Transcript Iodine deficiency world wide

Micronutrient
deficiencies
Prof. Pushpa Raj Sharma
Department of Child Health
Institute of Medicine
•Nutrients, such as vitamins, iron, copper, and zinc,
that are required in very small amounts by humans
in order to survive, as distinguished from the
macronutrients such as water, carbohydrate, protein
and fat, that are needed in large quantities.
•Micronutreints are essential to the body in small
amounts because they are either components of
Enzymes (the minerals) or act as coenzymes in
managing chemical reactions.
•Essential dietary elements required only in small
quantities. They are present in the body in amounts
less than .005% of body weight.
If we could give every individual the right
amount of nourishment and exercise,
not too little and not too much, we would
have found the safest way to health.
Hippocrates
Commonest micronutrient
deficiencies
• The World Health Report published
recently by WHO cites iron, vitamin A and
iodine deficiencies as three of the most
prevalent and critical nutrient deficiencies
in the world.
Burden of the disease
Globally:
• Between 100 and 140 million children are
vitamin A deficient
• Anemia, mostly due to iron deficiency,
affects some 2 billion people
• About 41 million infants are born every
year unprotected from losses in IQ or
more severe mental retardation due to
iodine deficiency.
Nepal:
• Vitamin A deficiency (VAD) causes an
estimated 14,000-20,000 Nepalese children to
die of infections annually.
• Iodine deficiency disorders (IDD) affect an
estimated 10 million Nepalese nationwide
• A Goiter prevalence of 41.5% among females
and 38.4% among males among school-aged
children 6-14 years
• The anaemia prevalence was highest among
infants aged 6-11 months (90%) and during the
second year of life (87.2%), and decreased
linearly with age to 59.2% in the 48-59 month
age group.
United Nations General Assembly Special
Session on Children convened in May 2002
set the following targets:
• The sustainable elimination of iodine deficiency
disorders by 2005;
• The sustainable elimination of vitamin A
deficiency by 2010;
• Reducing anemia prevalence, including iron
deficiency by a third by 2010;
• Accelerating progress towards the reduction of
other micronutrient deficiencies through dietary
diversification, food fortification and
supplementation.
Iodine :Micronutrient
•Iodide uptake is a critical first step in thyroid
hormone Synthesis.10 to 25% of radioactive tracer
(e.g., 123I) is taken up by the normal thyroid gland
over 24 h;
•Iodine deficiency, there is an increased prevalence
of Goiter.
•when deficiency is severe, hypothyroidism and
cretinism develops.
• Iodine deficiency remains the most common cause
of preventable mental deficiency
Iodine deficiency world wide
WHO Regions
a
Proportion of
population
with UI < 100 ต
g/L (%)
Population
with UI < 100 ตg/L
(in millions) b
Africa
47.6
48.342
The Americas
14.1
9.995
Eastern
Mediterranen
55.4
40.224
Europe
59.9
42.206
South East Asia
39.9
95.628
Western Pacific
19.7
36.082
Total
36.9
272.438
Iodine Deficiency prevalence in
Nepal
Iodine deficiency disorders (IDD) affect an
estimated 10 million Nepalese nationwide
A Goiter prevalence of 41.5% among females
and 38.4% among males among school-aged
children 6-14 years
Estimated Goiter Prevalence:
Note: The prevalence in the sample was assessed
for grades, 1, 2, as well as TGR (total goiter rate)
Group
Sample
Size
Women
15,540
Children 15,542
6-11
yrs (sch
ool aged
children)
Indicator
Visible or
palpable
goiter
(grades 1
and 2)
Visible or
palpable
goiter
(grades 1
and 2)
Prevalence in
Population
Sample
Affected*
G1
G2 TGR
48.1 1.3
50.0 2,887,515
40.5 0.0
40.5
1,328,648
The Nepal
Micronutrient
Status Survey
was completed
in 1998.
Iodine requirement
To meet iodine requirements, the current
recommended daily iodine intakes are:
• 50mg for infants (first 12 months of age)
• 90mg for children (2-6 years of age)
• 120mg for school children (7-12 years of
age)
• 150mg for adults (beyond 12 years of age)
• 200mg for pregnant and lactating women
Prevention of Iodine Deficiency
There is legislation governing IDD in Nepal. It was passed in
1955 and has been revised since. Salt iodization is
mandatory at the level of 20-60 ppm.
The estimated percent of households consuming salt with
some iodine is 91%. The estimate of households consuming
adequately iodized salt (15ppm or above) is 63%.
Sourced from the Between Census Household Information, Monitoring and Evaluation System 2000- BCHIMES.
