Biochemical and Clinical indices to assessnutritional status and response to nutritionalinterventions : VAD and IDD       ...
www.micronutrient.orgA world free from hidden hunger                                                2
THE HIDDEN HUNGERBangladesh is not in a complex nutritional emergency.Most of the malnutrition in our country is hidden an...
www.micronutrient.orgThe need for vitamins and minerals           Health Bargain              Prevent deaths        Decrea...
www.micronutrient.org    Micronutrient deficiencies :decreased cognition and production      billions of dollars loss     ...
Needed in minute quantities but its deficiencies cancause permanent damages.Victims of micronutrient malnutrition can suff...
Needed in minute quantities but its deficiencies cancause permanent damages.Victims of micronutrient malnutrition can suff...
www.micronutrient.org• Situation Analysis• Benefits of Vitamin A and iodine• Assessment                                   ...
Country Overview               www.micronutrient.org• Health, Population, Nutrition Development Sector Program  (HPNDSP) :...
Analysis          www.micronutrient.orgPopulation of >148 million (estimated )child population ( 0 – 59 months) of 22 mill...
Analysis      www.micronutrient.orgChild Development:• Anemia prevalence rates ( 6-59 months): 68%• IDD rates ( % with UIE...
www.micronutrient.orgCoverage of Key interventionsChild Survival• VAS: 88%• ZnS and LO ORS: 20% diarrhoea affected childre...
www.micronutrient.orgOutline• Situation Analysis• Benefits of Vitamin A and Iodine• Assessment                            ...
Technical brief on qualitative         universal salt iodizationwww.micronutrient.org
www.micronutrient.org  What is iodineA mineral needed for normal growth anddevelopment of the body.Produces thyroid hormon...
Deficiency            www.micronutrient.orgeffect the child even before they are born andchange their adult lives.IDD of t...
www.micronutrient.org  Iodine Deficiency DisordersGoiters most obvious signs of IDDCretinism most serious form of IDD     ...
www.micronutrient.orgRequirement :• Children (preschool)             90 ug• Children       6 – 10 years    120 ug• Males &...
www.micronutrient.orgIodine deficiency disorder (IDD) 56 m people are iodine deficient 23 m have goitre (4 m visible) 5 la...
www.micronutrient.org  Why does Bangladesh have iodine deficiencygeography is the primary factor.oceans and seas that is t...
www.micronutrient.org But why iodize salt?Salt is a superior food for iodizationLeast expensiveThe process requires minima...
www.micronutrient.org    IDD Elimination in Bangladesh – Salt production•    50,000 salt farmers•   70,000 acres salt prod...
www.micronutrient.org    IDD Elimination in Bangladesh – Salt processing•  Annual requirement / production 850,000 MT• 295...
IDD Elimination in Bangladesh – Status of SIP20 Large factories producing >50 tons/day96 medium factories producing 20 – 4...
www.micronutrient.orgMeans of salt transport                                             25
www.micronutrient.org            IDD Elimination in Bangladesh –    Iodine concentration in Salt at production level :    ...
www.micronutrient.org             IDD Elimination in Bangladesh             Coverage of iodized salt at household level   ...
Technical brief on Vitamin A            Supplementationwww.micronutrient.org
www.micronutrient.org  What is Vitamin AA fat soluble vitamin also known as retinal4 major functions in the body:• maintai...
www.micronutrient.orgRecommended Daily intake in ug RE by age and condition(1 ug RE = 33.3 IU                             ...
www.micronutrient.org        Situation Analysis    Children with night blindness: 0.03% (51,000)Pregnant women with night ...
www.micronutrient.orgSituation analysis          VAD is not a minor problem in Bangladesh.     Children suffer consequence...
www.micronutrient.orgVAD and Absorption of VA :Pro vitamin A/ beta carotene from vegetable sources is 20- 50%.Preformed vi...
www.micronutrient.orgVitamin A reduces child (6-59 mo) mortality by ~23%      In VA-deficient settings, VAS       recommen...
www.micronutrient.orgUnder 5 mortality has decreased significantly in Bangladesh,but One of the highest in the world :arou...
www.micronutrient.orgOutline• Situation Analysis• Benefits of Vitamin A and iodine• Assessment                            ...
www.micronutrient.org  Questions to be answered for effective  monitoring IDD control programsIs all the salt that is bein...
