Ibrahim Khatib

1
Nutrition in Jordan Facts and Uncertainties

• Ibrahim Khatib

2
PrologueNutrition a Global Challenge

• 10 million U5y - deaths /y in the developing
  world
• 7.3 million ( ¾) preventable deaths
• 53 are undernutrition - related
• causative factors include
• Pneumonia
  19
• chronic diarrhea
  18 ,
• newborn blood infection / pneumonia 10 ,
• preterm delivery
  10 ,
• asphyxia at birth
  8 ,
• malaria
  8
• Others
  27 .
• Year 2005 WHO Report, (cited in The Lancet,
  March 26, 2005 issue)

3
UnderNutrition Facts

• The most common health problem in developing
  countries
• Even in milder forms can weaken the immune system
• Increases attacks - frequency and severity - of
  diarrhea ARI
• At global level, underlies 60 of childhood
  mortality
• Causes are
• 1. Direct -
  inadequate access to food
• -
  inadequate intake of micronutrients,
  
• 2. Indirect- inadequate
  health care of mothers and children,
• -
  inadequate health services, and
• -
  unhealthy environments / poor hygiene
• Robert E Black, Saul S Morris and Jennifer
  Bryce. Where and why are 10 million children
  dying every year? (review).The Lancet, June
  2003. Vol. 3612226- 2234 pp

4
Jordan
5
Jordans Nutrition The Public Health Concerns

• Diet related degenerative diseases (among adults)
  
• Nutritional Deficiencies (among risk groups)

6
Diet Related Adulthood Problems

• Type 2-diabetes
• prevalence among adults 20
• CVD Cardio-Vascular Disease
• prevalence is on the rise
• Obesity has the fastest-growing rate

7
The Combat Partners and Roles

• Leading Role MOH Nutrition
  Division
• Complementary Role University Academics
• Supportive Role International
  organizations

8

• Domestic Reports
• From a Historic Perspective

9
Early 1960sEarly Discovery of VAD in Jordan

• First survey 1
• - sponsored by the WHO carried out in
  1963,
• - a clinic based interventional study
• - subjects young children admitted to
  hospitals
• - criteria ocular signs of
  xerophthalmia.
• Second survey 2
• The Jordan Paediatric Study, 1964
• - joint ICNND , ICNJ
• - a community based non-interventional
  study
• - subjects children
• McLaren DS, Shirajian E, Tchalian M, and Khoury
  G. Xerophthalmia in Jordan. Am J Clin Nutr 1965
  17 117-130.
• The Interdepartmental Committee on Nutrition for
  National Defense, and the Interdepartmental
  Committee on Nutrition for Jordan.
• The ICNND-ICNJ nutrition survey on
  infants and preschool children in Jordan
  (1962-63). US Government Printing Office, 1964.

10
Early 1960s1st Report on Xerophthalmia

• gt 300 xerophthalmic children / year
• Mean serum retinol (SRC) 55 µg/l
• McLaren DS, Shirajian E, Tchalian M, and
  Khoury G. Xerophthalmia in Jordan. Am J Clin
  Nutr 1965 17 117-130.

11
Early 1960s2nd Report on Xerophthalmia

• Proportion of U5y- children with mean
• SRC below 200 µg/l 37.
• The Interdepartmental Committee on Nutrition for
  National Defense, and the Interdepartmental
  Committee on Nutrition for Jordan. The ICNND-
  ICNJ nutrition survey on infants and preschool
  children in Jordan (1962-63). US Government
  Printing Office, 1964.

12
After 1965 VAD in Jordan Became a Forgotten
Risk

• Following the 1960s reports, concern in VAD
  risk faded !
• 35 years elapsed before non-ocular VAD could be
  re-discovered

13
1970s 1980s Growth Deficiency, Anemia and
Breast Feeding

• Anthropmetric reports on child growth deficits
• Special focus paid to anemia in infancy and its
  association with breast feeding practice

14
Early 1990s Stunting Zinc Deficiency The
JUST Project in North Jordan 1991-1994

• Area North Jordan 18 rural locations randomly
  selected.
• Subjects 6-24 months - children
• Stunting 16 , and anemia 40 .
• Supplements baby rusks
• Rusks fortified with zinc / or zinc iron /
  plain rusks
• Zinc/iron-intervention prevented only some infant
  growth declination.
• Conclusion
• Other micronutrients, such as iodine and vitamin
  A may be deficient.
• This fitted with the The World Summit For
  Children - The Nutrition Related Recommendations
  - Goals for the year 2000

