Pediatric Micronutrient Deficiencies, Epidemiology and prevention II. Vitamin A and iodine Drora Fra - PowerPoint PPT Presentation


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Pediatric Micronutrient Deficiencies, Epidemiology and prevention II. Vitamin A and iodine Drora Fra


To familiarize the students with the extent of the ... To understand the implications of those problems ... 3 million children have xerophthalmia ('dry eyes' ... – PowerPoint PPT presentation

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Title: Pediatric Micronutrient Deficiencies, Epidemiology and prevention II. Vitamin A and iodine Drora Fra

Pediatric Micronutrient Deficiencies,
Epidemiology and prevention II. Vitamin A and
iodine Drora Fraser
Drora Fraser
  • Director of the S. Daniel Abraham International
    Center for Health and Nutrition, Ben-Gurion
    University of the Negev (BGU), Beer-Sheva,
  • Member of the Epidemiology and Health Services
    Evaluation Department, Faculty of Health
    Sciences, BGU.

Course Objectives
  • To familiarize the students with the extent of
    the problems of micronutrient deficiencies
  • To understand the implications of those problems
  • Using the models of micronutrient interventions
    studied, learn the possible methods available and
    judge their applicability to their own specific

Prevalence of Vitamin A
  • Around the world
  • 250 million children vitamin A deficient (serum
    retinol lt0.70 ?mol/l)
  • 3 million children have xerophthalmia (dry
  • Areas with high rates of night blindness in
    children also have high rates of night blindness
    in mothers

Vitamin A deficiency consequences
  • Night blindness - ancient Egypt, Greek and
    Assyrian medical literature
  • Early deaths
  • High rates of respiratory and diarrheal diseases
  • Affects immunocompetence
  • Cured with animal and fish liver or plants with
    green and yellow pigments

Risk factors for VAD
  • Age
  • Diet
  • Disease
  • Seasonality
  • Culture
  • Clustering

VAD status
Death Hepatotoxicity Bone fracture Hemorrhage Ecze
Vit A level
Night blindness Xerophthalmic keratinization Death

Vit A intake µg/kg body weight
Public Health indicators of VAD and its
Ecological indicators of VAD
Illness related indicators for 6-71 month old
Preferred approach to prevention of VAD -1
Preferred approach to prevention of VAD-2
Nutrition intervention programs
  • Critical elements for successful programs are
  • Political commitments
  • Community mobilization participation
  • Human resources development
  • Targeting
  • Monitoring, evaluation management information
  • Replicability and sustainability

Dietary modification for VAD
  • Ex. Where food sources of vitamin A are
  • Thailand VAD in preschool children, pre-clinical
  • Animal foods expensive
  • Fruits are seasonal
  • Ivy gourd-underutilized, low esteem

Dietary modification for VAD
  • Ex. Home and community provision of vitamin A
    rich foods
  • Bangladesh gardening projects-women
  • High night blindness despite bi-annual
    supplementation programs
  • Low cost gardening techniques
  • Innovative resources, locally adapted

Fortification of VAD
  • EX. Guatemala sugar fortification
  • Low serum retinol levels
  • Low dietary intake of vitamin A
  • Sugar usually refined
  • Sugar consumed within a narrow range of daily
    intake across age groups
  • In 1970, sugar was fortified with vitamin A,
    program very successful (Arroyave, 1979 PAHO

Vitamin A supplementation
  • High dose vitamin A supplementation has been
    used in various countries
  • Need high coverage gt65 of population
  • Repeat delivery every 4-6 M required
  • Repeat delivery difficult to maintain
  • Easiest to integrate with other health care

Vitamin A supplementation
  • High dose vitamin A supplementation
  • EX Brazil
  • North Eastern Brazil
  • High rates of malnutrition
  • Animal food sources rare expensive
  • Cultural aversion to use of green leafy
  • Require volunteers, community involvement

