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Assessing Nutritional Status and Response to Interventions
- 1. 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. www.micronutrient.org
- 2. www.micronutrient.org A world free from hidden hunger 2
- 3. 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. www.micronutrient.org
- 4. www.micronutrient.org 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 4
- 5. www.micronutrient.org Micronutrient deficiencies : decreased cognition and production billions of dollars loss . 5% depression in GNP annually : 5
- 6. 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, . www.micronutrient.org
- 7. 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. www.micronutrient.org
- 8. www.micronutrient.org • Situation Analysis • Benefits of Vitamin A and iodine • Assessment 8
- 9. Country Overview www.micronutrient.org • 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 9
- 10. Analysis www.micronutrient.org 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 10
- 11. Analysis www.micronutrient.org 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 11
- 12. www.micronutrient.org 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 12
- 13. www.micronutrient.org Outline • Situation Analysis • Benefits of Vitamin A and Iodine • Assessment 13
- 14. Technical brief on qualitative universal salt iodization www.micronutrient.org
- 15. www.micronutrient.org 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 15
- 16. Deficiency www.micronutrient.org 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. 16
- 17. www.micronutrient.org Iodine Deficiency Disorders Goiters most obvious signs of IDD Cretinism most serious form of IDD 17
- 18. www.micronutrient.org Requirement : • Children (preschool) 90 ug • Children 6 – 10 years 120 ug • Males & Females 11+ years 150 ug • Pregnant and lactating women 175 -200 ug 18
- 19. www.micronutrient.org 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. 19
- 20. www.micronutrient.org 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 20
- 21. www.micronutrient.org 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. 21
- 22. www.micronutrient.org 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. 22
- 23. www.micronutrient.org 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 Chandpur Chittagong 39 25 Cox'S Bazar 48 Dhaka 94 Jhalokati Khulna 23 17 15 Narayanganj 31 Patiya 23
- 24. 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. www.micronutrient.org
- 25. www.micronutrient.org Means of salt transport 25
- 26. www.micronutrient.org 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 26
- 27. www.micronutrient.org IDD Elimination in Bangladesh Coverage of iodized salt at household level 100 83 84 81 80 70 70 67 67 Iodized salt (%) 60 Adequately 44 iodized (51%) 40 19 20 20 0 1995 1996 1997 1998 1999 2000 1993 1994 2001 2002 2003 2004 2005 2006 27
- 28. Technical brief on Vitamin A Supplementation www.micronutrient.org
- 29. www.micronutrient.org 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. 29
- 30. www.micronutrient.org Recommended Daily intake in ug RE by age and condition (1 ug RE = 33.3 IU 30
- 31. www.micronutrient.org 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, 31
- 32. www.micronutrient.org 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. 32
- 33. www.micronutrient.org 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. 33
- 34. www.micronutrient.org 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 34
- 35. www.micronutrient.org 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 50 100 37 80 30 19 23 35 34 60 24 21 24 40 52 48 45 20 42 41 35 0 1989-93 1992-96 1995-99 1999-2000 2004
- 36. www.micronutrient.org Outline • Situation Analysis • Benefits of Vitamin A and iodine • Assessment 36
- 37. www.micronutrient.org 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 37 Has it been eliminated as a public health problem
- 38. Indicators www.micronutrient.org Process 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 38
- 39. www.micronutrient.org 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 39
- 40. www.micronutrient.org 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 40
- 41. www.micronutrient.org To eliminate Vitamin A deficiency and its consequences Determine Existence Severity and Extent Of Vitamin A deficiency in the population 41
- 42. www.micronutrient.org 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 42
Editor's Notes
- Bangladesh has been implementing the sector wide approach (Swap) in health sector since 1998; currently implementing HNPSP for 2003-09-11 and next is expected to start in July 2011 for 2011-16. Goal Ensure health for all people by improvement in access to and utilization of HNP services MoHFW has already formulated the health and the Population policy and now preparing the sixth five year plan for 2011- 16 . The next sector plan is set against the broader GoB commitments (constitution, MDG, election manifesto, vision 2021, PRSP II, health policy, population policy and national women policy). The core goal of the National Health Policy is: To achieve sustainable improvement in health, nutrition, and family welfare status of the people, particularly of the poor and vulnerable groups, including women, children, and elderly people with ultimate aim of their economic and social emancipation and physical and mental well-being. Objective 4: Reducing the level of malnutrition among the population with a special focus on the children and the mothers, and taking an effective and coordinated programme to enhance nutrition for the people of all levels. Objective 5: Taking up effective programs for reducing the present child mortality and maternal mortality rates with the intention to keep these rates at a limited level. NNP and CIDD will be mainstreamed but CIDD may be given a project shape by UNICEF.
- Since the Dubai consultation was held, new data on the coverage of iodized salt have been collected through the 2005 Child and Maternal Nutrition Survey and the 2006 Multi-Indicator Cluster Survey (MICS) in Bangladesh. This figure shows that the coverage of iodized salt in Bangladesh has increased from about 20% in the early 1990s to 84% today. While these results are encouraging, a substantial proportion of household salt is inadequately iodized. A national survey in 2004-5, which measured the iodine content of household salt samples using titration, found that only 51% of household salt samples are adequately iodized (≥15 ppm). Thus, despite considerable progress, the quality of salt remains a major issue in Bangladesh.
- Vitamin A, also known as retinal, is fat soluble vitamin that has four major functions in the body; To maintain vision; vitamin A combines with the protein to form Rhodopsin. This combination allows the eyes to receive dim light, making vision possible at dusk or when changing from bright light to dark. The second function of vitamin A involves the growth and maintenance of mucous epithelial cells. These cells are found in the skin, eyes, and the respiratory, digestive, and urinary tracts. Vitamin A helps maintain these mucous linings which serve as protective barriers against infection. Vitamin A deficiency causes drying and keratinization of the eye thereby leading to blindness. Dryness of the skin also occurs forming a toad like skin. Growth and development is another area where Vitamin A has an important role. It is essential for the activity of bone cells, which must undergo a regular cycle of growth, maturation and degeneration to allow for normal bone development. So lack of it leads to stunted growth. Lastly, vitamin A is required to protect the body against bacterial and viral infections. It maintains the response and level of circulating cells (T lymphocytes) that fight against infection. So even mild deficiency leads to frequent and or severe illness due to infections and prevents recovery from simple infectious diseases like diarrhea, pneumonia and measles.
- However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake. However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.
- However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake. However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.