nutrient deficiency state in Ethiopia

1. Common Nutritional Problems in Ethiopia
Meseret Moroda (BSc,MPh in Nutrition)
Salale University
January ,2024

2. Iron deficiency Anemia
Session objectives
• At the end of the session the learner able to:
– Describe epidemiology of IDA
– Distinguish causes of IDA
– Assess IDA
– Manage IDA

3. Epidemiology
• Iron deficiency is the world's most common nutritional disorder. It
affects around 2 billion people.
• In developing countries, 51% of children under the age of four years,
40% of all women and 51% of pregnant women are affected.
• Up to the half million women who die in child birth each year do so
because of the effects of anemia.
• Even in developed countries, 18% of pregnant women suffer from iron
deficiency anemia.

4. IDA: A case of Ethiopia
EDHS 2016:
• Conducted on 15,683 women
• Anemia was detected in 24% of pregnant and nonpregnant women
• Anemia was reported in 57 % of preschool age
– The prevalence of anaemia decreases with the child’s age,
ranging from
– high of 78% among children age 6-8 months
– In children age 48-59 months low of 40% among

5. Classification of Anemia based on Public heath importance

6. Causes
• Causes of iron deficiency
– Low levels of iron in the diet.
– poor absorption of the iron that is consumed.
– rapid growth in children and adolescents.
– chronic iron loss

7. Causes of iron deficiency Anemia
• The main causes for failure to meet iron needs could be
I. Dietary
– Inadequate intake of both heme and non-heme iron rich
diets
– Regular consumption of high phytate plant-based meals
– Inadequate intake of iron absorption enhancers
– Inadequate intake of vit A, B- 12, folic acid, & possibly B-6

8. Cont…
2. Non dietary
–Increased physiological requirements such as menstruation
• Frequent parasitic infections including
– Malaria
– Hookworm
– Trichuriasis
– Schistosomiasis
• Abnormal blood cell production (sickle cell)

9. Cont…
• Who is at the greatest risk?
– Children 6-24 months
– Special risk infants: low birth weight, premature, and/or from
anemic mothers
– Women of reproductive age, especially pregnant women
– Adolescents (especially females)
– PLWHA

10. Stages of iron deficiency
10

11. Cont…
Assessment of Iron Nutritional Status
– Hemoglobin
– Hematocrit
– Serum iron concentration
– Total iron binding capacity
– Transferrin saturation
– Protoporphyrin
– Serum ferritin
– Transferrin receptors

12. 12

13. 13

14. Cont…
• Clinical features of IDA
– Shortness of breath
– Lethargy
– Headache
– Tinnitus
– Pallor of the conjunctiva, tongue, nail beds and soft palate
– Papillary atrophy of the tongue
– Nails become spoon shaped (koilnychia)
– Behavioral changes
– Impairment of cognitive function
– Short attention spans

15. Cont…
Health implications of IDA
– Poor reproductive performance
– High proportion of maternal death (10 – 20% of total deaths)
– High incidence of LBW (< 2500 g at birth)
– Intrauterine malnutrition
– Impaired scholastic performance (impaired psychomotor
development and intellectual performance)
– Decreased resistance to infection

16. Cont…
• Reduction of work capacity/productivity (10% decrease in
hemoglobin = 15% decrease in productivity )
• Iron deficiency anemia is associated with 22% of maternal deaths
worldwide, and about 50% of all anemia
• The risk of maternal mortality decreases by 20% for each 1 g/dL
increase in hemoglobin

17. Cont…
Prevention and control of IDA
– ensure regular consumption of iron
– meet the requirements of the body
– increase the content and bioavailability of iron in the diet
There are four main approaches interventions
 Food fortification
 Supplementation
Dietary improvement
Public health measures

18. Iron supplementation
The essential principle of management of IDA are:
• Treatment of the underlying causes such as parasitic infections or
gastrointestinal bleeding
• Iron replacement therapy
– Oral iron therapy is the preferred form of treatment
– Ferrous sulfate is the most inexpensive and widely used oral iron
preparation
– A total dose equivalent to 60 mg of elemental iron (300 mg of ferrous
sulfate) per day is adequate for adults and should be given between
meals either in the morning or at bedtime

19. Cont…
• In the case of infants and young children, 30 mg/day of elemental
iron would be adequate
• In general, over a period of 4 weeks a hgb rise of about 2 g/dl
would be expected
• It is important to continue iron therapy for about 3 months, even
after the hgb level becomes normal

20. Guideline iron supplementation for pregnant and children

21. Cont…
2. Fortification
• Foods successfully used as vehicles for food fortification are wheat,
bread, milk powder, salt, infant formula and sugar

22. Cont…
Dietary Improvement
– A large variety of iron-rich foods and to increase dietary iron
absorption.
– liver, and eggs are good sources of iron in a form that the body can
readily use.
– Grains, legumes, and vegetables, but in a form less easily absorbed
unless taken at the same time with meat or food rich in vitamin C, or
processed in a way to enhance the absorption of iron.

