Presentation on theme: "Overview of micronutrient deficiency disorders and clinical signs"— Presentation transcript:
1Overview of micronutrient deficiency disorders and clinical signs MicronutrientsOverview of micronutrient deficiency disorders and clinical signs
2Objectives Overview of major micronutrient deficiencies IronIodineVitamin AZincClinical featuresBiochemical assessmentTreatmentMicronutrient deficiencies in emergencies
3What is Malnutrition?Malnutrition = “lack of nutrients / poor nutrition”Two principle constituents:Protein-energy malnutritionDeficiency in micronutrients
4Vitamin A Thiamin Riboflavin Niacin Folate Manganese Magnesium Iron IodineCobalaminCobaltZincVitamin CVitamin EVitamin DVitamin KVitamin B6Vitamin B12SeleniumChromiumPhosphorusWhen we refer to micronutirent deficiencies, which ones are we actually referring to?All micronutrients are important for growth, health and development.But what do these three micronutrients, highlighted in white, have in common…These are endemic almost throughout the world including in most emergency-affected populations. The lack of access to these three micronutrients contribute the three MDDs of most public health significance.Micronutrient deficiencies are common throughout the world including in most emergency-affected populations….
5Overview of Micronutrient Deficiencies Common when dependent on relief foodPreventable, BUTFood sources not common and are expensiveFortification adds to cost of relief foodDifficult to recognizeSymptomatic cases often represent tip of icebergLaboratory assessment difficult & expensiveLack of 1 micronutrient typically associated with deficiencies of other micronutrientsHighest risk groupsYoung childrenPregnant WomenLactating women
7Anemia Iron deficiency anemia (IDA) Most common global nutrition problemCommon causes of anemiaIron deficiency anemia (IDA)Infections (malaria, hookworm, HIV)Other vitamin deficienciesHemoglobinopathiesHealth impactPerinatal & maternal mortalityDelayed child developmentReduced work capacityIron deficiency is the most common cause of anemia and most common preventable nutritional deficiency.
8Anemia- Risk Factors Low dietary intakes Diet poor in iron-rich foods/animal foodsHigh intake of inhibitors (Tea)Infections (malaria, helminthes infection, schistosomiasis)Blood loss
9Anemia- Signs & Symptoms Tiredness and fatigueHeadache and breathlessnessPallor: pale conjunctivae, palms, tongue, lips and skin
10Anemia- Assessment Hemoglogin (Hemocue) Hematocrit Blood can be tested for anaemia using different methods which look at the colour of the blood, the number of blood cells, or use a chemical which reacts with the haemoglobin.Hemoglogin (Hemocue)HematocritDefined by WHO as:Hb <11.0 g/dL – childrenHb <12.0 g/dL – womenHb <12.0 g/dL - MenWHO recommends blanket supplementation to all children 6-24mo where anemia prevalence >20-30%Require 0.8mg of bioavailable iron/day
11Indicators of Iron Status LabSoluble transferrin receptor (sTfR)Ferritin (FER)Iron (Fe) and total iron binding capacity (TIBC)Zinc protoporphyrin (ZP)Hemoglobin (Hb)Price, Complexity of TestField
12Anemia- Treatment Foods that are rich in iron include: Dietary diversificationFoods that are rich in iron include:MeatFortified cerealsSpinachCashew nutsLentils and beansFortificationIron supplementsWHO recommends blanket supplementation to all children 6-24mo where anemia prevalence >20-30%Require 0.8mg of bioavailable iron/day (BM only provides 0.4mg).
