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Panel west wednesday


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Panel west wednesday

  1. 1. First Global Conference on Biofortification November 10th, 2010 Keith P. West, Jr., Dr.P.H., R.D. Center for Human Nutrition Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, USA How Biofortification Fits into (Malnutrition) Interventions to Reduce Micronutrient Deficiencies
  2. 2. My Biofortification Vote Day dream believer Daily believer Weekend (Fri, Sat or Sun) believer Healthy skeptic Agnostic Bio-atheist
  3. 3. My Biofortification Vote Day dream believer Daily believer Weekend (Fri, Sat or Sun) believer x Healthy skeptic Agnostic Bio-atheist
  4. 4. Treat night blindness with roasted oxen liver Old Kingdom pyramind at Sakura: Depicts night blindness Night blind pregnant Woman in Nepal, 2000
  5. 5. Severe Iodine Deficiency 16th Century and Today Zhou Chen, 1516 Beggars and Street Characters Tibet, 2000
  6. 6. World History of Micronutrient Deficiency World up to early 20th C Deficient Deficient (biofortify) Sufficient (fortified) World from mid-20th C to new Millennium
  7. 7. Global Micronutrient Deficiencies Worldwide prevalence of anaemia 1993–2005: WHO 2008 Iodine Deficiency Worldwide; WHO 2004 Zinc Vitamin A Anemia Iodine
  8. 8. Worldwide Distribution of Child Deaths (Black, Morris & Bryce Lancet 2003;361:2226
  9. 9. Maternal-mortality Adjusted World Map
  10. 10. Life in Rural South Asia Undernourished, Pre-transition
  11. 11. •Protein-energy •Micronutrient s: Vitamin A, zinc, iron, iodine, folate, others •Behavioral Causes: Related to poor breast feeding, complementary feeding, home diet, poverty and poor education Nutritional Deficiencies •Infant or Child •Infection •Poor growth •Poor cognition & motor development •Death Child and Maternal Health Problems •Mother •Obstetric morbidity •Infection/sepsis •Anemia •Death Nutritional Deficiencies & Health Consequence Increased chronic disease risk? Demra, Dhaka, 1977
  12. 12. Altered tissue nutrient levels & metabolism Chronic dietary deficit of micronutrients Micronutrient Deficiencies as Public Health Problems Arise from Chronic Dietary Deficits in Relation to Need Systemic & non-specific defects Adapted from K West, J Nutr 2002 Clinical signs Poor dietary intakes Low blood/tissue nutrient /biomarker levels Abnormal functional tests Clinical disease
  13. 13. Diet Fortification Supplements Deficient Population Strategies for Preventing Micronutrient Deficiencies Biofortfication
  14. 14. Micronutrient Supplementation that Works • The vulnerable: • Pregnant women • Young children • Proven practices – • Six-monthly vitamin A < 5 years • Daily iron & folic acid in pregnancy • Zinc + ORS to treat diarrhea • Salt iodization to control “IDD”
  15. 15. Vitamin A Supplementation Reduces Preschool Child Mortality in Undernourished Societies Sommer A & West KP, 1996 Presently ~600 million vitamin A supplements distributed by UNICEF preventing ~1 million child deaths each year
  16. 16. Zinc Effective in Treating Diarrhea • Zinc deficiency increases risk of severe diarrhea; Zn limits it… • 10 mg oral zinc daily for 10–14 days • WHO/UNICEF policy • Rolling out • Very low cost • No mass zinc supplementation programs
  17. 17. Iron Prevents Iron Deficiency and Consequent Anemia Anemia Iron deficiency IDA Hookworm Malaria HIV/AIDS Anemia of Inflammatory Conditions Other vitamin deficiencies IDA= iron deficiency anemia
  18. 18. Modern Salt Iodization in China 1995 Per cent < 60 60 - 80 80 - 90 >= 90 Missing Data 19971999
  19. 19. Multiple Micronutrient Supplements Efficacies Unclear at Present
  20. 20. Micronutrient Fortification of Food Passive Delivery “Centrally” Processed Widely Consumed Technically Fortifiable Innovative Financing
  21. 21. Arroyave et al, PAHO 1979 Baseline 1 year later 6 mo later Effects of Sugar Fortification with VA in Guatemala
  22. 22. Impact of MSG + A in Indonesia 0 5 10 15 20 25 0 5 10 15 20 25 30 35 40 45 50 Serum Retinol (ug/dL) PercentofChildren Baseline 5 Months 11 Months Muhilal et al, Am J Clin Nutr 1988;48:1265
  23. 23. Flour Noodles Sugar Biofortified staple crops Salt
