Module 5 - Micronutrient Deficiencies

Why do wash itnervetnions improve nutritional status? Q2

- Because they address the underlying causes of nutrition - For example by addresisng access to safe drinking water, people will not have to travel far and therefore will not have to consume unsafe water which can expose them to infections which can affect absorption of nutrients

Supplementation Programs: Iodine

- Iodine supplementation in the form of oral doses of iodised oil usually occurs in regions of the world where Universal Salt Iodisation has not occurred - Children are given a single dose of iodised oil annually and a one off dose for adults - This is not a cost effective strategy and it may not reach certain population groups

Nutrition specific programmes

- They address the immediate determinants of fetal and child nutrition and development such as adequate food and nutrient intake, feeding, caregiving and parenting practices - Examples = Micronutrient supplementation for children, maternal micronutrient supplementation, promotion of optimum breastfeeding, dietary supplementation, fortification, NUTRITION SENSITIVE EXAMPELS - Bioforticaition -

Iodine

- WHO estimates that 31% of the worlds population have insufficient iodine intake and are likely to develop a spectrum of disorders called Iodine Deficiency Disorder (IDD) - Iodine is required for the synthesis of thyroid hormones, which are involved in regulation of gene expression, cell differentiation, maturation, bone development and most importantly brain development - Iodine deficiency is the leading cause of mental retardation globally and the most significant contributor to preventable brain damage during early stages of life - Reduced cognitive development in children can affect learning potential, which on a population scale can affect the educational and economic capacities of communities in iodine deficient areas - Goitre (enlargement of thyroid gland) affects adults and their ability to work in iodine deficient areas Causes - Low levels of iodine in soil and water

LO3

- What strategy is more appropriate to the population and situation

Essential task 5.10 - 2nd reading in same task - Water, sanitation and hygiene interventions for acute childhood diarrhea

Which WASH interventions are effective on reducing diarrhoea risk? - Point of use water quality improvement interventions (water filters and water disinfection such as chlorination and use of disinfectant ) - Handwashing with soap - There was greater impacts with water fitlration (53%) than with water disinfection (31%) - Handwashing can lead to 27% reduction in diarrhoea

Multi sectorial approaches in Essential task 5.9

not important

5.1 - Home based fortification

- A home based fortification strategy to improve Iron was the use of "sprinkles", a powder containing iron alone or with other vitamins/minerals which can be used at homes or schools and can be added to existing foods - Sprinkles are very cost effective - Another product is "nutributter", has a longer shelf life than sprinkles but is more expensive - These products "sprinkles" and "nutributter" are good ways at increasing micronutrient intake of women and children where deficiency prevalence is higher and where fortified foods are not readily available

Vitamin A

- An example of vitamin A food fortification is taht Vitamin A has been fortified in sugar (in Guatemala for 3 decades) and it reduced vitamin A deficiency significantly - Foritification in oils in India and Africa and asian countries have also led to improvements - However, some population groups don't get benefits such as infants, as they do not consume the amounts of sugar or oils required to sustain serum retinol levels - Large scale programs require commitments from the food industry and government, they require good infrastructure and food distribution systems - The foods not only need need adequate levels of Vitamin A but also sufficient amounts to be consumed - Regular monitoring of the food item to ensure that Vitamin A levels are maintained is necessary at both regional and central production sites

Supplementation Programs: Vitamin A

- As a public health nutrition strategy, Vitamin A supplementation is the most effective way to prevent it's deficiency - Primary focus of some programs is on supplementation of the children population group and some programs also supplement postpartum women - Supplementation involves the delivery of twice yearly doses of retinol capsules to children between 6 and 59 months of age PROS - Have been successful as in Nepals Vitamin A supplementation program CONS - Doesn't reach everyone/coverage e.g. poorest of poor may miss out - Sustainability as well

Iodine

- As salt intakes globally are high, and consumed widely around the world, fortifiying salt with iodine is very effective to address deficiencies in developing and developed countries - Iodine consumption is measured via urinary iodine levels, to see if fortification has worked in the population - There is high salt intake in developed countries, and salt intake has been recommended to be reduced due to concerns with BP and CVD, therefore this suggests that otehr foods need to be iodine fortified so they can be consumed rather than salt