Iron: Micronutrient
• Most Abundant Trace element in
body
• Functions
Structure of hemoglobin & Myoglobin:
O2 & CO2 Transport
Oxidative Enzymes
Cytochrome C
Catalase
Peroxidase
MAO (neurotransmitters)
• Causes
Deficiency
– Inadequate intake/ Poor bioavailability/ Infections/
Chronic blood loss/Decreased absorption
– Increased Demand (young children/ preg. &
Lactation)
• Manifestations
IDA : End stage of long process: Tip of iceberg
Stage
Manifestation
Diagnosis
Early
Storage iron depletion
N- Hb/Serum iron
 Ferritin/ marrow & liver iron
Second
Iron limited
erythropoiesis
N- Hb  Ferritin/ TIBC
Third
Iron Deficiency Anemia
 Hb/Ferritin/Serum iron,
MC/HC Anemia
The cutt-offs for haemaglobin and haemocrit
which are used to define anemia in people
living at sea level:
• Population GroupHaemoglobin(g/dL)
Haemocrit(%)
• Children 6 months to 5 years
11.033
Children 5-11 Years
11.534
• Children 12-13 years
12.036
• Non-pregnant women
12.036
• Pregnant women
11.033
• Men
13.039
Prevalence of Anaemia in Nepal
MOH/USAID
Sharma PR,
Baral MR,
Khetan BK
1975 National
1985
Kanti
Children’s
Hospital
6-23 months
24-71 months
319
946
19.5
25.7
0-1
1-4
1000
65.25
59.44
5-14
MOH, Child 1998
Health
Division
National
47.93
6-11 months
12-23 months
24-35 months
549
1220
978
90
87.2
74.9
36-47 months
48-59 months
637
515
70.2
59.3
Prevention of Iron Deficiency
• Supplementation with medicinal iron
- Pregnant women/ infants/ preschool children
• Increasing dietary intake
- promoting breast feeding/ timely introduction of
weaning foods
• Enhancing bioavailability
-  Vit. C,  tannins & phytates
• Control of infections
- Feeding during illness/ Deworming
• Food fortification
Iron doses
Oral iron therapy ( safe, cheap, effective)
Dose 6mg/kg/d : infants & children
60-120 mg/d: adolescents and adults
- Parenteral thearapy (not very safe but ensures
compliance)
Vitamin A: Micronutrient
•First Vitamin Discovered (1913)
•Functions:
Maintenance of Normal Vision
Growth, Repair and Cell Differentiation
Health of Epithelial Cells
Pregnancy and Fetal Development
Protection Against Infection
Deficiency
• Causes
– Inadequate intake/ Infections/ Measles
• Manifestations
–
–
–
–
–
–
–
–
XN Night Blindness (Earliest manifestation)
X1A Conjunctival xerosis
X1B Bitot’s Spots
X2 Corneal xerosis
X3A Corneal ulcer/Keratomalacia < 1/3
X3B Corneal ulcer/Keratomalacia > 1/3
XF Fundal changes
XS Corneal Scarring
Prevalence of Vit A deficiency Nepal: preschool children
Age
group
number cases
%
Number cases
%
6-11
0
0
0.00
1995
0
0.00
11-23
4457
3
0.07
4534
2
0.04
24-35
4305
8
0.19
4348
10
0.23
36-47
3455
18
0.52
3470
21
0.61
48-59
3084
14
0.45
3102
24
0.77
National
15307
42
0.27
17455
57
0.33
Night blindness Bitot’s Spot
Nepal mocronutrient status survey 1998
Prevalence of Vit A deficiency Nepal: school children
2.5
2
6 years
7 Years
8 Years
9 Years
10 Years
11 Years
1.5
1
0.5
0
Night
blindness
Bitots
Spots
Burden of Disease in Nepal
•Vitamin A deficiency (VAD) causes an
estimated 14,000-20,000 Nepalese children
to die of infections annually.
Vitamin A requirement
Infants< 6-12 months of age
only if not breastfed (breast
fed children in this group
should be protected by post
partum supplementation of
their mothers.)
50,000 IU orally
Infants 6-12 months of age
100,000 IU orally, every 4-6
months
Children> 12 months of age
200,000 IU orally, every 4-6
months
Mothers (post-partum,
lactating)
200,000 IU orally within 8 wks
of delivery
Zinc : Micronutrient
• In 1958, a 21 year old male patient in
the Iranian city of Shiraz.
• In 1974 the Food and Nutrition Board of
the US National Academy of Sciences
• The immunological effects of zinc
deficiency during the late 1960s.
• BMJ 2003;326:409-410 ( 22 February )
Ananda S Prasad Editorials
Zinc
• 3rd most abundant trace element in
body
• There are no zinc stores in the body to
mobilize from, and in 16 hours an
animal can be deficient with rapid
effects.