15
Deficiency Surge
Inadequacy
(1) Store/ Pool Depletion
(2) Physio-Metabolic Changes
(3) Growth Immunity Impairments (e.g.,
non-Ocular VAD)
(4) Clinical Manifestations (e.g., Ocular VAD
Xerophthalmia)
DEATH
16
VAD, IDA, IDD International Reports
Reduced Learning Capacity Intellect Populatio
n loss estimate 1015 I.Q. points
Slow Community Development
17
1995IDD Baseline Survey

• Results
• mild to moderate IDD problem
• Prevalence 37 (in age group 8- years)
• Action enforcing a universal salt iodination
  program

18
1997VAD Un-tackled Question

• Is VAD a hidden culprit and thus involved in the
  growth curve declination that starts at
  mid-infancy ?

19
VAD Clustering

• VAD hits specific regions within the high-risk
  country
• VAD concentrates within high-risk families
  communities
• IVACG Statement on VAD

20
Non-ocular VAD Recognizing the Immediate
Impact

• growth development
• Immunity
• Vulnerability to ill health
• Predisposition to IDA
• Vision acuity
• Skin and epithelia

• faltering
• depressed (infections / diarrhea ARI)
• increased
• enhanced
• impaired
• roughen / dry

21
1997MOH - Pilot Trial

• Design
• Convenient (well-located) sample of U5y
  children
• Results
• 35 at risk of VAD (SRC lt 250 µg/L).
• Conclusion
• Launching a well designed study is warranted
  .

22
1999 The School Snack Program, SSP

• Onset initiated on tentative basis ( 1
  year program)
• Snack iron fortified biscuit (70 gram)
  
• fresh milk (100ml)
• one season fruit
• Sponsor Minstry of Planning / the Social
  Security Package
• Sites hamlets of 8 underprivileged
  governorates
• Locations elementary governmental schools
• Recipients young pupils aged 5.5-10 years
• Duration continued through the scholastic
  years
• September 1999 May 2000
• September 2000 May 2001
• September 2001 May 2002
• Still going on

23
1999 - 2002 The Launching of the Two MOE
School Surveys

• Justification
• The baseline / impact assessments of the SSP

24
1999-2000 MOE- 1st School Survey Study of the 7
Underprivileged Districts

• Baseline Prevalence
• - VAD 21.8
• - stunting 19.9
• - anemia 18.8
• Supplement daily mid-morning snack
• 1 time vitamin A
  capsule
• Except on stunting, intervention made a
  difference
• Conclusion
• VAD in poor school children may be a public
  health issue.

25
2001-2002 MOE- 2nd School Survey - Part
1Study of the 8 Underprivileged Districts

• Approach interventional study .
• Target Areas poorest - remote villages of 8
  disadvantaged districts.
• Supplement daily snack meal one vitamin A
  capsule
• Intervention included a Nutrition Education
  Campaign
• VAD prevalence 32.9
• Conclusion
• VAD among poor school children is a public health
  problem

26
2001-2002 MOE- 2nd School Survey - Part 2
Al-Saafi Study

• Approach controlled interventional study (3
  study groups)
• Study Area poor Ghor villages (AlSaafi)
• VAD prevalence 35.3
• Effective supplementation daily snack the VA
  capsule
• Conclusion
• A National Vitamin A Program in Jordan should
  phase in.

27
December 2002 The Royal Philanthropic
Gratuity-1

• The Royal Philanthropic Gratuity developed after
  a royal visit of King Abdullah II to the MOE and
  knowing of the VAD story
• The king expressed his wish to see
  vitamins/minerals tablet supplements reaching
  all school children.
• Multivitamin/mineral tablet supplementation
  started early 2003

28
2002North Badia Survey

• Population U5y Beduin children
• Prevalence rates of
• stunting 20
• anemia 19
• non-ocular VAD 22

29
May, 2002 The Wheat Flour Fortification

• The Nicosia - EMRO Workshop in February, 2002
• National- wheat flour- fortification program May,
  2002
• Fortificants iron and folate

30
Early 2003Jordan Population and Family Health
Survey DoS-DHS

• Anemia prevalence in children
• 34 in the U5y
• 65 in age group 10-11 months

31
Early 2003 MOH National Nutrition Study (U5y
Children)

• Anemia 20.1 .(Hb lt11 g/dl)
• Iron deficiency (ID) 26.1
• Iron deficiency anemia (IDA) 10.1
• VAD prevalence 15.2

