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Mahmud 6 introduction to key indicators


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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.
  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.
  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. 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,.
  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.
  8. 8.• Situation Analysis• Benefits of Vitamin A and iodine• Assessment 8
  9. 9. Country Overview• 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
  15. 15. 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. 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. 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. 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. 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. 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
  25. 25. www.micronutrient.orgMeans of salt transport 25
  26. 26. 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. 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
  29. 29. 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. 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. 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 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