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2.6 a addressing-micronutrient_deficiencies_omar_dary

Addressing MND

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2.6 a addressing-micronutrient_deficiencies_omar_dary

  1. 1.     This presentation is part of the Agriculture and Nutrition Global Learning and Evidence Exchange (AgN-GLEE) held in Guatemala City, Guatemala from March 5-7, 2013. For additional presentations and related event materials, visit: http://spring-nutrition.org/agnglee-lac
  2. 2. iLiNS project Presentation by: Omar Dary Place: AgNGLEE-Central America Guatemala City, Guatemala 6-March-2013 Importance of Food Fortification and in-Home “Fortification” to Complement the Nutrient Adequacy of the Diet
  3. 3. Abt Associates | pg 2OD-2013-01 Why stunting has changed little in Guatemala? Source: ABC News
  4. 4. Abt Associates | pg 3OD-2013-01 Guatemala (ENSMI- 2008-2009) Wasting (w/h) Underweight (w/a) Stunting (h/a) 1.4 % 13.1% 49.8 % Ghana (2008-DHS) Wasting (w/h) Underweight (w/a) Stunting (h/a) 9.0 % 17.8 % 28.0 % Anthropometric indicators in pre- school age children < 2 S.D. Why do not consider other reasons beyond protein-energy undernutrition?
  5. 5. Abt Associates | pg 4OD-2013-01 What about breast-feeding practices, use of snacks, or stimulus? Pictures from Dr. Ram Shrestha, URC, visit to Guatemala 2012.
  6. 6. Abt Associates | pg 5OD-2013-01 Causes of stunting and anemia Type of growth and development Physical Factors: good nutrition, good health, disease resistance Social Factors (Care) : Early stimulation, belonging to a family, attention, love Genetic, Demographic & Environmental Factors: Race, gender, ethnicity, altitude, sun-exposure, intestinal flora “Food Security” (Foods) Child/mother health practices, Immunization (Health) Safe water and hygienic foods, healthy environments (Hygiene) Macronutrients supply: cereals, pulses, oil and fats, animal protein Some vitamins and minerals: milk, eggs, fruits, vegetables, fortified foods Avoidance of toxins and anti-nutritional factors: mycotoxins, e.g. Well absorbed Fe/Zn (fermentation, meat, fish, fortification, supplementation) Wasting, underweight and overweight Essential fatty acids supply, mainly n-3 (fatty fish, and certain vegetable oils) Non-digestible oligosaccharides and fiber: healthy intestine status.
  7. 7. Abt Associates | pg 6OD-2013-01 Stunting is only an indicator; the important is to correct its causes. Taken from: Thompson, R. A., & Nelson, C. A. (2001). Developmental science and the media: Early brain development. American Psychologist, 56(1), 5-15. Complementary feeding Nearly half of the “1000 days” depends on the mother nutritional status. Exclusive lactation Pregnancy
  8. 8. Abt Associates | pg 7OD-2013-01 Nutritional value of breast milk depends mostly on the mother’s diet Type I Nutrients (dependent)* Vit. B-1 60% Choline 56% Vit. B-2 53% Vit. A¶ 56% Vit. B-6¶ 80 % Vit. D¶ ? *** Vit. B-12¶ 16 %** Iodine 6-23 % Vit. C 50 % Selenium 52 % Type II Nutrients (independent) Sufficient Satisfy A.I., but… Folate Iron (Niacin)**** Zinc¶ Calcium Copper Notes: * Estimated proportion of the Adequate Intake (AI) for the child of an under-nourished mother. ** Not possible to increase during the lactation period; it requires good status pre-pregnancy. *** Depends on sun exposure. **** It could be synthetized from the amino-acid tryptophan ¶ Deficiency associated to stunting. References: Allen LH, Adv Nutr 2012; 3:362-369; and Allen LHGJ, In: Dealange FM WKJ (Ed). Micronutrient deficiencies in the first months of life. Basel: Karger Ag; 2003. pp 55-88.
  9. 9. Abt Associates | pg 8OD-2013-01 Dietary sources of some nutrients Nutrient Milk Meat, poultry Eggs Pulses (beans) Whole cereals Vege- tables Fruits & roots Sugar, oil, pol. rice ref. flours Vit. B-1 + ++ + +++ ++ + + - Vit. B-2 +++ ++ ++ + + ++ + - Niacin (B-3) + +++ + ++ + ++ + - Vit. B-6 + ++ ++ ++ ++ ++ ++ - Folate (B-9) - + ++ ++++ + ++ + - Vit. B-12 ++ + ++ - - - - - Vit. C + - - - - +++* +++ - Vit. A +++** + +++ - - (++) ++ - Vit. D +++** + + - - - - - Iron - ++++ (+) (+++) (++) (++) (+) - Zinc - ++++ - (+++) (++) (+) (+) - Calcium +++ + + (++) (+) (++) - -
  10. 10. Abt Associates | pg 9OD-2013-01 Nutrient inadequacy(%) of the most vulnerable member of the family in the Dominican Republic -2007 Source: Dominican Republic ENCOVI-2007. RED/USAID and the National Office of Statistics (ONE), 2012 Socio-economic groups 2007 - DHS Stunting: 9.8% Underweight: 3.1% Wasting: 2.2%
