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 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.

2 A world free from hidden hunger

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.

4 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

5 Micronutrient deficiencies : decreased cognition and production billions of dollars loss. 5% depression in GNP annually :

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,.

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.

8 Situation Analysis Benefits of Vitamin A and iodine Assessment

9 Country Overview Health, Population, Nutrition Development Sector Program (HPNDSP) : endorsed for Development Project Proposal ( ) 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

10 Analysis 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

11 Analysis 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

12 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

13 Outline Situation Analysis Benefits of Vitamin A and Iodine Assessment

Technical brief on qualitative universal salt iodization

15 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

16 Deficiency 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.

17 Iodine Deficiency Disorders Goiters most obvious signs of IDD Cretinism most serious form of IDD

18 Requirement : Children (preschool) 90 ug Children 6 – 10 years120 ug Males & Females 11+ years150 ug Pregnant and lactating women ug

19 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.

20 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

21 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.

22 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.

23 IDD Elimination in Bangladesh – Salt processing Annual requirement / production 850,000 MT 295 salt factories in 8 zones set up in the 1990s

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. IDD Elimination in Bangladesh – Status of SIP

25 Means of salt transport

26 IDD Elimination in Bangladesh – Iodine concentration in Salt at production level : mg/ kg of salt (ie 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

27 IDD Elimination in Bangladesh Coverage of iodized salt at household level

Technical brief on Vitamin A Supplementation

29 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.

30 Recommended Daily intake in ug RE by age and condition (1 ug RE = 33.3 IU

31 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,

32 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.

33 VAD and Absorption of VA : Pro vitamin A/ beta carotene from vegetable sources is %. 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.

34 Vitamin A reduces child (6-59 mo) mortality by ~23% August 2011 In VA-deficient settings, VAS recommended in 6-59 m old children to reduce morbidity & mortality

35 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

36 Outline Situation Analysis Benefits of Vitamin A and iodine Assessment

37 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

38 Indicators 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 ProcessImpact

39 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; moderate; mild and goiter by palpating or ultrasonogram among women and children

40 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 % None % Mild 20 – 29.9 Moderate > 30% Severe

41 To eliminate Vitamin A deficiency and its consequences Determine Existence Severity and Extent Of Vitamin A deficiency in the population

42 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

43 Thank you