Supplementation Programs: Iron

- Countries with low prevalance of iron deficiency anaemia, after screening, if iron deficient, supplementation is provided by the primary care GP, this what occurs in developed countries - In contrast, where theres a large proportion of population affected by iron deficiency, universal iron supplementation is the approach used such as in developing countries - Iron deficiency has been implemented as part of the Thailand national nutrition policy and has resulted in the declining rates of anaemia in women and school aged children but there have been barriers to implamentation of the program which are also global barriers to iron supplementation - There have been barriers such as, lack of regular supply of iron tablets, women and health workers not understanding impact of anemia on health, side effects of medication such as constipation, and not attending clinics where supplementation occurs - Since poor diet/nutrition impacts on a number of different nutrients, it may be more practical to supplement a number of nutrients at one time e.g, Iron and folate supplementation has been more effective in reducing anemia in pregnant women than Iron alone

Single vs multiple nutrient supplementation

- Debate exists whether single or multiple nutrients should be supplemented - It may be more practical to supplement multiple nutrients since poor diet and lack of dietary diversity and infections can impact multiple nutrients causing them to be deifciient - Iron and folate supplementation for pregnant women has been more ffective at reduce anemia than iron supplemetation alone

Vitamin A

- Deficiency in Vitamin A affects around 190 million children and 19 million pregnant women worldwide - Widespread in South and South East Asia and Africa, but eliminated in developed countries - Vitamin A is required for vision, cell differentiation and maturation and immunity and reproduction - Vitamin A deficiency is the leading cause of paediatric blindness in the developing world and in adolescents and adults it causes Xeropthalmia (drying of epithelial lining of eye) and night blindness - Vitamiin A deficiency affects maternal outcomes (increase risk of maternal death in pregnant women who have night blindness duet ot the asscoiated risk of infection) - Vitamin A and immune function is associated, so vitamin A deficiency is an underlying cause of early childhood deaths due to milaria and other infections Causes - Poor diet quality (lack of meat and animal product consumption in particular) and lack of food diversity is a causative factor contributing to vitamin A deficiency - Globally, Vitamin A deficiency appears as a problem in countries where the food supply lacks preformed Vitamin A (meat and dairy products) and precursor carotenoids (fruit and vegetables) - Vitamin A deficiency is wide spread in South and South East Asia and vast regions of Africa, Vitamin A deciicency has been elimited in developed countries

5. Food fortification

- Food fortification involves the addition of vitamins and minerals to food products to restore nutrients lost during processing or to incorporate nutrients that are low/absent in the populations foods supply - Food fortification is considered a public health nutrtiion strategy to prevent micronutrient deficiency from occuring - Food fortification for micronutrient deficiency requires using foods that are readily available and which are consumed by the population at an affordable price, usual foods include flour, salt, maize, sugar, oils. - Universal salt iodisation is seen as the most successful example of a global food fortification strategy - Food fortification programs can be implemented on a national scale, aiming for high coverage of the population and programs that are targeted at population sub groups using specially formulated foods e.g. fortified supplements for pregnant women

Iron contrinued

- In Brazil, iron is added to wheat flour and has had signficiant large scale effects on anaemia - Other strategies include fortifiation of milk and water in smaller population groups but these are yet to be tested on larger populatio ngroups - Thailand has been successful in reducing anaemia levels in women and children by fortifying condiments and a wider range of foods such as soy sauce, fish sauce and noodles, noodles are affordable and highly consumed in poor areas - School based programs are the most effective in supplying children with fortified foods in the form of say porridge, milk, biscuits

Iron

- Involved in the oxygen carrying function of haemoglobin in blood - Affects both developing and developed countries and is the biggest contributor to nutritional anaemia - Anaemia is where the number of RBC's or their oxygen carrying capacity is insufficient to meet physiologic needs - Anaemia affects 1.62 billion people world wide - Menstruating women are at most risk of anaemia due to iron excretion in periods - Iron deficiency linked to mortality associated with infections such as malaria Causes - Poor diet (lack of iron), pregnancy and menstruation are risk factors for iron deficiency anaemia

Essential Task 5.4 - Zimmerman Geographical and Geological influecnes on nutrition, Iodine deficiency in industrialised countries

