Pediatric Micronutrient Pediatric Micronutrient Deficiencies, Deficiencies,

Epidemiology and Epidemiology and prevention I.prevention I.

Introduction, principles and iron deficiencyIntroduction, principles and iron deficiency

Drora Fraser

Drora FraserDrora 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.

Course Objectives: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

The “hidden hunger”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.

The status in the worldThe 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

Nutritional status in Nutritional status in populationspopulations

0

100

200

Severe micronutrient malnutrition

Nutritional status flux of populations

Nutrient overload

Which micronutrients are Which micronutrients are involved?involved?

Group A Group BIron ZincVitamin A FolateIodine Vitamin -

B12 + others

InterventionsInterventions 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

When planning an intervention: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

SupplementationSupplementation 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

Food fortificationFood 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

Dietary diversificationDietary diversification• Introduce to the diet nutrient

rich foods

• Change dietary habits

• Encourage people to grow new foods

• Increase market availability of specific foods

Iron deficiency - consequencesIron 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

Iron deficiency - definitionsIron deficiency - definitionsAge/gender Hemoglobin< hematocrit<

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

Iron deficiency & public healthIron 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 >20%

Moderate 12.0 -19.9%

Low 5.0 - 11.9%

Preferred approaches to Preferred approaches to prevention of iron deficiencyprevention of iron deficiencyIntervention Severe Moderate Mild

Supplementation Target groups General pop + + + +

+ + + +

+ +

Fortification Target foods Universal

+ + + + + +

Food based Nut. Educ. Food product.

+ + +

+ + + +

+ + + +

Public health measures to Public health measures to prevention of iron deficiencyprevention of iron deficiency

Measure severe moderate mild

Immunization ++++ ++++ ++++

Parasite cont. +++ +++

HW/S (1) +++ +++

DD/ARI (2) +++ +++

Personalhygiene

++++ ++++ ++++

Short term prevention of IDA*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)

Iron Iron deficiency deficiency

in the in the Negev, Negev,

southern southern IsraelIsrael

Anemia (%) in Negev Jewish children: Anemia (%) in Negev Jewish children: Beer-Sheva & DimonaBeer-Sheva & Dimona 1985 & 1993 1985 & 1993

0

10

20

30

40

50

60

70

BS DIM BS DIM

<10

10--11

All

1985 1993

Percent

Naggan L, Levy A, Shoham-Vardi I, 1994

N=228N=228

N=49N=49

N=100N=100 N=100N=100

Anemia (%) in Negev children Ministry Anemia (%) in Negev children Ministry of Health data infants at 1 year of age.of Health data infants at 1 year of age.

2.8

15.117.9

9.6

17.6

27.3

33.3

0

5

10

15

20

25

30

35

JC-93 BC-93 BC-96

<10 10--11 All

Percent

Hb distribution in Jewish children attending MCH* clinics for routine

vaccinations 1999

4

19

23

69

15

0

5

10

15

20

25

6-11 months 12-24 months

<10 10--11 All

n=127 n=65

PERCENT

Short term prevention of IDAShort 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

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

Food fortification e.g. ironFood fortification e.g. iron

To be considered:

Chemical composition

Stability

Bio-availability

Cost

Taste

Iron fortification that have Iron fortification that have been usedbeen used

Fish sauce NaFe EDTASugar Thailand, GuatemalaCurry powder & South AfricaCheese Amino acid chelatesWheat flour BrazilMaize flourMilk Ferrous sulphate, ammonium

citrateSoybasedformulae

Pyrophosphate, Vitamin Cadded

Community studies: ThailandCommunity 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.

Community studies: IndiaCommunity 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 >90% Urban: Women 30%, men <7%

Community studies: Venezuela 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

Cost effectiveness of iron Cost effectiveness of iron fortificationfortification

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

Conclusions - iron deficiencyConclusions - iron deficiency

• Iron deficiency is common worldwide• It’s 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