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2003 NNS VAD Prevalence by Age
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Early 2003NNSWomen in the child bearing age

• Anemia gt 30 (Hb lt12
  g/dl)
• Iron deficiency (ID) gt 40 (low ferritin)
• ID anemia gt 20 (low Hb
  ferritin)

37
West Bank Gazza - Nutrition Survey, 2003A
Meaningful Finding

• Population U5y children
• VAD Prevalence 22

38
Evidences on Regional Vitamin A - Low Levels
39
Adapted from the Palestine Vitamin A Deficiency
Survey Among U5y-children. Maram Project-draft
report. May 2004.
40

• End Points

41
Undernutrition in the ME Ongoing Misconception

• Recognition of undernutrition in the East
  Mediterranean countries as a community-threatening
  risk is still inadequate.
• Planners have little recognition that no single
  developing community may claim to be off the
  hook of malnutrition.
• It is not fully clear to all those concerned that
  undernutrition particularly strikes at the high
  risk groups level.
• International scientific bodies / expertise can
  play a key role to help bridging the awareness -
  gap between the concerned native parties the
  who know and who do not know .

42
2005 The Royal Philanthropic Gratuity-2

• HM King Abdulla II expressed his wish to see the
  SSP extending so that it reaches to all young
  school children.
• Vitamin/mineral fortified biscuits shall be
  replacing the Multi-VM tablet supplements
  starting from January 2006.

43
DEPARTMENT OF HEALTH HUMAN SERVICES
Public Health Service _________________
__________________________________________________
__________________________________________________
_______________________________

Centers for Disease Control and
Prevention (CDC)

Atlanta GA 30341-3724

• February 28, 2005
• Dr. Ibrahim Khatib,
• Lab. 9
• Jordan
• Dear Dr. Khatib
• The Nutrition Laboratory at the Centers for
  Disease Control and Prevention (CDC) in Atlanta
  would like to thank you for your participation in
  the VITamin A Laboratory-External Quality
  Assurance (VITAL-EQA) program as part of the CDC
  International Micronutrient Malnutrition
  Prevention and Control (IMMPaCt) program. As you
  know, the goals of the VITAL-EQA program are to
  help laboratories maintain and improve the
  quality of their serum vitamin A measurements and
  to assure that there are a few laboratories in
  each region of the world that can reliably
  perform serum vitamin A measurements for
  nutrition surveys for public health assessments
  and research studies.
• We are sending this letter to you to inform you
  of your excellent performance in Round 1 (Fall
  2003), Round 2 (Spring 2004), and Round 3 (Fall
  2004). We appreciate your participation and look
  forward to similar results in future rounds.
• If you should have any questions, please dont
  hesitate to contact us at vitaminalab_at_cdc.gov or
  contact Bridgette Bowen at MHBowen_at_cdc.gov,
  770-488-4304, or fax at 770-488-4139.
• Sincerely,
• Bridgette M. H. Bowen
• Chemist/Technical Analyst
• Mail Stop F-18

44
VAD IDA the Social Components

• VA status and anemia always correlated with
• Maternal nutrition education
• Consumption of animal based food
• Socio-economic status

45
Front line - MCH - Service Providers.
not adequately trained to promote ..

• exclusive breast-feeding,
• complementary feeding,
• diet during pregnancy,
• vitamin A and IFA supplements,
• training of community volunteers .

46
In JordanMNDs are No Longer a Hidden Hunger

• s-PEM is common MNDs are major causes
• Stunting remains the devious face of s-PEM
• Vitamin A, Iron, and Zinc deficiencies endemic
• Anemia due to IDA and / or VAD prevalent

47
Ongoing Combat

• Programs
• Iodination of Table Salt (1996)
• Wheat Flour Fortification (Iron and Folic
  acid May 2002)
• Monitoring
• MOH - Nutrition Division
• Activity Support
• Goverment
• International Organizations

48
2005The National High Commission on Nutrition
in Jordan

• Recommendation
• Jordan needs switching from tablet supplement
  distribution to food (flour) fortification to
  secure higher coverage for other risk groups
• Pitfall
• Consideration of the need for before / after
  assessments is weak

49
Urgent Ambitions

• Checking whether VAD affects women in
  reproductive age
• Eliminatation of VAD as a health risk factor
• Only lt 5 of the age group 6-71 months to have
  low serum retinol (lt 0.70 µmol/L)
• Exploration of unrecognized MNDs
• There is an immediate need for studying the B12
  status

50
Public Health Care Strategy Domains

• Prevention of health risks and diseases to
  sustain healthier lives of families.
• Preparedness for responding to emergencies, such
  as epidemics.
• The elimination of HC - social disparities by
  focusing on underprivileged areas.
• Provision of higher level care to all the
  population groups at reasonable cost.