23. Cont…
Public health measures
– Birth spacing, the control of parasitic infections, immunization
to prevent infections, and improved water supply and
sanitation.
– Changing of dietary habits and food preparation practices
through nutrition education, Control of malaria infection &
Control of febrile and chronic diseases
– Pregnant women require much higher amount of iron than is
met by most diets.

24. Cont…
Reading assignment
– Why Iron deficiency Anemia is still a problem of all courtiers?
– How adherence to Iron/Foliate supplementation during
pregnancy is assessed?
– How iron content of Ethiopian staple foods can be modified and
improved?
– What is your recommendation for Iron supplementation during
adolescence in Ethiopia?

25. Iodine
Session objectives
• At the end of this session you will be able to
– Describe Iodine deficiency disorders
– Describe the epidemiology of IDDs
– Assess Iodine deficiency
– Design measures to eliminate IDDs

26. Iodine
• It is essential for the synthesis of the thyroid hormones (thyroxin &
triiodothroxine)
• Important for physical growth and neural development.
• Failure to have adequate level of iodine in the blood:
– Insufficient production of these hormones, which affect many
different parts of the body- muscle, liver, kidney, and the
developing brain.

27. Cont…
Iodine deficiency disorders (IDDs)
– The term Iodine Deficiency Disorders (IDDs) was introduced by
Hetzel in 1983
– Encompass the wide spectrum of the effect of suboptimal
iodine nutrition on health, including
Physical impairment
 Mental retardation

28. Cont…

29. Epidemiology
Iodine status based on urinary iodine concentration in school aged children

30. Cont…

31. Cont…

32. Cont …
Causes of IDD
• Soil devoid of iodine
– Erosion of the land (mountainous topography )
– Crops growing in this type of soil
– Animal products from animals grazing grass growing in this soils
• Poor consumption of sea foods
• Increased consumption of goitrogens
– Foods that contain goitrogenic factors include cabbage, cassava, beetroot,
bamboo shoot
• Deficiency of other micronutrients (Iron, selenium, etc)

33. Cont…
Health consequences of iodine deficiency
• The most damaging effect of inadequate intake of iodine is on the
developing brain
• Cretinism is an extreme form of neurological damage due to severe
iodine deficiency or fetal hypothyroidism
• Cretinism is a congenital disease characterized by mental and
physical retardation and commonly caused by maternal iodine
deficiency during pregnancy

34. Cont…
• Iodine deficiency alone lowered mean IQ scores by 13.5 IQ points
• Thyroid enlargement at any period in life
• Impaired reproductive outcomes
• Child mortality
• High degree of apathy
• Reduced work productivity leading to economic stagnation of
communities.

35. Recommended iodine intakes

36. Cont..
Iodine status Assessment
• Target population
– The preferred target group is school age children between 6 and 12 years, and if
possible, 8-10 years old children
– Pregnant women are a prime target group for IDD control activities
Assessment Methods
• Urinary iodine excretion
–Good indicator of recent iodine intake
• Thyroid size
– By palpation and ultra sound measurement
• Measuring TSH
• T3 or T4

37. Cont…
Intervention strategies
• Programs may include one or both of the following strategies
–Food based approaches
–Fortification
–Nutrition education
–Nutraceutical approach (supplementation)
• Food source :Milk, sea foods, drinking water, plant source depends
on whether or not iodine present in the soil, iodized salt

38. Types of vitamin A
Retinol and carotene
• Vitamin A is found in animal foods as the preformed vitamin and in green
and yellow plant foods as the pro vitamin beta carotene.
• Vitamin A is a term used collectively for a group of compounds having
similar biologic activity.
• The parent compound in this group is called retinol.

39. Vitamin A
Source
• Found in animal foods and is usually associated with animal fats.
• Liver, whole milk, foods containing milk fat (butter, cream, and
cheeses), egg yolk, and margarine are good sources.
• Beta carotene and other biologically in active carotenoids occur in
yellow and dark green vegetables and in some yellow fruits.

40. 40

41. What are the consequences of vitamin a deficiency?
• Vitamin A deficiency has long been associated with blindness.
• But more importantly, recent research reveals that vitamin A deficiency is
associated with increased morbidity and mortality among young children.
• Vitamin A deficiency leads to a cessation of growth, deterioration of
epithelium and eventually death.
• Vitamin A deficiency is one of the most serious nutritional diseases in
developing countries because:
1. It causes blindness
2. It affects young children below 15 years

42. The common symptoms of vitamin a deficiency?
1. Night blindness:
– The child cannot see in the dusk or half darkness. He/she has to go in to the house
early in the evening
2. Conjuctival xerosis:
– The conjuctival covering the white surface of the eyeballs become dry and rough
instead of being moist, smooth and shining. The child cannot open and close his/her
eyes because it is painful.
3. Bitot’s spots:
 A foamy, or cheesy accumulation, which forms in the inner quadrant of the cornea
in the eyes.
 The cornea the central transparent part of the eye becomes cloudy.

