Causes and solutions Wan Abdul Manan Wan Muda, for Wan Abdul Manan - - PowerPoint PPT Presentation

Tackling Micronutrient Deficiencies: Causes and solutions

Wan Abdul Manan Wan Muda, for Wan Abdul Manan Wan Muda, Jomo KS and Tan Zhai Gen 1st October 2019

Micronutrient Nutrition

• Micronutrients – also known as vitamins and minerals –

are essential components of a high-quality diet and have a profound impact on health. Required only in tiny quantities, however they are essential building blocks of healthy brains, bones and bodies.

• Micronutrient deficiencies are often referred to as

‘hidden hunger’ because they develop gradually over time, their devastating impact not seen until irreversible damage has been done

• Millions of children suffer from stunted growth,

cognitive delays, weakened immunity and disease as a result of micronutrient deficiencies.

+ Tackling Micronutrient Deficiencies: Causes and solutions

Common Micronutrient Deficiencies

• Iodine deficiency - can lead brain damage in children,

particularly, during fetal development and in the first few years of a child’s life.

• Vitamin A deficiency - weakens the immune system and

increases a child’s risk of contracting and dying from infections like measles, and diarrhoeal illnesses.

• Iron deficiency - anemia, risk of hemorrhage during

childbirth can lead to maternal deaths. Risk of babies born prematurely, vulnerable to infections, learning disabilities, and delayed development.

• Zinc deficiency - impairs immune function and risk of

gastrointestinal infections which can lead to mortal diarrhea.

• Calcium, vitamin D, and folate deficiencies are of

concern during pregnancy, risk of health complications for both the mother and growing baby.

+ Tackling Micronutrient Deficiencies: Causes and solutions

Micronutrients intake

Source: Bee Koon P et al. (2013).Nutritional status and dietary intakes of children aged 6 months to 12 years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia) British Journal of Nutrition, 110, S21–S35 doi:10.1017/S0007114513002092 + Tackling Micronutrient Deficiencies: Causes and solutions

Micronutrient Requirements

• The dietary requirement for a given micronutrient is

defined as the level which meets criteria for being adequate to minimise risk of nutrient deficit or excessive intake.

• Nutrient requirements vary between individuals based on

a range of factors, including age, sex, physical activity levels, and can be higher during periods of pregnancy, lactation, and disease.

• The UN Food and Agricultural Organization (FAO) and

World Health Organization (WHO) publish tables of nutrient requirement values across demographic groups

+ Tackling Micronutrient Deficiencies: Causes and solutions

Micronutrient Nutrition

Micronutrient deficiency is more prevalent in countries with poor dietary diversity

• To ensure adequate micronutrient intake through dietary intake

alone (with the use of fortified, processed foods), a diverse diet is required.

• Micronutrient-rich foods include fruit and vegetables, meat

and dairy, pulses, seafood, nuts and seeds.

• In contrast, cereal, root and tuber commodities tend to be energy-

dense but micronutrient-poor.

• In the chart below we have plotted the hidden hunger index in

children (on the y-axis) versus the share of dietary energy attained through the consumption of cereals, roots and tubers. Overall, we see that countries where the average diet is rich in micronutrient- poor cereals tend to have higher levels of micronutrient deficiency (here shown as hidden hunger in children).

+ Tackling Micronutrient Deficiencies: Causes and solutions

+ Tackling Micronutrient Deficiencies: Causes and solutions

92.3 58.1 76.2 83.7 58.9 92.3 41.3 90.1 55.7 63.1 89.1 53.4 90.1 29.9 20 40 60 80 100 Vitamin A Vitamin C Niacin Riboflavin Thiamin Iron Calcium Girl Boy Source: Nutrition Society of Malaysia, 2015

+ Tackling Micronutrient Deficiencies: Causes and solutions

Nutrient intakes as a percentage of children’s Recommended Nutrient Intake

Urinary iodine level (µg/L) in Malaysia by state, 2008

140.7 207 131 101.9 150.2 76.9 78.7 76.5 118 125.5 120.8 126 77.8 85.8 85.2 115.2 50 100 150 200 250 WP Labuan WP Putrajaya WP Kuala Lumpur Sarawak Sabah Kelantan Terengganu Pahang Johor Malacca Negeri Sembilan Selangor Perak Penang Kedah Perlis

Recommended minimum iodine level of 100 µg/L

Source: Wan Nazaimoon & Rusidah, 2010

+ Tackling Micronutrient Deficiencies: Causes and solutions

Population affected by anaemia by age group, 2015

Men 15-59 years 23% Women 15-45 years 51% Women 50-59 years 8% Elderly women 10% Elderly men 8%

Source: NHMS 2015, as reported by Awaluddin, et al., 2017

+ Tackling Micronutrient Deficiencies: Causes and solutions

Total population 4.9 million (95% CI 4.6-5.1)

Prevalence of anaemia (Hb, 11gm) among pregnant mothers at the 36th week of gestation who attended government health facilities, 2004–2015

38.3 32.6 28.9 26.7 24 21.5 20.8 16.2 14 11.8 9.3 8.2 5 10 15 20 25 30 35 40 45 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Prevalence (%) Year

Source: Health Information Centre, Ministry of Health, Malaysia

+ Tackling Micronutrient Deficiencies: Causes and solutions

Prevalence of Vitamins and Minerals Supplement Uses

Malaysian Adults – Total – 28.05% Men – 24.29% Women – 32.12%

Type of Supplements: Vitamin C 15.68% Multivitamin and multimineral 8.87% Calcium 5.84% Vitamin B-complex 5.62% Folic Acid 2.70% Vitamin E 2.62% Iron 2.06 Zinc 1.32 Vitamin A NA Vitamin B12 0.78