51
The HCST - Health Priorities

• Public health / Health care problems / Common
  diseases
• Fertility problem
• Non-epedimic diseases
• Genetics
• Diagnostic techniques
• Environmental health
• Oral and dental health
• Fronteirs technologies in medicine
  (Bio-Nano)/combating cancer

52
Health Priorities Fulfillment Tools

• Inadequate research
• Limited capacity in budgeting programs
• Low health / nutrition literacy

53
Policies and Child Nutritional Poblems

• A nutritional disorder is more than an
  individuals health issue
• It should be recognized as leading to disfunction
  in
• Social, Demographic, Cultural sectors
• economy - decreased manpower productivity
• - burden on
  health care system
• Nutrition Surveillance System (NSS) is a need
• Strategic Resources
• - Qualified Health-Manpower
• - Efficient MCH-Care Centers
• - Sustainable Flow of supplements

54
Needs of Public Health

• There is no need for building fancy hospitals
• Building a delivery system that reaches the
  community is a strategic need
• The first tool is capacity building and training

55
Thank You
56
MNDs Significance in Childhood

• Frequent diarrheas and infections / suppressed
  immunity
• Stunting / Subnormal child growth pattern
• Low IQ / compromised cognitive development
• Poor performance / school achievement
• Weak muscles / decreased work potential
• Anemia / reduced physical and mental potential
• Increased risk of death

57
MNDs Selected Outcomes

• Iodine Deficiency Disorders (IDD)
• Goiter
• Cretinism
• - mental deficiency
• - Physical anomalies
• IDA
• Anemia
• Poor Learning
• Non-ocular VAD
• Depressed immunity infections / diarrhea
  ARI
• Physical growth deficiency
• Predisposition to IDA
• Ends with visual impairment / Nutritional
  blindness

58
Domestic Research References

• Khatib I, and Hijazi S. JUST-Percentiles a
  cross-sectional study of the declination
  observed in the Jordanian child growth curve and
  its association with the local patterns of infant
  weaning. Jordan University of Science
  Technology (JUST)-Publications,1992, Irbid-Jordan
  .
• Khatib I, Hijazi S, and Aggett P. A longitudinal
  -interventional-study of the impact of zinc
  fortified weaning food on linear growth of
  infants in northern Jordan.The Higher Council for
  Science and Technology Publications,1995,
  Amman-Jordan.
• The IDD National Committee Iodine Deficiency in
  Jordan,1995 . A national baseline study. Report
  of UNICEF office-Amman, 1995.
• The IDD National Committee Iodine Deficiency in
  Jordan, 2000. A national baseline study. Report
  of UNICEF office-Amman, 2000.
• Khatib I. High prevalence of subclinical vitamin
  A deficiency in Jordan a forgotten risk Food
  Nutr Bull., September 2002, 3 23 (Supp.
  228-236).
• Khatib I and Hijazi S. Poverty Linked vitamin
  A deficiency (VAD) in Jordan is endemic and
  coupled with compromised vitamin E Status. ( A
  report submitted to the MOE in 2002 currently
  under-modification for publication ).
• Khatib I . Supplementation with vitamin A
  capsules along with iron fortified school meals
  can have positive impact on the growth of young
  school children a controlled trial. (An abstract
  to be orally presented in the X Auxology Congress
  , Florence-Italy , July 4-7, 2004)
• Khatib I and Hijazi S. Nutritional status of the
  under 5 years beduin children. A study report
  submitted to the sponsor the Jordanian Badia
  Development Program, December 31,2003 .
• Department of Statistics. The 2002 Jordan
  Population and Family Health Survey. The ORC
  Macro Publications,2003.
• The National Committee on Micronutrients. The
  year 2003 National Nutrition Study of Anemia
  and VAD . MOH . (report in press).

59
VAD - Grading System

• Clinical
• Serum Retinol Concentration (SRC_ µg / L )
• gt 300 normal
• 300-201 borderline
• 200-101 deficient
• lt 100 severely deficient (Clinical
  Emergency)
• Community
• VAD Prevalence
• lt 5 acceptable
• 5 - lt 10 mild
• 10 - lt 15 moderate
• gt 15 severe (Public Health Problem)