- Iodine deificency is not just a problem in developing countries it also affects many industrialised countries - Iodine deficient soils are common in industrialised countries such as Southern Australia TREATMENT AND PREVENTION: - Most effective way to control iodine deiciency is industrialised countries is via salt iodisation, this is because: 1. Salt is consumed by almost every individual 2. Salt intake is fairly consistent throughout the year 3. Iodisation technology is simple and easy to implement 4. Adding iodine to salt doesn't affect taste 5. Salt iodisation is cost effective

Iron

- Iron fortification of commonly consumed foods such as wheat flour is cost effective in large populations which require more iron and has been used in developed countries in foods containing wheat such as cereals, biscuits and cakes - However, once again, these foods need to be consumed enough by people to influence the nutritional intakes of all population sub groups - Groups at risk of iron deficiency are those with high requirements due to growth (adolescents) or due to small intake of food such as infants, young children, pregnant women and elderly - Important to provide nutrition education on the important of selecting and including iron fortified foods in diet - Iron fortification programs have limitations such as 1. Iron fortification technologically is more difficult compared to other nutrient fortifications and can alter the taste and appeal of food - Developing countries may lack the technology to allow iron fortification to occur

6. Indirectly addressing malnutrition: Nutrition-sensitive interventions and water, Sanitation and Hygiene (WASH)

- Nutrition sensitive interventions are those which address the underlying determinants of fetal and child nutrition and development such as food security, access to health services and a safe and hygienic environment

Background (LO2)

- Over the course of the 19th and 20th centuries, the science understanding micronutrient deficiencies was developed - Many of the deficiencies were identified and reduced during this time in only industrialised countries - Food fortification programs were fundamental in reducing these deficiencies in countries like the USA, things like scurvy (vit c) , anaemia (iron), pellagra (niacin(\) - Iodised salt was introduced to reduce the level of iodine deficiency in USA and Switzerland and was successful in doing so - Following this was other food fortification which were successful in eliminating most of these deficiences due to a well developed food production system, appropriate packaging and labelling, establishment of monitoring and surveillance systems and high levels of consumer awareness - The focus then switched to developing countries as they have high levels of micronutrient deficiencies particularly Vitamin A, Iron and Iodine

LO1

- So in PHN poverty, SES, availability and so on are the determinants

Essential Task 5.4 - Zimmerman Geographical and Geological influecnes on nutrition, Iodine deficiency in industrialised countries - Iodine nutrition in industrialised countries: The examples of France, USA, Australia, UK and Ireland

- The highest prevalence of iodine deficiency is in Europe - About half the population of Western and Central Europe are iodine deficient REASONS: - Most European nations have weak or non-existent governmental programmes to address iodine deficiency - Awareness of the important of iodine deficiency is underestimated as many countries have not conducted systematic assessment or monitoring of their populations - Laws regarding iodised salts vary widely in Europe as well as the types and amount of iodine used FRANCE - Have iodised househould salt AUSTRALIA - Major source of dietary iodine are milk and milk products and iodised salts - Largest iodine source in Australia has been milk containing iodine residues - Salt in bread is replaced with ioidsed salt in Australia

Essential Task 5.3 - Interview Sonia Brockington (worked in International nutrition)

- The main deficiencies were protein, iron, zinc, Vitamin A, iodine, in the developing areas - Infants and mothers are at a high risk of malnutrition - The elderly and the disabled are also high risk of malnutrition

LO2

- The timeline between developed vs developing countries - How has the timing differed

Could interventions to address WASH be cheaper and more sustainable than nutrient specific interventions? Why?

- Yes, for example, washing hands is very simple and can greatly reduce the risk of infection

Essential Task 5.11 -

COMPARE AND CONTRAST THE STRENGTHS/LIMITATIONS OF EXISTING STRATEGIES Why do various strategies need to be used? - Multiple strategies are more effective e.g. can't just focus on sanitation and hygiene e.g. giving soap, if they don't have access to safe drinking water - Multiple isssues contribute to problems, so multiple strategies will also be required - Multiple populations may require multiple strategies in the one area e.e.g what works for children may not work for adults.