• Functions:
Metabolism (functions in over 200 enzymatic
reactions)
Antioxidant function
Immunity and Wound healing
Fetal Growth and Development
Zinc and its effect
When pregnant mice were fed a diet
moderately deficient in zinc, their offspring
exhibited a malfunctioning immune system
for the first six months of life. More
alarming, the second and third generations
also showed signs of poor immunity - even
though they were fed a zinc-plentiful diet.
Jean Carper, writing in Jean Carper's
Total Nutrition Guide, in reference to
zinc studies done at U.C. Davis
Symptoms of Zinc Deficiency
Delayed skeletal maturation
and
defective mineralization of
bone (monkeys)
Weight loss
Intercurrent infections
Hypogonadism in males
Lack of sexual development
in females
Growth retardation
Dwarfism
• Delayed puberty in
adolescents
• Rough skin
• Poor appetite
• Mental lethargy
• Delayed wound healing
• Short stature
• Diarrhea
• Pneumonia
• Stretch marks (striae)
Symptoms of Zinc Deficiency
• White spots on
fingernails
• Reduction in collagen
turnover and synthesis
(in chicks)
• Reduction in collagen
(in humans)
• Poor Immune system
• Acne
• Cross-linking of
collagen
• Hyaluronic acid
abnormalities (in swine)
• Defective connective
tissue
• Macular degeneration
• Cataracts (in salmon)
Deficiency
• Severe Deficiency
– Acrodermatitis enteropathica
– Syndrome of hypogonadism, stunting, anemia,
anorexia and hepatosplenomegaly
• Mild/Subclinical Deficiency
True estimate: currently not possible : Lack
of valid marker for nutriture
? common in children/women developing
world
–  susceptibility to infection/wound-healing time.
– ? Growth retardation/? Pregnancy related
complications and LBW
Vitamin A and zinc are micronutrients known to be important
in the maintenance of normal immune function
Zinc deficiency is associated with chronic diarrhea, growth
failure, and immune deficiency.
Supplementation resulted in a 23 percent reduction (95
percent confidence interval, 12 to 32 percent) in the risk of
continued diarrhea and a 39 percent reduction (95 percent
confidence interval, 6 to 70 percent) in the mean number of
watery stools per day.
Tomkins A, Behrens R, Roy S. The role of zinc and vitamin A deficiency in
diarrhoeal syndromes in developing countries. Proc Nutr Soc 1993;52:131-142.
Three Recommended Daily Allowances of zinc given daily
by caretakers or by field workers substantially reduced
theduration of diarrhea.
.Strand TA, Chandyo RK, Bahl R, Sharma PR, Adhikari RK, Bhandari N, Ulvik RJ,
Molbak K, Bhan MK, Sommerfelt H. Pediatrics. 2002 May;109(5):898-903.
An emphasis on the costs and economic benefits of an
alternative therapy is an important aspect of health
services research. The cost savings and theattractive
cost-effectiveness indicates the need to further assess
the role of micronutrients such as zinc and copper in
the treatment of acute diarrhea in a larger and more
varied population
Patel AB, Dhande LA, Rawat MS. Cost Eff Resour Alloc. 2003 Aug 29;1(1):7.
Zinc in growth and respiratory
infection
• Zinc-deficient Bangladeshi infants showed
improvements in growth rate and a reduced
incidence of acute lower respiratory infection
after zinc supplementation. In infants with serum
zinc concentrations > 9.18 micro mol/L,
supplementation improved only biochemical zinc
status.
Osendarp SJ, Santosham M, Black RE,
Wahed MA, van Raaij JM, Fuchs GJ.
Am J Clin Nutr. 2002 Dec;76(6):1401-8.
Safe Upper Limit of Zinc Intake
• 0.5 -1 yr
• 1 -6 yr
• 10 -12 yr
13mg/d
23mg/d
32mg/d
34mg/d
Girls
Boys
Trace elements in human nutrition
and health. Geneva. WHO 1996.
Intestinal Diseases and
micronutrients
Three months after treatment, significant differences in
serum copper, zinc and magnesium were seen in patients
with E. VERMICULARIS infection, and in serum magnesium
levels in patients with G. LAMBLIA.
Olivares JL, Fernandez R, Fleta J, Rodriguez G, Clavel A. Serum mineral levels in children with intestinal parasitic
infection Dig Dis. 2003;21(3):258-61
Children with inflammatory bowel disease have abnormal
levels of the trace elements which is more marked in those
with Crohn's disease The reduced free radical scavenging
action of zinc and selenium as a result of their deficiency may
contribute to the continued inflammatory process of IBD.
Ojuawo A, Keith L. The serum concentrations of zinc, copper and selenium in children with inflammatory bowel
disease.Cent Afr J Med. 2002 Sep-Oct;48(9-10):116-9.
The doctor of the future will give no medication, but
will interest his patients in the care of the human
frame, diet and in the cause and prevention of
disease.
Thomas A Edison
Thank you