Indicators               www.micronutrient.org           Process          ImpactProcess indicator is the iodine content of...
www.micronutrient.orgTitration method can be done in any Laboratory:liberating iodine from salt and titrating withsodium t...
www.micronutrient.orggoiter by palpating or ultrasonogram among womenand childrenGrade 0 not palpableGrade 1 Palpable but ...
www.micronutrient.orgTo eliminate Vitamin A deficiency and its consequences   Determine   Existence   Severity and   Exten...
www.micronutrient.orgClinical symptoms like night blindness , bitot’ s spot, xerosis, keratomalacia, xeropthalmiaDietary i...
www.micronutrient.orgThank you                               43
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Mahmud 6 introduction to key indicators

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  • Bangladesh has been implementing the sector wide approach (Swap) in health sector since 1998; currently implementing HNPSP for 2003-09-11 and next is expected to start in July 2011 for 2011-16. Goal Ensure health for all people by improvement in access to and utilization of HNP services MoHFW has already formulated the health and the Population policy and now preparing the sixth five year plan for 2011- 16 . The next sector plan is set against the broader GoB commitments (constitution, MDG, election manifesto, vision 2021, PRSP II, health policy, population policy and national women policy). The core goal of the National Health Policy is:   To achieve sustainable improvement in health, nutrition, and family welfare status of the people, particularly of the poor and vulnerable groups, including women, children, and elderly people with ultimate aim of their economic and social emancipation and physical and mental well-being. Objective 4: Reducing the level of malnutrition among the population with a special focus on the children and the mothers, and taking an effective and coordinated programme to enhance nutrition for the people of all levels. Objective 5: Taking up effective programs for reducing the present child mortality and maternal mortality rates with the intention to keep these rates at a limited level. NNP and CIDD will be mainstreamed but CIDD may be given a project shape by UNICEF.
  • Since the Dubai consultation was held, new data on the coverage of iodized salt have been collected through the 2005 Child and Maternal Nutrition Survey and the 2006 Multi-Indicator Cluster Survey (MICS) in Bangladesh. This figure shows that the coverage of iodized salt in Bangladesh has increased from about 20% in the early 1990s to 84% today. While these results are encouraging, a substantial proportion of household salt is inadequately iodized. A national survey in 2004-5, which measured the iodine content of household salt samples using titration, found that only 51% of household salt samples are adequately iodized (≥15 ppm). Thus, despite considerable progress, the quality of salt remains a major issue in Bangladesh.
  • Vitamin A, also known as retinal, is fat soluble vitamin that has four major functions in the body; To maintain vision; vitamin A combines with the protein to form Rhodopsin. This combination allows the eyes to receive dim light, making vision possible at dusk or when changing from bright light to dark. The second function of vitamin A involves the growth and maintenance of mucous epithelial cells. These cells are found in the skin, eyes, and the respiratory, digestive, and urinary tracts. Vitamin A helps maintain these mucous linings which serve as protective barriers against infection. Vitamin A deficiency causes drying and keratinization of the eye thereby leading to blindness. Dryness of the skin also occurs forming a toad like skin. Growth and development is another area where Vitamin A has an important role. It is essential for the activity of bone cells, which must undergo a regular cycle of growth, maturation and degeneration to allow for normal bone development. So lack of it leads to stunted growth. Lastly, vitamin A is required to protect the body against bacterial and viral infections. It maintains the response and level of circulating cells (T lymphocytes) that fight against infection. So even mild deficiency leads to frequent and or severe illness due to infections and prevents recovery from simple infectious diseases like diarrhea, pneumonia and measles.
  • However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.   However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.
  • However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.   However, this should not level the impression that VAD is a minor problem in Bangladesh which does not require further attention. 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. In Bangladesh, vitamin A intake has repeatedly been reported as inadequate. As the animal source of VA is expensive for most families, vegetables are the primary sources of vitamin A in the diet. However families only consume a quarter of the vegetables needed to meet the vitamin A requirement. As with other vitamins and minerals, various social and economic factors contribute to the inadequate intake.