1. Introduction

Definition: (Key point) - Micronutrient deficiency is defined as a deficiency in one or more micronutrients - Affect over 2 billion people in developed and developing countries - Vitamin A, Iron and Iodine are key micronutrients listed in the Copenhagen Consensus as priority global health challenges and are key concerns - Deficiencies in the above nutrients create high costs such as health, lives lost and economic costs - Rectifying/fixing micronutrient deficiencies is considered as one of the top 3 international development priorities Key point 2: - Micronnutrient deicicines in developing countries are frequently ascoaited with poverty, poor diet and low levels of maternal education and lack of access to health care - In developed countries, micronutrient deficineies are generally found in socioeconomcally disadvatnaged groups

Essential Tasks

Essential Task 5.1 - Career one (not importnt) Essential task 5.2 - - Essrntial task 5.3 - Interview with sonia brockington - Protein and energy macronutrient deficienies in Sudan - Anaemia was common - Zinc deficiency as well - Vitamin A - Children under 5 are highr isk groups and pregnant women to deficiencies

Essential Task 5.7 - "The early nutrition and Anaemia prevention project"

Goal of program - Micronutrient fortification in Northern Asutralia to improve nutrition and prevent iron deficiency anaemia of Aboriginal infants and young children aged 6-24 months Strategies - Educate carers and mothers on optimal child nutrition and iron defiiceny anaemia - Promote infant and child nutrition in the broader community - Providing "sprinkles" to homes - Employ community based workers to deliver project activities What is sprinkles - A single dose sachet of powder containing micronutrient/s that can be used to fortifiy any SEMI-SOLID (must have some liquid to dissolve) food consumed by infants and young children - Sprinkles have only a 2 year shelf life Benefits/advantages of the Sprinkles intervention - It was accepted by the community, some people did not accept it but the vast majority did accept it - If adequate distribution is achieved, sprinkles can maintain haemoglobin levels within the normal range without anaemia - Home based fortification programs can increase intake where fortified foods are not readily available - Low burden on consumers e.g. simple to use as you just sprinkle powder - Sprinkles have a 2 year shelf life so it's long lasting - Sprinkles are cost effective Challenges - Adequate distribution was not achieved and was lower than planned - Community based workers were absent at times, they didn't have transport to make visits which meant distribution didn't happen to it's full potential, many mothers were also away - Theres a chance that overtime people may not comply anymore so it may not be sustainable - Some nutrients may not have a long shelf life or the bio-avaialbility may decrease due to heat or storage - It may not be accepted, some parents declined sprinkles in the Aboriginal project - Some people who are very disadvantaged may not have the food to add it in the first place

Essential Task 5.8 - "International union of Nutriional sciences statement on benefit and risks of genetically modified foods for human health and nutrition"

Is biofortification of crops a good solution to Vitamin Deficiency diseases? In answering this question, think about the following: Is genetic modification of foods appropriate? When? Why or why not? What are some key risks and benefits of biofortification? Who stands to benefit from biofortification (are there any vested interests?) - In rich countries, people have access to an inexpensive supply of safe and healthy food - But in poorer countries micronutrient malnutrition is widespread, this can be due to money, where food budgets account for 2/3 or more of total expenditure... so poorer/developing countries stand to benefit more from biofortification - The solution to malnutrition and micronutrient deficineces is provision of a consistent and sufficient quantity of high quality nutrient dense foods - Low agency intervention - Can reach a wider amount of people/coverage including the most diadvantaged Challenges - Public perception of genetically modified foods e.g. genetically modified foods are unnatural, may cause resistance to implementation of programs - There may be unknown side effects or health outcomes by introducing specific traits in crops/plants - Industry inv involvement doesnalways have same motives as public health which means there can be ethical concerns about commercial interests versus the public good

3. Public health nutrition approaches to micronutrient deficiencies

The WHO/CDC Logic model for micronutrient interventtions in public health maps out the programme theory and relationships between inputs and SDGS (sustainable development goals) The main global strategies which directly address micronutrient deficiencies can be broadly categorised into: Supplementation Food fortification Home based approaches Biotechnological approaches

Essential Task 5.4 - Zimmerman Geographical and Geological influecnes on nutrition, Iodine deficiency in industrialised countries - Importance of food industry

The importance of food industry use of iodised salts in industrialised countries - WHO recommends salt iodisation to control iodine deficiency - 'Universal salt iodsation' means to describe the iodisation of all salt for human and livestock sonsumption - But universal salt iodisation is rarely achieved as many countries do not iodise salt at all for livestock and food industries are often reluctant to use iodised salt - The limited use of iodised salt by food industries is one of the main reasons for iodine deficiency in industrialised countries - In industrliased countries, most of total salt intake, 90% of total salt intake comes from processed foods, table salt only contributes 8-15% of total salt intake, so it's important for food industries to iodise their foods - Iodising bread is effective by including bakers salt enriched with iodine...water can be iodised but it is higher cost

