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
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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 Bargain
Prevent deaths
Decrease burden of disease
Alleviate suffering
Social Development Bargain
Educational 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 :
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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,
.
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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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Country Overview
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• 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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Analysis
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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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Analysis
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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
• Situation Analysis
• Benefits of Vitamin A and Iodine
• Assessment
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Technical brief on qualitative
universal salt iodization
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What is iodine
A 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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Deficiency
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effect 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 IDD
Cretinism most serious form of IDD
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Requirement :
• Children (preschool)
• Children
6 – 10 years
• Males & Females 11+ years
• Pregnant and lactating women
90 ug
120 ug
150 ug
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 cretinism
250,000 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
•
•
•
•
•
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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Chandpur
Chittagong
25
48
Cox'S Bazar
94
Dhaka
Jhalokati
Khulna
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17 15
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Narayanganj
Patiya
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IDD Elimination in Bangladesh – Status of SIP
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 daily
50% 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.
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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 Bangladesh
Coverage of iodized salt at household level
81
83
84
2004
2005
2006
100
80
67
70
70
60
Adequately
iodized
(51%)
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20
19
20
1994
40
1993
2003
2002
2001
2000
1999
1998
1997
1996
0
1995
Iodized salt (%)
67
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Technical brief on Vitamin A
Supplementation
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What is Vitamin A
A 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%
In VA-deficient settings, VAS
recommended in 6-59 m old
children to reduce morbidity &
mortality
August 2011
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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 annually
neonatal & post-neonatal rates have fallen more slowly
Neonatal mortality
Post-neonatal mortality
1-4y mortality
160
140
120
Mortality rate
50
37
100
30
80
35
60
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23
24
21
24
42
45
41
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40
20
52
48
35
0
1989-93
1992-96
1995-99
1999-2000
2004
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Outline
• Situation Analysis
• 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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Indicators
Process
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Impact
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
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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 children
Grade 0 not palpable
Grade 1 Palpable but not visible
Grade 2 Visible
TGR No of grades 1 and 2 divided by total examined
0 -4.9% None
5-19.9% Mild
20 – 29.9 Moderate
> 30% Severe
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To eliminate Vitamin A deficiency and its consequences
Determine
Existence
Severity 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 severe
15 – 25 ug/dl moderate
25 – 40 ug/dl marginal
> 40 ug/ dl adequate
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Thank you
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