13Iodine Deficiency Disorders (IDD) Significant cause of preventable brain damage in childrenHealth effects:Increased perinatal mortalityMental retardationGrowth retardationPreventable by consumption of adequately iodized salt
14Iodine Deficiency Affects the Brain CretinismGoiterEven mild IDD can reduce IQ by 13.5 points!Reduced intellectualperformance*Goiter manifests only a small portion of IDD
15IDD- Risk Factors Low iodine level in food products grown on iodine-poor soilerosion, floodsmountainous areasdistance from sea (low fish intake)Non-availability of iodized food (salt)
16IDD- Assessment Measure urinary iodine excretion (UIE) Measure urinary iodine excretion (UIE)Measure levels of thyroid hormones in bloodMeasure degree of goitreGrade 0 No GoitreGrade 1 Palpable GoitreGrade 2 Visible Goitre
17Price, Complexity of Test Salt Iodine MeasurementTitrationGold standardLabWYD Iodine CheckerSingle wavelength (585 nm) spectrophotometerMeasures iodine level (ppm) in salt based on the absorption of the iodine-starch blue compoundPrice, Complexity of TestVarious methods are available for testing the iodine content of salt. The “goal standard” for detecting iodine content in salt is the titration method. However, titration requires skilled laboratory personnel and is time-consuming and costly, so it is not recommended for routine monitoring purposes. Prior studies have shown that rapid salt kits are suitable and appropriate to accurately distinguish between iodized and non-iodized salt. Rapid kits are field-friendly, inexpensive, and sensitive, so UNICEF recommends them for qualitative assessment of salt iodization in household surveys or spot checks of food quality. The WYD Iodine Checker, which uses a single wavelength spectrophotomometer to measure the iodine level in salt based on the absorption of the iodine-starch blue compound, has been shown to be highly precise, accurate, and sensitive when compared to the titration method.Rapid KitQualitatively measures iodine content in saltHighly sensitive but not specificInexpensiveField
18This picture shows a field worker testing salt for the presence of iodine using the MBA rapid salt test kit
19Goiter examinationExamination for goiterCretinism
20Vitamin A Deficiency (VAD) Leading cause of preventable blindness among pre-school childrenAlso affects school age children and pregnant womenWeakens the immune system and increases clinical severity and mortality risk from measles and diarrhoeaSupplementation with vitamin A capsules can reduce child mortality by 23%.WHO (2002) estimates that 21% of all children suffer from VAD, mostly in Africa and AsiaWHO 2005: “Vitamin A deficiency (VAD) is a public health problem in more than 118 countries and affects more than million preschool children worldwide.”
21VAD- Signs & Symptoms Clinical deficiency is defined by: night blindnessBitot’s spotscorneal xerosis and/ or ulcerationscorneal scars caused by xerophthalmiaWHO classification through various stages.
22WHO Classification of Xerophthalmia 1N Night blindness2B Bitot’s spotsX3 Corneal xerosisX4 Corneal ulcerations -KeratomalaciaX5 Corneal scars - permanent blindness2BX3X4X5
23XeropthalmiaBitots spots (X1B) are foamy white areas on the white of the eye. Be careful not to confuse them with other types of eye problems. These signs will most often be seen in children.Corneal Xerosis(X2)Keratomalacia (X3)
24VAD- Risk Factors Low availability of vitamin A-rich foods Lack of breastfeedingHigh rates of infection (measles, diarrhoea)Malnutrition
25VAD - Assessment Clinical assessment for night blindness Biochemical assessmentRetinolSerum analyzed by HPLCCutoff: < 0.7 µmol/LRetinol-binding protein (RBP)Serum or DBS analyzed by ELISACutoff: ~ < 0.7 µmol/L
26Dried Blood Spots for RBP Quick and easy field friendly techniqueCollection through venipuncture or finger stickFasting not necessaryDBS should completely dry and be protected from humidityStorage of DBS at –20oC only for short term, –70oC for long termShipping of DBS cards on frozen ice packs to the laboratory
27Poor Quality DBSDry blood spot cards need to be prepared and stored properly. If they are not processed properly it will not be possible to analyze them
28VAD- Treatment As pre-formed vitamin A in foods from animals SupplementationCapsules given during immunization daysFood FormsAs pre-formed vitamin A in foods from animalsLiver, fishAs pro-vitamin A in some plant foodsred palm oil, carrots, yellow maizeFortified blended foods (CSB or WSB)
29High dose oral supplements of vitamin A Rapid and targetedHighly effective in lowering mortality in infants and children in third world communitiesHighly effective in reducing complications in measlesReduced prevalence of malaria in children in Papua New Guinea
30Zinc DeficiencyZinc essential for the function of many enzymes and metabolic processesZinc deficiency is common in developing countries with high mortalityZinc commonly the most deficient nutrient in complementary food mixtures fed to infants during weaningZinc interventions are among those proposed to help reduce child deaths globally by 63% (Lancet, 2003)
31Zinc Deficiency- Signs & Symptoms Hair lossSkin lesionsDiarrheaPoor growthAcrodermatitis enteropathicaDeathWHO 2005: “Vitamin A deficiency (VAD) is a public health problem in more than 118 countries and affects more than million preschool children worldwide.”