  • Mahmud 6 introduction to key indicators

    1. 1. Biochemical and Clinical indices to assessnutritional status and response to nutritionalinterventions : VAD and IDD ByDr Zeba Mahmud, Director, Micronutrient InitiativeTraining on Assessment of Nutritional Status 18-22 December 2011Date : 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 DisasterManagement and Food and Agriculture Organization of the United Nations (FAO) with the financial support of the EU and USAID. www.micronutrient.org
    2. 2. www.micronutrient.orgA world free from hidden hunger 2
    3. 3. THE HIDDEN HUNGERBangladesh is not in a complex nutritional emergency.Most of the malnutrition in our country is hidden andoccurs on a much larger scale than can be imagined. Itis not only due to lack of food as such; it has more todo with a diet which is insufficiently varied, leading todeficiency of certain micronutrients. www.micronutrient.org
    4. 4. www.micronutrient.orgThe 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 4
    5. 5. www.micronutrient.org Micronutrient deficiencies :decreased cognition and production billions of dollars loss . 5% depression in GNP annually : 5
    6. 6. Needed in minute quantities but its deficiencies cancause permanent damages.Victims of micronutrient malnutrition can suffer fromintellectual impairment,growth stunting,susceptibility to infections,mental retardation,. www.micronutrient.org
    7. 7. Needed in minute quantities but its deficiencies cancause permanent damages.Victims of micronutrient malnutrition can suffer frompoor health,low working capacity,blindness,behavioral changes,learning disabilitiesand even death. www.micronutrient.org
    8. 8. www.micronutrient.org• Situation Analysis• Benefits of Vitamin A and iodine• Assessment 8
    9. 9. Country Overview www.micronutrient.org• Health, Population, Nutrition Development Sector Program (HPNDSP) : endorsed for 2011-16• Development Project Proposal (2011 - 16) 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 9
    10. 10. Analysis www.micronutrient.orgPopulation of >148 million (estimated )child population ( 0 – 59 months) of 22 millionChild 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 10
    11. 11. Analysis www.micronutrient.orgChild 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 11
    12. 12. www.micronutrient.orgCoverage of Key interventionsChild Survival• VAS: 88%• ZnS and LO ORS: 20% diarrhoea affected childrenChild Development• HH level coverage of iodized salt: 84%Women’s Health• IFA coverage among P&LW: 55%BDHS 2007, USI Survey 2006, GOB 2004 12
    13. 13. www.micronutrient.orgOutline• Situation Analysis• Benefits of Vitamin A and Iodine• Assessment 13
    14. 14. Technical brief on qualitative universal salt iodizationwww.micronutrient.org
    15. 15. www.micronutrient.org What is iodineA mineral needed for normal growth anddevelopment of the body.Produces thyroid hormone necessary fornormal development and function of the brain andnervous system.maintains the metabolic rate and energymetabolism.Found in the mines of Chile and underground inJapan 15
    16. 16. Deficiency www.micronutrient.orgeffect the child even before they are born andchange their adult lives.IDD of the women during pregnancy can effectboth foetus and infant.Women have abortions and stillbirths.Children are born with low birth weights andpermanent physical and mental birth defects.School children may have lower intelligence andMore learning disabilities.It significantly reduces mental capacity and workpotential. 16
    17. 17. www.micronutrient.org Iodine Deficiency DisordersGoiters most obvious signs of IDDCretinism most serious form of IDD 17
    18. 18. www.micronutrient.orgRequirement :• Children (preschool) 90 ug• Children 6 – 10 years 120 ug• Males & Females 11+ years 150 ug• Pregnant and lactating women 175 -200 ug 18
    19. 19. www.micronutrient.orgIodine 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. 19
    20. 20. www.micronutrient.org Why does Bangladesh have iodine deficiencygeography is the primary factor.oceans and seas that is the water are the primary sources.absorbed into the atmospherereleased in the soil through rainHeavy rainfall and floods wash away large amounts of iodineleaving 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 20
    21. 21. www.micronutrient.org But why iodize salt?Salt is a superior food for iodizationLeast expensiveThe process requires minimal capital investment and imposeslow operating expense.Every day every person everywhere in the world eats salt.Humans consume salt in a predictable range. 21