  11. 11. Abt Associates | pg 10OD-2013-01 Risk of inadequacy during the life course (relative to energy intake) Nutrient Children Women Men 1-3 y old 4-6 y old 19-30 y old  60 y old 19-30 y old  60 y old Vit. B-2 + + + ++ + +++ Folate (B-9) + ++ +++ ++++ + +++ Vit. B-12 + ++ ++ ++++ + ++ Vit. A +++++ ++++ + +++ + ++ Iron +++ + +++++ +++ +++ ++++ Zinc ++++++ +++++ + ++ ++ ++++ Calcium +++++ ++++++ ++ +++++ + +++ Iodine +++++++ ++++++ +++ ++++ + +++ Source: Dominican Republic ENCOVI-2007. RED/USAID and the National Office of Statistics (ONE), 2012 Questions: 1. Why to extend supplementation with iron from 6-24 months of age to 59 months of age? 2. Why to supply additional folic acid to children younger than 36 months of age?
  12. 12. Abt Associates | pg 11OD-2013-01 Anemia prevalence on 6-59 m children - Dominican Republic 2009 Source : Amarilis Then Paulino, MSP. 2011. 2009-Micronutrient Survey
  13. 13. Abt Associates | pg 12OD-2013-01 Results of a real fortification program: Wheat flour in Jordan-2010 Nutrient Additional content (mg/kg) % EAR Expected Real Children Women Iron –FeSO4 34 27 52 % 20 % Vitamin A 1.5 1.2 29 % 52 % Indicator Children (3-5 years old) Women (15-49 years old) 2002 2010 2002 2010 Iron Def. (ferr. (<11 & < 12 ng/mL) 10.1 % 4.8 %* 20.0 % 19.8 % Anemia (<11 &12 g/dL) 20.2 % 17.0 % 29.3 % 30. 6 % IDA 26.1 % 13.7 %* 38.7 % 35.1 % Serum retinol (<0.7 mol/L) 15.2 % 18.3 % - 4.8 %
  14. 14. Abt Associates | pg 13OD-2013-01 Combining food vehicles to increase coverage and the solution (additional micronutrient intakes) Source: Dominican Republic ENCOVI-2007. RED/USAID and the National Office of Statistics (ONE), 2012 Source: Martorell R. Caracterización de los patrones de consumo aparente en Centro América
  15. 15. Abt Associates | pg 14OD-2013-01 Theoretical contribution (%EAR) through fortified food for 1-2 y old children in D.R. Nutrient Diet Wheat flour/ Salt (I) Rice/ sugar (Vit A) Maize flour Total (extremes) P-20 P-80 P-20 P-80 P-20 P-80 P-20 P-80 P-20 P-80 Vit. B-2 85 170 5 22 0 0 0 7 90 198 Folate (B-9) 73 205 13 61 68 193 0 26 155 488 Vit. B-12 61 255 0 0 40 114 0 15 100 384 Vit. A 42 123 0 0 31 131 0 0 73* 254 Iron 77 131 5 24 4 10 0 11 86 176 Zinc 42 101 0 0 3 9 0 5 46 115 Calcium 22 50 0 0 0 0 0 0 22 50 Iodine ? ? 112 224 0 0 0 0 112 224 * Vit.A capsules: 200,000 IU = 60 mg = 0.278 mg/d if 80% absorpt. = 127% EAR of vit. A for 1-2 year old children.
  16. 16. Abt Associates | pg 15OD-2013-01 In-home “fortification” (% EAR-INCAP) for children 1-2 years old in the D.R. Nutrient Breast milk* Diet – P-20 Diet + FF P-20 MNP- WHO MNP- Guate. MNP- TAG** LNS*** Vit. B-1 25 106 140 - - 42-125 75 Vit. B-2 50 85 90 - - 42-125 100 Niacin (B-3) 25 149 179 - - 50-150 100 Vit. B-6 100 128 160 - - 42-125 450 Folate (B-9) 117 73 154 - 76 42-125 113 Vit. B-12 100 61 100 - - 43-129 71 Vit. C 169 192 192 - 77 77-231 231 Vit. A 130 42 73+supp 143 48 63-190 190 Iron 9 77 86 231 77 62-185 166 Zinc 94 43 46 93 44 36-108 108 Calcium 44 22 22 - - - 20 * From mother with good nutrition, 39% energy supply; ** Technical advisory group: 60-180 days supply, WHO formula for emergencies; *** Lipid Nutrient Supplements: They also contain n-3 and n-6 essential fatty acids.
  17. 17. Abt Associates | pg 16OD-2013-01 Anemia Prevalence in 1999 0 10 20 30 40 1-2y.old 2-5y.old 6-11y.old Adolescents Women Wheat Flour consumption 250 g/day Iron Fortification Level 20.0 mg/kg as Ferrous Sulfate (+10 intrinsic) Iron Intake through wheat flour 5.0 mg/day Micronutrient Level % EAR in 650 mL/day Iron (As ferrous sulfate) 10 mg/L 112% Vitamin A 300 µg/L 68% Vitamin C 70 mg/L 182% Zinc 5.0 mg/L 96% Anemia in 1-2 year old Children After Fortification of Milk 0 10 20 30 40 1999 2000 Impact of milk fortification in Chile. Skim milk is a natural source of vit. B-2, B-12, calcium
  18. 18. Abt Associates | pg 17OD-2013-01 Population coverage Additional intake Target fortificationMass fortification Supplements for home “fortification” Supplements ODM-2011-3-Micr.Mex. Dietary Diversification Nutrition specific interventions
  19. 19. Abt Associates | pg 18OD-2013-01 The risk of not integrating ODM-2011-3-Micr.Mex. MandatoryVoluntary General population Specific groups Coverage Compliance Mass fortification Target fortification Market driven fortification And this without considering the supplements Principles and concepts are UNIVERSAL, but the solutions are LOCAL (need and context)

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Addressing MND

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