  24. 24. Goal of Biofortification Effectiveness & Safety Increasing Intake UL Riskofinadequacy Riskofexcess EAR 1 RDA1 217-03
  25. 25. Goal of Biofortification Effectiveness & Safety Increasing Intake UL Riskofinadequacy Riskofexcess EAR 1 RDA1 217-03
  26. 26. Prevents corneal blindness and milder xerophthalmia Normalized epithelia, immunity, less severe morbidity, reduced anemia Tissue and plasma repletion Dietary adequacy VA Deficiency Expect to Respond to Biofortification Return/ protect function Expect to Respond Expect to respond use to assess effect Partially addresses underlying dietary risk
  27. 27. Data Collection Activity Purpose Baseline survey (panels) to assess individual: More than 1 survey likely needed to assess seasonal intakes, trends and individual estimates • Micronutrient status and prevalence of deficiency Quantify nutrient status; calculate % marginal or deficient to establish prevalence and severity of deficiency • Dietary micronutrient intake Quantify intake for all groups; evaluate against RDA, EAR and UL to estimate dietary gaps and risks for each nutrient • Candidate staple food products intake Quantify staple food items portion size distributions among groups to estimate intakes of biofortified food & nutrients Representative assessments for biofortified food potency Monitor over time/ambient conditions biofortified nutrient delivery in foods Repeated periodic survey Monitor population responses to interventions : changes in status, prevalence of deficiency, nutrient and biofortified food intakes Assessment, Monitoring and Evaluation
  28. 28. Prepared by Nina Series for the ACC-SCN of the UN -appointed Commission on the Nutrition Challenges of the 21st Century, 1998
  29. 29. Prevalence of Low Serum Concentrations of Micronutrients among Women in 1st Trimester NNIPS-3, Nepal 61 20.6 0.7 11.6 27.7 46.3 31.8 32.8 13.9 0 20 40 60 80 Zinc <8.6 um ol/L Iron <8.95 um ol/L Copper <11.8 um ol/L Folate <6.8 nm ol/L B12 <147.7 pm ol/L B6 <20 nm ol/L Riboflavin <11.3 nm ol/L Vit E <10 um ol/L Vit D <25 nm ol/L % Jiang et al, J Nutr 2005
  30. 30. Antenatal Vitamin A Supplementation in Nepalese Mothers Increased Lung Volume by ~46 ml in Offspring by 9-13 Years of Age Forced Vital Capacity Checkley W, West KP, Wise R et al NEJM 2010;362:1784 Massaro D NEJM 2010
  31. 31. Antenatal Iron+Folic Acid Supplementation and Child Mortality to 7 Years of Age, Nepal Christian P et al Am J Epidemiol 2009
  32. 32. Antenatal Folic Acid Supplementation and Kidney Function in Children ~7 Years of Age, Nepal Stewart CP et al J Nutr 2009
  33. 33. HPLC system Micronutrient Deficiency Assessment in need of major advances for population assessment
  34. 34. Summary Thoughts • Micronutrient deficiencies reflect a diet quality problem of poor populations that remains to be been solved: Biofortification addresses this problem head on • Questions remain: bioavailability, efficacy/ effectiveness/safety, specific population group needs, additional nutrient needs, etc • Nutritionists need to be ready to apply, adapt, test, help integrate, monitor, guide, advocate from evidence, and advance biofortified products as they “arrive”
  35. 35. Summary Thoughts • Improved methods of dietary and status assessment, and food composition databases are needed to quantify, monitor, and know when closing dietary gaps • Continued research is needed to better understand and explain health implications of what we do, define new horizons… • Agriculture-nutrition: an intersection of science, program, political, economic and commercial communities that can advance the human condition. Biofortification sits at this intersection.
  36. 36. THANK YOU
  37. 37. Hidden Hunger = low nutrient density imbalanced nutrient densities chronic micronutrient inadequacy MDG #1: Eradicate Severe Hunger MDG 4 & 5: Reduce Child & Improve Maternal Health --------HealthConsequence------- Less Known Well Known Micronutrient deficiencies: Depleted nutriture Altered metabolism Impaired function Deficiency disorders: Blindness, severe infection, mental retardation, death, complications of pregnancy, fetal loss, etc Supplement Improve diet Different Micronutrient Deficiency Control Approaches to Achieve Different MDGs? Long-acting HealthConsequences