Pediatric Micronutrient Deficiencies, Epidemiology and prevention I. Introduction, principles and iron deficiency Drora Fraser

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Pediatric Micronutrient Deficiencies,
Epidemiology and prevention I.Introduction,
principles and iron deficiencyDrora Fraser
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Drora Fraser

• Director of the S. Daniel Abraham International
  Center for Health and Nutrition, Ben-Gurion
  University of the Negev (BGU), Beer-Sheva,
  Israel.
• Member of the Epidemiology and Health Services
  Evaluation Department, Faculty of Health
  Sciences, BGU.

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Course Objectives

• To familiarize the students with the extent of
  the problems of micronutrient deficiencies
  worldwide
• 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 situation

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The hidden hunger

• Millions of people suffer and may die from lack
  of minute traces of nutrients. Methods of
  prevention are cheap and simple. Their universal
  application could yield health and economic
  benefits comparable to those achieved by the
  smallpox eradication.
• Dr. V. Ramalingaswami, Chair, LTNDP task force
  on health research and development, End hidden
  hunger conference, Montreal, Canada, October 1991.

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The status in the world

• Deficiencies of iron, Vitamin A and iodine are
  highly prevalent
• 1/3 of the human race is affected and is at
  increased risk of death, disease or disability
• Deficiencies disproportionately affect
  vulnerable groups
• Deficiencies damage human capital and national
  economic development

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Nutritional status in populations

• Nutritional status flux of populations

Severe micronutrient malnutrition
Nutrient overload
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Which micronutrients are involved?

• Group A Group B
• Iron Zinc
• Vitamin A Folate
• Iodine Vitamin - B12
• others

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Interventions

• There are options for effective interventions
• Supplementation
• Food fortification
• Dietary diversification
• Public health measures such as parasite and
  diarrheal disease control, improve sanitation and
  hygiene

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• When planning an intervention
• Incorporate knowledge of factors such as
  location and clustering, severity, prevalence and
  multiple causes of deficiencies
• Take account of the level of country development
  and ability to implement and sustain the
  intervention
• Set in place continuous monitoring and feed back
  mechanisms
• Incorporate flexibility to be able to respond to
  monitored changes

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Supplementation

• The method of choice when treatment is needed
  i.e. to address the problem of severe
  micronutrient deficiency
• Can be used as a preventive measure by targeting
  groups at high risk
• Has been shown to be a cost-effective approach
• Most efforts to control Vit A and iron
  deficiencies used this method

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Food fortification

• Is not appropriate for therapeutic measures
  (except for iodized salt)
• Requires active participation of the food
  industry
• Requires intervention by governmental agencies
  for regulating levels of fortification and foods
  to be fortified
• Requires ongoing monitoring

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Dietary diversification

• Introduce to the diet nutrient rich foods
• Change dietary habits
• Encourage people to grow new foods
• Increase market availability of specific foods

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Iron deficiency - consequences

• Impaired physical growth
• Compromised cognitive development
• Impaired learning capacity
• Reduced muscle function
• Decreased physical activity and lower work
  productivity
• Lowered immunity
• Increased risk of infectious disease

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Iron deficiency - definitions

• Age/gender Hemoglobinlt hematocritlt
• g/l mmol/l
  l/l
• child 6M-5Y 110 6.83 0.33
• 5-11Y 115 7.13 0.34
• 12-14Y 120 7.45 0.36
• women 120 7.45 0.36
• pregnancy 110 6.83 0.33
• men 130 8.07 0.39

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Iron deficiency public health

• Iron deficiency prevalence in a population is
  2 to 2.5 times the rates of anemia.
• Category of public Prevalence of
• health importance anemia in risk gp.
• High gt20
• Moderate 12.0 -19.9
• Low 5.0 - 11.9

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Preferred approaches to prevention of iron
deficiency
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Public health measures to prevention of iron
deficiency
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Short term prevention of IDA

• In infancy
• Avoid gestational ID
• Try to prevent premature delivery and low birth
  weight
• Increase birth spacing
• Delay pregnancy beyond teens
• Delay ligation of umbilical cord (by 30-60
  seconds)

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Iron deficiency in the Negev, southern Israel
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Anemia () in Negev Jewish children Beer-Sheva
Dimona 1985 1993
P e r c e n t
N49
N228
N100
N100
Naggan L, Levy A, Shoham-Vardi I, 1994
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Anemia () in Negev children Ministry of Health
data infants at 1 year of age.
P e r c e n t
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Hb distribution in Jewish children attending MCH
clinics for routine vaccinations 1999
PERCENT
n127 n65
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Short term prevention of IDA

• In children and adolescents
• Give preventive iron supplementation
• Institute parasite and malaria control where
  needed
• Periodic de-worming, where needed
• General vitamin and mineral fortification of
  school meal programs

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Sustainable approaches to elimination of
micronutrient deficiency e.g. iron

• Iron fortification of foods, foods in the target
  group
• Foods consumed regularly
• Consumed in sufficient quantities
• Consumed in stable amounts
• Centrally processed foods
• Foods that are easy to fortify

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Food fortification e.g. iron

• To be considered
• Chemical composition
• Stability
• Bio-availability
• Cost
• Taste

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Iron fortification that have been used
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Community studies Thailand

• Fish sauce fortified with NaFeEDTA to 0.5-1 mg
  iron/ml. Average per capita consumption 10-15
  ml/day. Should provide 0.4 mg absorbable iron.
• Trial was in 2 villages
• In the trial village, anemia rates were reduced.

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Community studies India

• 7,000 persons used iron fortified salt
• 7,000 persons used regular salt
• Several locations Rural I anemia rates
• 98-53 young children
• 23-9 in older children
• 77-32 in adults
• Rural II all ages anemia gt90
• Urban Women 30, men lt7

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Community studies Venezuela

• Increased in anemia seen between 1989-90 and
  1992
• Prevalence measured in 7, 11 and 15 year old
  children
• Iron deficiency increased from 13.5 to 30.5
• Anemia increased from 3.6 to 19.0.
• February 1993, started fortification of maize
  flour and white wheat flour with ferrous fumarate

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Cost effectiveness of iron fortification

• Fortification Place Cost(1) Protect(2)
• Salt A 0.12 0.12
• Flour B 0.16 --
• Sugar C 0.12 0.12
• Sugar D 1.00 1.00
• Tablets E 3.2-5.3 3.2-5.3

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Conclusions - iron deficiency

• Iron deficiency is common worldwide
• Its consequences are far reaching
• Effective measures are available
• Supplementation has been successfully used in
  various populations
• Fortification has been successfully implemented
  in various locations using different foods
• The programs were cost effective