1. Pediatric Micronutrient Deficiencies, Epidemiology and prevention I. Introduction, principles and iron deficiency Pediatric Micronutrient Deficiencies, Epidemiology and prevention I. Introduction, principles and iron deficiency Drora Fraser

2. Drora 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.

3. 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

4. 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.

5. The status in the world u Deficiencies of iron, Vitamin A and iodine are highly prevalent u 1/3 of the human race is affected and is at increased risk of death, disease or disability u Deficiencies disproportionately affect vulnerable groups u Deficiencies damage human capital and national economic development

6. Nutritional status in populations Severe micronutrient malnutrition Nutritional status flux of populations Nutrient overload

7. Which micronutrients are involved? Group AGroup B IronZinc Vitamin A Folate IodineVitamin - B12 + others

8. Interventions There are options for effective interventions: u Supplementation u Food fortification u Dietary diversification u Public health measures: such as parasite and diarrheal disease control, improve sanitation and hygiene

9. When planning an intervention: u Incorporate knowledge of factors such as: location and clustering, severity, prevalence and multiple causes of deficiencies u Take account of the level of country development and ability to implement and sustain the intervention u Set in place continuous monitoring and feed back mechanisms u Incorporate flexibility to be able to respond to monitored changes

10. Supplementation u The method of choice when treatment is needed i.e. to address the problem of severe micronutrient deficiency u Can be used as a preventive measure by targeting groups at high risk u Has been shown to be a cost-effective approach u Most efforts to control Vit A and iron deficiencies used this method

11. Food 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

12. Dietary diversification Introduce to the diet nutrient rich foods Change dietary habits Encourage people to grow new foods Increase market availability of specific foods

13. Iron 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

14. Iron deficiency - definitions Age/genderHemoglobin<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

15. Iron deficiency & public health Iron deficiency prevalence in a population is 2 to 2.5 times the rates of anemia. Category of publicPrevalence of health importanceanemia in risk gp. High>20% Moderate12.0 -19.9% Low 5.0 - 11.9%

16. Preferred approaches to prevention of iron deficiency

17. Public health measures to prevention of iron deficiency

18. 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)

19. Iron deficiency in the Negev, southern Israel

20. Anemia (%) in Negev Jewish children: Beer-Sheva & Dimona 1985 & 1993 PercentPercent Naggan L, Levy A, Shoham-Vardi I, 1994 N=228 N=49 N=100N=100

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

22. Hb distribution in Jewish children attending MCH* clinics for routine vaccinations 1999 n=127 n=65 PERCENTPERCENT

23. Short 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

24. Sustainable approaches to elimination of micronutrient deficiency e.g. iron Iron fortification of foods, foods in the target group: u Foods consumed regularly u Consumed in sufficient quantities u Consumed in stable amounts u Centrally processed foods u Foods that are easy to fortify

25. Food fortification e.g. iron To be considered: Chemical composition Stability Bio-availability Cost Taste

26. Iron fortification that have been used

27. Community 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.

28. Community studies: India u 7,000 persons used iron fortified salt u 7,000 persons used regular salt u Several locations Rural I anemia rates: v 98%-53% young children v 23%-9% in older children v 77%-32% in adults u Rural II: all ages anemia >90% u Urban: Women 30%, men <7%

29. 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

30. Cost effectiveness of iron fortification FortificationPlace Cost (1) Protect (2) SaltA0.120.12 FlourB0.16 -- SugarC0.120.12 SugarD1.001.00 TabletsE 3.2-5.3 3.2-5.3

31. Conclusions - 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