a world free from hidden hunger

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Biochemical and Clinical indices to assess nutritional status and response to nutritional interventions : VAD and IDD By

Dr Zeba Mahmud, Director, Micronutrient Initiative Training on Assessment of Nutritional Status 18-22 December 2011

Date : 20 December 2011, Venue: ICDDR’B

The Training is organized by the National National Food Policy Capacity Strengthening Programme (NFPCSP) . The NFPCSP is jointly implemented by the Food Planning and Monitoring Unit (FPMU), Ministry of Food and Disaster

Management and Food and Agriculture Organization of the United Nations (FAO) with the financial support of the EU and USAID.

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A world free from hidden hunger


THE HIDDEN HUNGER

Bangladesh is not in a complex nutritional emergency. Most of the malnutrition in our country is hidden and occurs on a much larger scale than can be imagined. It is not only due to lack of food as such; it has more to do with a diet which is insufficiently varied, leading to deficiency of certain micronutrients.

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The need for vitamins and minerals

Health BargainPrevent deaths

Decrease burden of diseaseAlleviate suffering

Social Development BargainEducational performance

Family and parenting impacts

Economic Development Bargain Investments in human capital

Improvements in productivity

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Micronutrient deficiencies :

decreased cognition and production

billions of dollars loss.

5% depression in GNP annually :


Needed in minute quantities but its deficiencies can cause permanent damages.

Victims of micronutrient malnutrition can suffer from intellectual impairment, growth stunting, susceptibility to infections, mental retardation, .


Needed in minute quantities but its deficiencies can cause permanent damages.

Victims of micronutrient malnutrition can suffer from poor health, low working capacity, blindness, behavioral changes, learning disabilities and even death.

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• Situation Analysis

• Benefits of Vitamin A and iodine

• Assessment

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www.micronutrient.orgCountry Overview• Health, Population, Nutrition Development Sector Program

(HPNDSP) : endorsed for 2011-16

• Development Project Proposal (2011 - 16) for Control of Iodine Deficiency Disorder (CIDD) under BSCIC, MOI is under process

• Operation plan for National Nutrition Service approved on 17 October 2011

• Age for VAS to be from 6 months instead of 9 months

• Revolving fund being utilized to procure KIO3

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www.micronutrient.orgAnalysis

Population of >148 million (estimated )child population ( 0 – 59 months) of 22 million

Child Survival:• Under five mortality : 61/1000 live births (190,000)• Clinical / sub clinical VAD: 22% (estimated)• 2 wk diarrhea prevalence: 10%BDHS 2007, NSP 2004, BSCIC, UNICEF 2006

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www.micronutrient.orgAnalysis

Child Development:• Anemia prevalence rates ( 6-59 months): 68%• IDD rates ( % with UIE below 100 ug/L): 34%

Women’s health:• Anemia prevalence rates • PLW: 49%• NPNL: 46%• VAD NPNL: 33%BDHS 2007, NSP 2004, BSCIC, UNICEF 2006

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Coverage of Key interventions Child Survival• VAS: 88%• ZnS and LO ORS: 20% diarrhoea affected children

Child Development• HH level coverage of iodized salt: 84%

Women’s Health• IFA coverage among P&LW: 55%

BDHS 2007, USI Survey 2006, GOB 2004

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Outline


• Benefits of Vitamin A and Iodine

• Assessment


Technical brief on qualitative universal salt iodization

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What is iodineA mineral needed for normal growth and development of the body. Produces thyroid hormone necessary for normal development and function of the brain and nervous system. maintains the metabolic rate and energy metabolism. Found in the mines of Chile and underground in Japan

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www.micronutrient.orgDeficiencyeffect the child even before they are born and change their adult lives. IDD of the women during pregnancy can effect both foetus and infant. Women have abortions and stillbirths. Children are born with low birth weights and permanent physical and mental birth defects. School children may have lower intelligence and More learning disabilities. It significantly reduces mental capacity and work potential.

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Iodine Deficiency Disorders

Goiters most obvious signs of IDDCretinism most serious form of IDD

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Requirement :• Children (preschool) 90 ug• Children 6 – 10 years 120 ug • Males & Females 11+ years 150 ug• Pregnant and lactating women 175 -200 ug

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Iodine deficiency disorder (IDD)

56 m people are iodine deficient 23 m have goitre (4 m visible)5 lakhs have cretinism250,000 people are mentally impaired

41,000 still births occur yearly; 33,000 infants die in the first year of life 15,000 women give birth to mentally impaired children annually.

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Why does Bangladesh have iodine deficiency

geography is the primary factor. oceans and seas that is the water are the primary sources.absorbed into the atmosphere released in the soil through rain Heavy rainfall and floods wash away large amounts of iodine leaving behind iodine deficient soil. Bangladesh is a delta for three major rivers. The flood cycle of rivers, compounded by monsoon rains, routinely leaches iodine from the soil

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But why iodize salt? Salt is a superior food for iodization

Least expensive The process requires minimal capital investment and imposes low operating expense. Every day every person everywhere in the world eats salt. Humans consume salt in a predictable range.

