care providers that is practical and take into account family views and realities and also include clear instructions on the frequency of meals, the amount to be fed in each meal and solutions to the problems of individual child and family.[16]
The community programs must be planned and undertaken by and with the community, initiated to deal with the expressed 'felt needs' of the people and within their fullest possible involvement, participation, organization and action. All efforts should be made to assist people in informing themselves of their problems and resources and in generating their own solutions.[17]
Food safety education imparted to mothers through change agents can be successfully used to bring down the prevalence of diarrhea in small children residing in urban slums along with improvements in knowledge, attitude and practices of their mothers regarding environmental sanitation, personal hygiene and feeding practices.[18]
Food Safety Education intervention imparted through change agents resulted in reduction in the prevalence of diarrhea. Improvements were found in the knowledge and practice of mothers related to etiology of diarrhea, hand washing practices, preparation and feeding of ORS. Significant impact of education was found in the fully educated mothers, which can be a result of enhanced training of mothers by the volunteers as well as the portable information offered by the leaflets and calendars.[8] After imparting food safety education for a period of about one month consisting of 5 sessions, there was a 33% reduction in diarrhea in children below 2 years of age.[19]
The community can be taught how to alter its existing practices to reduce diarrheal episodes. It has also been said that, "Showing people how to do things for themselves may take a little time but it is relatively inexpensive, sustainable and long lasting. Moreover, people are strengthened by it".[20]
References
1. World Health Organisation (WHO). The World Health Report 1998 -Life in 21st Century, A vision for all. WHO. Geneva.
2. Moterjemi Y. Research Priorities on Safety of Complementary Feeding 2000; 106: 1304-1305.
3. Kaferstein F, Abdussalam M. Food Safety in the 21st Century. Bull WHO 1999; 77(4) : 347-351.
4. Kaul M, Kaur S, Wedhwa S, Chhibber S. Microbial contamination of weaning foods. Indian J Pediatr 1996; 63(1): 79-85.
5. Kumar V, Kumar L, Diwedi P. Morbidity related to feeding pattern in privileged rural infants. Indian Pediatrics 1981; 18 (10): 743-749.
6. Singh R, Kumar OA, Rana RS. Breast feeding and weaning practices among urban muslims of District Lucknow. Indian J Pediatr 1992; 29 (2): 217-219.
7. Margaret Kosek, Caryn Bern and Richard L. Guerrant. The global burden of diarrheal disease, as estimated from studies published between 1992 and 2000. Bulletin of World Health Organization 2003; 81(3).
8. Sheth M. and Arora S. Impact of an educational intervention for the mothers of children less than 3 years of age on diarrhea prevention and its management.
Abstracts of Scientific Presentations, 9th Asian Conference on Diarrheal Diseases & Nutrition. All India Institute of Medical Sciences and the Indian Council of Medical Research. September 28-30, 2001; 84.
9. Ise T, Tanable Y, Sakuma F, Jordan U, Serrate E, Pena H. Clinical evaluation and bacterial survey in infants and young children with diarrhea in the Santa Cruz General Hospital, Bolivia. J Trop Pediat 1994; 40(6) : 369-374.
10. Hoque BA, Juncker T, Sack RB, Ali M, Aziz KMA Sustainability of water, sanitation and hygiene education project in rural Bangladesh a 5-year follow up. Bull WHO 1996; 74(4) : 431-437.
11. Motarjeni Y, Kaferstein F, Moy G, Guevedo F. Contaminated weaning food: a major risk factor for diarrhea and associated malnutrition. Bull WHO 1993; 71 (1): 79-92.
12. Khing- Maung- (U), Moy- Khin, Nyunt - Nyunt-Wai, Nyi-Win -Hman, Thein -Thein Myint and Butler T. C. Risk factors for persistent diarrhea and malnutrition in Burmese Children 11, Behavior related to feeding and hand washing. J Trop Pediatrics 1994; 40(1) : 44-46.
13. Imong SM, Rungruengthankit K, Ruangyuttikam C, Wongsawasdi L, Jackson DA, Drewett RF. The bacterial content of infant weaning foods and water in rural northern Thailand. J Trop Pediat 1989; 35: 14-17.
14. Black RE, Lopez de Romana G, Brown KH, Bazalar OG, Kanashirao HC. The incidence and aetiology of infantile diarrhea and major routes of transmission in Huascar, Peru. American Journal of Epidemiology 1989; 129(4): 189, 785-799.
15. Pinfold JV, Horan NJ. Measuring the effect of a hygiene behavior intervention by indicators of behavior and diarrhoeal disease. Transactions of the Royal Society of Tropical Medicine and Hygiene 1996; 90 (4): 366-371.
16. Bhan MK, Bhatnagar S, Behl R. Persistent diarrhea and associated malnutrition in children. Bulletin of Nutrition Foundation of India 1996; 17 (2): 1-4.
17. Jelliffe B, Derrick and Jelliffe Patrice EF. Community Action - Family Nutrition Programmes. Proceedings of a joint IUNS/ UNICEF/ICMR working conference held at the National Institute of Nutrition 1977; Hyderabad, India.
18. Sheth M, Obrah M. Diarrhoea prevention through food safety education. Indian J of Pediatr 2004; 71 : 879-882.
19. Sheth M. and Mehrotra S. Food Safety Education: A sustainable way to reduce diarrheal incidences.
Abstracts of Scientific Presentations. September 28- 30, 2001. 9th Asian Conference on Diarrheal Diseases & Nutrition. Organized by All India Institute of Medical Sciences and the Indian Council of Medical Research, New Delhi. 92-93.
20. Oshaung A, Benbouzed D, Guilbert JJ. Education Handbook for Nutrition trainers. WHO Publication 1993.(Sheth Mini, Dwivedi Reeta)