Cost effectiveness of VAD preventive programs
Vitamin A deficiency - summary
  • Vitamin A deficiency is highly prevalent
  • It has severe consequences especially in the
  • Supplementation, fortification and dietary
    changes have all been used successfully to reduce
    its prevalence
  • The cost of the programs is not high if
    integrated into existing child care services

Iodine deficiency (ID)
  • Iodine must be obtained from the environment
  • Thyroid hormones, thyroxin and triiodothyronine
    (T4 T3) contain 4 and 3 iodine atoms,
  • Adults need 100-150 ?g/daily
  • Children require less in total, but more per Kg
    body weight

Iodine deficiency consequences
  • The following are affected by iodine deficiency
  • Thyroid size enlargement (goiter)
  • Mental and neuromotor abilities
  • Reproductive results
  • Physical growth

Consequences of ID
  • Neuromotor and cognitive impairment are the most
    important effects of ID
  • Where ID is severe and mothers have severe ID,
    endemic cretinism is found
  • results include
  • cognitive impairment
  • learning, speech deficits
  • psychomotor problems

Consequences of ID
  • Reproductive effects
  • Rates of reproduction may be lower
  • Fetal and postnatal survival lower
  • Motor performance in childhood impaired
  • Iodine correction in a group of Chinese
    communities doubled the neonatal survival rates
  • Other effects

Consequences of ID
  • Economic effects
  • no clear evidence available
  • ID results in lowered energy, lowered learning
    capacity, increase burden of fetal and postnatal
    mortality probably interfering with social
  • Physical growth
  • Hypo-thyrodism retards growth and development

Over- correction of ID
  • When ID is severe and there are are thyroid
    nodules in ID persons, and when iodine treatment
    is introduced without appropriate control and
    monitoring, a fraction of the population will
    develop thyrotoxicosis.

ID prevalenceassessment methods
  • Goiter rates ()
  • Classification of goiters into grades 0, 1 and 2
  • ID suspected when gt5 of school age children
    have grade 1 or 2 goiters
  • Urinary iodine ()
  • Can define individual status
  • Used to define population status
  • Used to monitor interventions

Prevention of ID - fortification
  • Salt fortification
  • Unique in micronutrient supplementation as no
    dietary changes required
  • Fortified product more expensive
  • Social marketing to create demand
  • Mass media campaigns
  • Universal salt iodization is the goal
  • Level of fortification 25-50 mg iodine/Kg

ID prevention-supplementation
  • Drops and tablets
  • Original study showing that iodine prevents
    goiter used sodium iodide tablets given to school
    children twice per year
  • Lugols solution also used in classrooms
  • Iodinated oil
  • Iodinated poppy seed oil - New Guinea
  • Intra-muscular or oral routes
  • Well accepted
  • Costly due to delivery teams required

ID National Programs
  • Ecuador
  • 1957-58 National survey showed high prevalence
    rates of goiter and cretinism
  • 1984 joint enterprise between government and
    Belgium government agencies started
  • Local trained teams
  • Data collection systems

ID National Programs
  • Nigeria
  • Moderate deficiency
  • All salt imported, 3 companies
  • The largest company reported that by 1995, 97
    of salt was iodized
  • The company promoted the iodized salt sale

ID National Programs
  • Bolivia
  • Landlocked country
  • 1981 survey showed goiter prevalence of 68.1
  • National program started with the formation of a
    government agency in early 1980s
  • Help provided by the Italian govt.
  • Iodinated oil used to reach gt1.4 million persons

ID National Programs
  • Europe and North America
  • Iodized salt universally available
  • Mass media campaign
  • Medical education
  • Nutrition education
  • Cooperation of industry
  • Iodine deficiency nearly non existent

Iodine deficiency - summary
  • Iodine deficiency occurs in geographic clusters
  • It results in severe mental and physical
  • It can be virtually eliminated by national
    supplementation programs
  • Correction of ID should be performed with close
    monitoring to prevent adverse reactions