1. Are we overdoing it with micronutrient supply to pre-schoolers? Omar Dary USAID, Bureau for Global Health, Nutrition Division Micro-University Washington DC March 7 th, 2014 OD-2014-6

2. 2 Types of nutrients needed for a healthy life Macronutrients Fats Proteins Carbohydrates Energy Building Blocks Semi-micro nutrients Essential fatty acids and amino acids, Ca, Mg, P Membranes Enzymes Hard structures Genetic material Micronutrients Vitamins and Minerals Catalysis Regulation Function, Vision

3. 3 Specific nutritional deficiencies (old name) Characteristics Consequences are independent from the protein-energy intake (i.e. quality of the diet is essential)* Traditional (1990 Children Summit) Iodine, Vitamin A, Iron (the “big three”) Nowadays (in addition to the big 3) DevelopedDeveloping Folate, Vit. D, Vit. C Zinc, Vit. B 12, Vit. B 2 Calcium * “Hidden Hunger”

4. Co nsequen ces of iodine deficiency 44

5. 5 Consequences of vitamin A deficiency Deterioration of ocular conjunctive and cornea Less capacity to fight infections Alterations in growth and development Impaired visual and reproductive capability Night blindness Permanent blindness Death

6. Neural tube defects within 28 days after conception. Discapacities: Leg paralysis Anencephaly Bad control of bladder and intestinal evacuations Learning difficulties Modified from Jorge Rosenthal Consequences of folate and B 12 deficiencies 6 6

7. 7 Do these nutrients have any adverse effect? Nutrient TemporalPermanent Iodine Hyperthyroidism (in population that were iodine deficient) Thyroid Cancer (in adults from all sources of iodine) Vitamin A (as retinol) Intra-craneal pressure (infants and young children) Teratogenic Effects (fetus) Bone fragility (adults) Folic acid* (*precursor of folate that requires B 2, B 6, B 12, niacin) Triggering of certain cancers (colon, prostrate) Antagonist of anti- cancer, and eczema treatments Brain damage due to masking of megaloblastic anemia due to B 12 deficiency (elderly) Lack of evidence does not mean absence of adverse effects.

8. 8 EAR RNI LOAEL NOAEL UF UL Modified from the International Programme on Chemical Safety (IPCS), 2002. How to estimate safety?

9. 9 Figure modified from Institute of Medicine, the Academies of Science, USA.. An example with iodine (DRI values for 1-3 year old children) 6590 200 Iodine: µg/d

10. 10 Estimating efficacious iodine content for salt Parameter Ch 1-3F 19-30PregnantLactatingM 19-30 “EAR” (µg I/d)659516020995 Energy (kcal/d)11002400263728043050 If salt intake by adult male is 10 g/d 3.67.88.69.210.0 [I] in salt (mg/kg)18.012.218.622.79.5 Information: In 1996, WHO estimated the iodine content in salt at homes as 15 mg/kg, based on RNI of 150 µg/d of adults and 10 g/d salt intake. For factories, a 33% overage was calculated (15 x 1.33 = 20 mg/kg). Notice that this calculations are for averages and not for minimum values.

11. 11 However, the criteria of success is 90% or more samples with a content of 15 mg iodine/kg 104060 0.15 0.30 0.45 0.60 Content (mg/kg) Frequency 205070 80 30 Low variation Moderate variation Large variation

12. 12 Values of urinary iodine concentration vs performance of the salt iodization programs Country UIC (µg/L) Median iodine content (mg I/kg) % salt samples iodine >15 mg/kg Germany-2004-6 (sch. age) 11015-25(80% users) USA 2007-8 (6-11 y. old) 215?? Cambodia-2008 (8-10 y. old) 2227.162 % Guatemala-2011 (women) 13912.243 % Dominican Rep.- 15-19 y women 4092135 % In many countries in the world, more than 80% of salt samples contain iodine, and the average content is around 30 mg/kg, and for some 60 mg/kg. Nevertheless, MNP are “universally” formulated with iodine.

13. 13 Source : Menchú et al. (INCAP). Estudio complementario la ENCOVI- 2006 de Guatemala; 2013. Dietary availability of vitamin A, Guatemala-2006 Diet adequacy (density) Safety of retinol (density)

14. 14 Source : Menchú et al. (INCAP). Estudio complementario la ENCOVI- 2006 de Guatemala; 2013. Total supply vitamin A (diet+fortified sugar 9 mg/kg ) Diet adequacy (density) Safety of retinol (density)

15. 15 Source : Menchú et al. (INCAP). Estudio complementario la ENCOVI- 2006 de Guatemala; 2013. Total supply vitamin A (diet+fortified sugar+suppl) Diet adequacy (density) Safety of retinol (density) And… the country also introduced MNP with vitamin A !!!

16. 16 Reference: Daly LE et al.,J Am Med Sci 1995;274:1698-1762. Data from Ireland. Folic acid has reduced NTD-affected pregnancies

17. 17 Reference: Hirsch et al., J Nutr 2011. The change of serum folate in Chile after fortification of wheat flour before after Serum folate (ng/ml*) * ng/mL x 2.273 = nmol/L

18. 18 Median of serum folate (nmol/L) before and after flour fortification with folic acid Countries ChileUSAC.RicaW.BankEcuador Before9102218.5-23.8 14 After382225- Information: The cut-off point for deficiency of folate is 6.8-10 nmol/L; the cut-off point of 15.9 nmol/L has been proposed for identifying risk of NTD. Women of child-bearing age However, folic acid is being incorporated into MNP for children. Do we know that it is needed? Do we know that it is safe? Countries Ecuador Before 25.4 After Children 1-5 years old Reference: Data no published of the National Survey of Nutrition, 2013.

19. Next Session Room Numbers: Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room. Thank you! Integration of Family Planning Services into MNCH Programming in Liberia301 The Realities of Integration: NCDs and TB in Ethiopia (Continued)302 Integrating Family Planning with Obstetric Fistula Services: Achieving Reproductive Intentions307 Operational Research Training in the 21st Century308 Constant Contact: Reinforcing Provider Training with Mobile Messages and Supervision in Ghana (Continued)310 Indoor Residual Spraying: A Weapon in the Fight Against Malaria311 Increasing District Level, Evidence-Based Decision Making in Cote d'Ivoire405 Making Every Life Count: Strengthening Civil Registration-Vital Statistics Systems407 How Strengthening Medicines Regulatory Authorities Can Increase Access to Medicines (Continued)413 Child TB: No More Crying, No More Dying?414 Creating the Next Condom: TPPs for Next Generation MPTsBetts Theatre Sustainable Health Gain from Smart Governance of Hospitals and Health Systems Continental Ballroom Gender, Medicines, and the Road to Equity #AreWeThereYet? Grand Ballroom