43. Cont…
 It reflects more advanced vitamin A deficiency, but tends to be reversible with treatment.
 It was common in Ethiopia before small pox was eradicated from the country
4. Corneal ulceration:
– an ulcer on the cornea may leave scar, which can affect vision.
5. Keratomalacia:
– The eyeballs become opaque and soft, jelly like substance; hereafter there will be a
rapid destruction of the eyeball and no hope of recovery after the condition reached
the stage of keratomalacia.

44. Identifications of vitamin A deficiency at
the community level
Vitamin A deficiency sign/symptoms in underfive
age children
Who cut - off level for
identifying a public
health problem
Night blindness >1%
Bitot’s Spot(s) >0.5%
Conjuctival
Xerosis/ulceration/kratomalacia
>0.01%
Corneal scar >0.05%

45. Vitamin A Deficiency Disorders (VADD)
• A comprehensive term that covers all effects of the deficiency state including
those on health, survival and vision
• VADD are public health consequences attributable to vitamin A deficiency
• These are:
– Xerophthalmia
– Corneal ulceration
– Anemia
– Stunted growth
– Impaired immunity
– Increased severity to infection (e.g. measles, diarrhea, etc)
– Mortality

46. Cont…
• Vitamin A deficiency is defined as plasma retinol levels of vitamin A:
 <10 μg/dL (0.35 μmol/L) – Deficient
 < 20 μg/dL (0.7 μmol/L) – Low
 >= 30 μg/dL (1.05 μmol/L) – Normal
• Plasma retinol concentrations of less than 10 μg/dL are usually associated
with Bitot’s spots and other signs of deficiency

47. Causes of VAD
– Decrease in take of Vit A rich sources
– Inadequate intestinal absorption, with chronic intestinal disorders or
fat malabsorption
– Low intake of fat
– Increased Vitamin A excretion ( cancer, urinary tract disease and
chronic infectious disease)
– Low protein intake or PEM
– Increased need
47

48. Prevention and Control of Vitamin A deficiency
• The elimination of VAD can best be achieved through a comprehensive
approach that combines strategies.
• There are five main types of intervention for VAD as suggested by WHO:
A. Promoting breast milk
B. Supplementation
C. Food fortification
D. Dietary modification
E. Infection control

49. Zinc
• Zinc is a component of many enzyme systems including those involved in
protein synthesis ,carbon dioxide transport, and use of vitamin A
 Zinc is present in all organs, tissues, fluids and secretions.
 It is highly concentrated in specialized areas of the brain, pancreas and
adrenal glands, but is present in all cells particularly the nucleus.
• zinc plays a central role in gene expression, protein synthesis and cellular
division makes it extremely important during the periods of rapid growth
both pre- and postnatally.
• Zinc deficiency in adults occurs mainly as a result of disease that either
hinders absorption of zinc or cause excessive excretion of zinc in the urine.

50. Facts about Zinc & The body
Over 300 body enzymes work by zinc.
Our body doesn’t have any storage system for zinc.
 Zinc is easily lost from our body through sweating.
 Zinc is soluble in water.
Acts as a coenzyme
Cell growth & protien synthesis
50

51. Deficiency of Zinc.
Zinc deficiency
1. Zinc deficiency is a number one deficiency especially on children.
2. Birth related problems, underweight newly born babies, weak learning
capacity,
3. loosing test and smelling feelings, poor apatite,
4. slow healing of wound,
5. depression,
6. prostate problems, weak libido,
7. hair and nail problems,
8. acne and rash,
9. losing weight,
10. bad body odor,
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52. Signs/sxs of Zn deficiency
•Growth retardation (Dwarfism)
•Enlarged liver and spleen
•Anemia
Hair loss, diarrhea,
Delayed sexual maturation and impotence,
Eye and skin lesions
Loss of appetite, weight loss
Delayed healing of wounds,
Taste abnormalities, and mental lethargy.
52

53. Source of zinc
Meats, sea foods, Liver, milk & Fish
Zinc absorption is greater from a diet high in animal protein than
a diet rich in plant proteins.
 Root and tuber crops are low in zinc content.
Plant source foods that are more common in the diets of
developing countries are low in zinc and also contain zinc
absorption inhibitors such as phytate and tannin. Thus the
population is at high risk for zinc deficiency.
53

54. Preventions and control of zinc
• Similar to previous

55. • Group assignment
G1-Nutritional surveillance
 survey vs surveillance
 polices and programs related to nutrition
 global to local nature of malnutrition
G2-nutrional anthropology
 Food (faddism, aversions and prejudices )
 Factor affecting food preference
 Omission certain foods from diet for groups (children,
pregnant ,lactating women