32Zinc Deficiency- Assessment No simple, quantitative biochemical test of zinc statusSerum ZincCan fluctuate as much as 20% in 24-hour periodLevels decreased during acute infectionsExpensiveHair zinc analysis
33Zinc Deficiency- Treatment Regular zinc supplements can greatly reduce common infant morbidities in developing countriesAdjunct treatment of diarrhea 20mg /day x 10 daysPneumoniaStuntingZinc deficiency commonly coexists with other micronutrient deficiencies including iron, making single supplements inappropriateDietary diversificationAnimal protein (oysters, red meat)WHO 2005: “Vitamin A deficiency (VAD) is a public health problem in more than 118 countries and affects more than million preschool children worldwide.”
34What do the micronutrients in red have in common? Vitamin AThiaminRiboflavinNiacinFolateManganeseMagnesiumIronIodineCobalaminCobaltZincVitamin CVitamin EVitamin DVitamin KVitamin B6Vitamin B12SeleniumChromiumPhosphorusWhat do these micronutrients, highlighted in red, have in common?These three MDDs are characteristic of emergency affected populations. Deficiencies of these three rarely occur in stable populations or non-emergency affected populations.In this context, we will now discuss the specific reasons and risk factors associated with the diseases associated with deficiencies in these three micronutrients.What do the micronutrients in red have in common?
35Micronutrient deficiencies in emergencies Deficiencies of:Vitamin C scurvyNiacin (vitamin B3) pellagraThiamin (vitamin B1) beriberi…usually associated with situations where populations are fully dependent on limited commodities for their food needs.
36Vitamin C - Ascorbic Acid Humans are among the few species that cannot synthesize vitamin C and must obtain it from foodManufacture of collagenHelps support and protect blood vessels, bones, joints, organs and musclesProtective barrier against infection and diseasePromotes healing of wounds, fractures and bruisesSourcesCitrus fruits, strawberries, kiwifruit, blackcurrants, papaya, and vegetables
37Scurvy – Signs & Symptoms Small blood vessels fragileGums reddened and bleed easilyTeeth looseJoint painsDry scaly skinlower wound-healing, increased susceptibility to infections, and defects in bone development in children
38ScurvyScurvy – Perifollicular hemorrhagesTwo photos show that accurate diagnosis of MDDs are very difficultBleeding around the bases of the hair on the legs (Perifollicular hemorrhage) and the gums in between the teeth are signs of scurvy. There may be areas of bruising as seen in second picture. There may also be swelling of the bone joints.
39Thiamin – Vitamin B1 What it does in the body energy production and carbohydrate and fatty acid metabolismvital for normal development, growth, reproduction, healthy skin and hair, blood production and immune functionDeficiency due to diets of polished rice
40Beri Beri- Signs & Symptoms Develop within 12 weeksDry Beriberi peripheral neuropathyDifficulty walking and paralysis of the legsReduced knee jerk and other tendon reflexes, foot and wrist dropProgressive, severe weakness and wasting of musclesWet Beriberi cardiopathyEdema of legs, trunk and faceCongestive heart failure (cause of death)
41Wrist & foot drop:Dry Beri BeriEdema:Wet Beri Beri
42Riboflavin Deficiency Deficiency is rare and often occurs with other B vitamin deficienciesSeveral months for symptoms to occurBurning, itching of eyesAngular stomatitisCheilosisSwelling and shallow ulcerations of lipsGlossitis
44Niacin – Vitamin B3Essential for healthy skin, tongue, digestive tract tissues, and RBC formationProcessing of grains removes most of their niacin content so flour is enriched with the vitamin
45Pellagra – Signs & Symptoms ‘three Ds’: diarrhea, dermatitis and dementiaReddish skin rash on the face, hands and feet which becomes rough and dark when exposed to sunlight (pellagrous dermatosis)acute: red, swollen with itching, cracking, burning, and exudatechronic: dry, rough, thickened and scaly with brown pigmentationdementia, tremors, irritability, anxiety, confusion and depression
47SummaryMajor risk factors for micronutrient deficiency diseases include poor dietary intake, infection, disease and sanitationThe 4 major MDD are anemia, iodine deficiency, vitamin A deficiency, and zinc deficiencyTreatment for MDD include dietary diversification, supplementation, and food fortification