Essential Task 5.6 - Thapa "Nepals Vitamin A supplementation program 15 years on"

The report: "Nepals Vitamin A supplementation program 15 years on: Sustained growth in coverage and equity and children still missed" About the report: - Talks about the Vitamin A supplementaiton program which has successfully expanded, in 2006 survey, it was found that 87.5% of children reported receiving supplementation. - 12.5% of children did not recieve supplementation as they were either from the poorest of the poor families, mothers with no education or residents of rural areas. Questions: 1. Identify the main key elements which the paper mentions which were essential to the success of the program and consider how these elements could be applied to other micronutrient supplementation programs - Female Community Health volunteers (FCHV) (volunteers can get burdened by workload and fatigue, so it's important volunteers are looked after as they are important) - Sustained support and funding from donors such as AusAID, UNICEF, USAID - Systematic and incremental appraoch - The non-political nature of the programme - The program had a high social value 2. Another important aspect of this paper is the investigation and discussion of those who did not receive supplementation (12.7%), why is this consideration an important part of a public health nutrition approach? - This is important based on the principles, everyone must have access, particularly those at most disadvantage (equity)

Essential task 5.5 - Organisations (not important)

These organsisations play roles in addressing the micronutrient deficiencies dicsussed: 1. Micronutrient initiative (Nutrition International) 2. Iodine global network 3. Global alliance for improved nutrition

Essential Task 5.10 - Great investment in Water, Sanitation and Hygiene is key to fight against undernutrition

What are WASH interventions ? - Interventions that focus on water, sanitation and Hygiene - The goal of wash programmes is to contribute to the reduction of mortality and morbidity, especially in children under 5yo - Sanitation and hygiene are underlying causes of under nutrition coupled with a lack of access to safe drinking water... this is because poor sanitation, hygiene and a lack of safe drinking water can be a source of infections (caused by intestinal parasites) and repeated diarrhoea which affected the nutritional status of chuldren - Poor santiation around young children can lead to them to absorbe pathogens present in soil such as E.coli, which can enter the body and affect the absorption of nutrients to the intestinal lining as it can damage the intestinal lining - Lack of access to safe drinking water close to where people live can affect nutritional status...... the further people live from safe water, the more they cut their water use due commute.... they then choose a water source that is unfit for consumption and they reduce activities that use water such as safe hygiene practices.

Essential task 5.9 - Ruel and Alderman Nutrition sensitive interventions and programmes how they can help to accelerate in improving maternal and child nutrition, the LANCET

What are nutrition sensitive interventions, how do they differ from nutrition specific interventions? - Nutrition sensitive interventions draw on complementary sectors such as agriculture, health, early child development, education and water and sanitation to address the underlying determinants of fetal and child nutrition and development which include poverty, food insecurity, lack of access to adequate care resources at the maternal, household and community level and access to health, water and sanitation services. - Nutrition sensitive programmes can serve as delivery platforms for nutrition specific programmes, potentially increasing their scale, coverage and effectiveness - Examples of programmes include: Agriculture/food security(homestead food production such as homegardens which increase availability of food and access to food) maternal mental health womens empowerment schooling (parental eduation asscoiated with better eating habits) water sanitation and hygiene social safety nets

Biotechnology and the Prevention of micronutrient deficiency diseases

What is biofortification? - Biotechnology/biofortification involves increases the nutrient density of crops - It involves key research areas such as developing new varieties of plants and crops through conventional farming practices such as orange flesh sweet potato, development of drought and pest resistant seeds and genetic modification of foods to increase micronutrient levels - There is debate around the ethics of genetic manipulation of seeds but also the ethics of not porgressing with biofortication especially when there are micronutrient defiiceines prevalent - Biofortification is diffferent to fortification, as bioforticiation aims to increase the nutrient levels in crops during plant growth rather than through manual means during processing of the crops - Bioforticiation is therefore a way to reach populations where supplementation and conventional fortification activities may be difficult to implement or limited