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IDD Elimination in Bangladesh – Salt production

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50,000 salt farmers • 70,000 acres salt production area • Process of drying up of seawater by solar heat. • 750 salt ghonas (clusters of salt beds) in the coastal

zones (i) the Chittagong – Cox’s Bazaar area, and (ii) the Sathkhira area.

• monitored by 15 salt centers of BSCIC.

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IDD Elimination in Bangladesh – Salt processing •

Annual requirement / production 850,000 MT• 295 salt factories in 8 zones set up in the 1990s

Zone wise factory

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94

31151723

48

39

Chandpur

Chittagong

Cox'S Bazar

Dhaka

Jhalokati

Khulna

Narayanganj

Patiya


20 Large factories producing >50 tons/day 96 medium factories producing 20 – 49 tons/day 91 Small factories producing <20 ton/day

30% do not operate daily50% of them are not operating for less than 1 year. 20% of them are closed since 1-5 years 26% of them are closed since 5-10 years.

IDD Elimination in Bangladesh – Status of SIP

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Means of salt transport

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IDD Elimination in Bangladesh –Iodine concentration in Salt at production level : 20-50 mg/ kg of salt (ie 20-50 ppm of iodine) to

provide 150 ug of iodine/ person / day

• In

Iodine lost is • 20% from production to household• 20% during cooking nd before consumption

• And average intake is 10 g / person / day

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IDD Elimination in BangladeshCoverage of iodized salt at household level

19 20

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67 67 70 70

81 83 84

0

20

40

60

80

100

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Iodi

zed

salt

(%)

Adequately iodized (51%)


Technical brief on Vitamin A Supplementation

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What is Vitamin AA fat soluble vitamin also known as retinal

4 major functions in the body: • maintain vision (rods and cones cell of the eye).• growth and maintenance of mucous epithelial cells

(skin, mucus membrane of mouth etc) which serve as protective barriers against infection.

• Growth and development of bone cells. • maintains the response and level of circulating cells

(T lymphocytes) that fight against infection.

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Recommended Daily intake in ug RE by age and condition (1 ug RE = 33.3 IU

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Situation Analysis

Children with night blindness: 0.03% (51,000)Pregnant women with night blindness: 2.4% (58,000)Lactating mothers with night blindness: 2.7% (78,000)

Inadequate Vitamin A in Children & women causes Increased severity to morbidity and mortality

Low health development,

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Situation analysis

VAD is not a minor problem in Bangladesh.

Children suffer consequences of inadequate vitamin A nutriture long before they suffer from night blindness

manifested by increased rates of infection, anemia, growth retardation and mortality.

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VAD and Absorption of VA : Pro vitamin A/ beta carotene from vegetable sources is 20- 50%.Preformed vitamin A from animal sources is 70% to 90%

The best source (Animal source): of Retinol/ VA is expensive

vegetables are the primary sources of vitamin A in the diet. families only consume a quarter of the vegetables needed to

meet the vitamin A requirement.

Absorption also requires intake of adequate oil/ fat and vitamin C and iron.

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Vitamin A reduces child (6-59 mo) mortality by ~23%

August 2011

In VA-deficient settings, VAS recommended in 6-59 m old

children to reduce morbidity & mortality

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Under 5 mortality has decreased significantly in Bangladesh, but One of the highest in the world : around 352 thousand U5 die annuallyneonatal & post-neonatal rates have fallen more slowly

52 48 42 45 41

3534

24 21 24

50

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3019 23

0

20

40

60

80

100

120

140

160

1989-93 1992-96 1995-99 1999-2000 2004

Year

Mor

talit

y ra

te

Neonatal mortality Post-neonatal mortality 1-4y mortality

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Outline


• Benefits of Vitamin A and iodine

• Assessment

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Questions to be answered for effective monitoring IDD control programs

Is all the salt that is being produced iodized as per requirement

Is the salt adequately iodized

Is the adequately iodized salt reaching the target

What impact is the salt iodization having on the iodine status of the population

Has it been eliminated as a public health problem

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www.micronutrient.orgIndicators

Process indicator is the iodine content of salt at the production site, wholesalers, retailers and Households

Impact indicator is to monitor the effect of salt iodization on target population and see trend

Process Impact

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Titration method can be done in any Laboratory: liberating iodine from salt and titrating with sodium thiosulphate by burette

Urinary measurement of ug/l of iodine can be done By observing colour change in spectrophotometer after mixing with ammonium persulphate or chlorate < 20 severe; 20-49 moderate; 50-99 mild and goiter by palpating or ultrasonogram among women and children

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goiter by palpating or ultrasonogram among women and childrenGrade 0 not palpableGrade 1 Palpable but not visibleGrade 2 Visible

TGR No of grades 1 and 2 divided by total examined0 -4.9% None5-19.9% Mild20 – 29.9 Moderate> 30% Severe

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To eliminate Vitamin A deficiency and its consequences

Determine

ExistenceSeverity and Extent

Of Vitamin A deficiency in the population

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Clinical symptoms like night blindness , bitot’ s spot, xerosis, keratomalacia, xeropthalmia

Dietary intake

Tissue concentration (liver and serum)< 15 ug/dl severe15 – 25 ug/dl moderate25 – 40 ug/dl marginal> 40 ug/ dl adequate

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Thank you

a world free from hidden hunger

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