    22. 22. www.micronutrient.org 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. 22
    23. 23. www.micronutrient.org IDD Elimination in Bangladesh – Salt processing• Annual requirement / production 850,000 MT• 295 salt factories in 8 zones set up in the 1990s Zone wise factory Chandpur Chittagong 39 25 CoxS Bazar 48 Dhaka 94 Jhalokati Khulna 23 17 15 Narayanganj 31 Patiya 23
    24. 24. IDD Elimination in Bangladesh – Status of SIP20 Large factories producing >50 tons/day96 medium factories producing 20 – 49 tons/day91 Small factories producing <20 ton/day30% do not operate daily50% of them are not operating for less than 1 year.20% of them are closed since 1-5 years26% of them are closed since 5-10 years.www.micronutrient.org
    25. 25. www.micronutrient.orgMeans of salt transport 25
    26. 26. www.micronutrient.org IDD Elimination in Bangladesh – Iodine concentration in Salt at production level : 20-50 mg/ kg of salt (ie 20-50 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 26
    27. 27. www.micronutrient.org IDD Elimination in Bangladesh Coverage of iodized salt at household level 100 83 84 81 80 70 70 67 67Iodized salt (%) 60 Adequately 44 iodized (51%) 40 19 20 20 0 1995 1996 1997 1998 1999 2000 1993 1994 2001 2002 2003 2004 2005 2006 27
    28. 28. Technical brief on Vitamin A Supplementationwww.micronutrient.org
    29. 29. www.micronutrient.org What is Vitamin AA fat soluble vitamin also known as retinal4 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. 29
    30. 30. www.micronutrient.orgRecommended Daily intake in ug RE by age and condition(1 ug RE = 33.3 IU 30
    31. 31. www.micronutrient.org 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, 31
    32. 32. www.micronutrient.orgSituation 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. 32
    33. 33. www.micronutrient.orgVAD and Absorption of VA :Pro vitamin A/ beta carotene from vegetable sources is 20- 50%.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. 33
    34. 34. www.micronutrient.orgVitamin A reduces child (6-59 mo) mortality by ~23% In VA-deficient settings, VAS recommended in 6-59 m old children to reduce morbidity & mortality August 2011 34
    35. 35. www.micronutrient.orgUnder 5 mortality has decreased significantly in Bangladesh,but One of the highest in the world :around 352 thousand U5 die annuallyneonatal & post-neonatal rates have fallen more slowly Neonatal mortality Post-neonatal mortality 1-4y mortality 160 140 120 Mortality rate 50 100 37 80 30 19 23 35 34 60 24 21 24 40 52 48 45 20 42 41 35 0 1989-93 1992-96 1995-99 1999-2000 2004
    36. 36. www.micronutrient.orgOutline• Situation Analysis• Benefits of Vitamin A and iodine• Assessment 36
    37. 37. www.micronutrient.org Questions to be answered for effective monitoring IDD control programsIs all the salt that is being produced iodized asper requirementIs the salt adequately iodizedIs the adequately iodized salt reaching the targetWhat impact is the salt iodization having on theiodine status of the population 37Has it been eliminated as a public health problem
    38. 38. Indicators www.micronutrient.org Process ImpactProcess indicator is the iodine content of salt at theproduction site, wholesalers, retailers andHouseholdsImpact indicator is to monitor the effect of saltiodization on target population and see trend 38
    39. 39. www.micronutrient.orgTitration method can be done in any Laboratory:liberating iodine from salt and titrating withsodium thiosulphate by buretteUrinary measurement of ug/l of iodine can be doneBy observing colour change in spectrophotometerafter mixing with ammonium persulphate or chlorate< 20 severe; 20-49 moderate; 50-99 mild andgoiter by palpating or ultrasonogram among womenand children 39
    40. 40. www.micronutrient.orggoiter by palpating or ultrasonogram among womenand childrenGrade 0 not palpableGrade 1 Palpable but not visibleGrade 2 VisibleTGR No of grades 1 and 2 divided by total examined0 -4.9% None5-19.9% Mild20 – 29.9 Moderate> 30% Severe 40
    41. 41. www.micronutrient.orgTo eliminate Vitamin A deficiency and its consequences Determine Existence Severity and Extent Of Vitamin A deficiency in the population 41
    42. 42. www.micronutrient.orgClinical symptoms like night blindness , bitot’ s spot, xerosis, keratomalacia, xeropthalmiaDietary intakeTissue concentration (liver and serum)< 15 ug/dl severe15 – 25 ug/dl moderate25 – 40 ug/dl marginal> 40 ug/ dl adequate 42
    43. 43. www.micronutrient.orgThank you 43
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