+ Tackling Micronutrient Deficiencies: Causes and solutions

Intake of Fruits and Vegetables

WHO recommendations: 5 servings per day (Fruits = 2 servings, Vegetables

= 3 servings)

About 10% of Malaysian adults met the WHO recommendations Adequate intake of fruits (=2 servings) – 9.9% Adequate intake of vegetables (=3 servings) – 11.2% (NHMS 2015) Top 5 Vegetables and Fruits consumed by Malaysian adults (MANS

2014) Vegetables Prevalence Fruits Prevalence Green leafy vegetables 66.0% Apple 34.3% Cabbage 19.0% Papaya 21.0% Fruity vegetables 10.8% Orange/mandarin 16.3% Seedy vegetables 10.7% Banana 15.3% Tuber vegetables 10.5% Guava 14.4%

+ Tackling Micronutrient Deficiencies: Causes and solutions

Prevention and treatment of micronutrient deficiency If micronutrient requirements cannot be met through dietary intake alone (for example if households do not have access to or cannot afford the dietary diversity required) common strategies to address deficiencies are:

• Supplementation: supplementation is the delivery of

concentrated micronutrients in pill, powder or liquid form;

• Food fortification: fortification is a subset of food

processing and involves the addition of small amounts

• f micronutrients to food products (such as cereals,

wheat flours and rice);

• Biofortification: the use of agronomic and plant-

breeding approaches in agriculture to increase the concentration of micronutrients in staple food crops. The most well-known example is so-called ‘golden rice‘, which is rice grown with high concentrations of vitamin-A.

+ Tackling Micronutrient Deficiencies: Causes and solutions

JENIS MAKANAN

Pakej 1 Pakej 2 Pakej 3 Pakej 4 Pakej 5 Pakej 6 Pakej 7 Pakej 8 Pakej 9 Pakej 10 Pakej 11 Pakej 12 Pakej 13

Beras (5 kg)

√ √ √ √ √ √

Bihun (2.8-3 kg )

√ √ √ √ √ √

Susu Tepung Penuh Krim (1.8 -2 kg)

√ √ √ √ √ √ √ √ √ √ √ √

Bijirin Sarapan (0.9-1 kg)

√ √ √ √ √ √ √ √ √ √ √ √

Biskut (1.8-2 kg)

√ √ √ √ √ √ √ √ √ √ √ √

Telur (30 biji)

√ √ √ √

Ikan sardin (7 tin kecil:155g/tin)

√ √ √ √

Ikan bilis (500 g)

√ √ √ √

Marjerin (240-250g)

√ √ √ √ √ √

Minyak Masak (1 kg)

√ √ √ √ √ √

Serbuk Malt Coklat (1 kg)

√ √ √ √ √ √ √ √ √ √ √ √

Multivitamin (30/ 60 biji atau 50-120ml)

√ √ √ √ √ √ √ √ √ √ √ √ √

Susu Khas/ Susu Formula (1.6-2 kg)

√

PILIHAN PAKEJ

+ Tackling Micronutrient Deficiencies: Causes and solutions

National Plan of Action on Nutrition Malaysia III

+ Tackling Micronutrient Deficiencies: Causes and solutions

National Plan of Action on Nutrition Malaysia III

+ Tackling Micronutrient Deficiencies: Causes and solutions

• Sabah and Sarawak was gazette as areas that selling of

iodized salt is mandatory under the Food Act 285

• Proposal to include Peninsular Malaysia and Labuan to

ban the sale of salts that do meet Potassium Iodide and Sodium Iodide as a strategy to reduce iodine deficiency is still pending – Universal Salt Iodisation (USI)

• Prevention and cure include:

Mandatory sale of iodised salt in Sabah and Sarawak Education and promotion including nutrition and health counseling to improve nutritional status in the affected Distribution of iodised salt to pregnant mothers and malnourished children in the endemic areas Monitoring activities Research

1 8

Prevention and Monitoring of Iodine Deficiency Disorders in Malaysia

18 Bahagian Peakanan, KKM

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19

Anemia Prevention and Monitoring Program Among Pregnant Mothers

Activities:

• Supplying hematinic (Ferrous

Fumarate, Vitain C, Folic Acid and B=complex)

• Developed nutritional

guidelines for anemic pregnant mother for health workers

• Educational materials

(booklets and posters).

• Nutrition education and

counseling for anemic pregnant mothers.

+ Tackling Micronutrient Deficiencies: Causes and solutions

Approaches to Combat Micronutrient Deficiencies

• Supplementation - Analysis of available supplementation programs

show that provision of micronutrient supplementation is most effective when combined with other maternal and child health interventions through primary health care systems or health care delivery systems

• Pregnant women and lactating women - Strong evidence exists

that daily iron supplementation improves hemoglobin concentrations and iron stores and reduces the risk of anemia, iron deficiency, and iron deficiency anemia during pregnancy

• Children – to increase hemoglobin concentrations has also been seen

in children however not for the overall physical growth of infants or

• children. It can also modestly improve mental development scores
• Vitamin A supplementation in children - Integrated approaches

are not only more effective, but also cheaper than stand-alone supplementation programs

• Iron and folic acid supplementation during pregnancy - Iron

supplementation during pregnancy is usually delivered through antenatal care

+ Tackling Micronutrient Deficiencies: Causes and solutions

Fortification

• Food fortification can be with single, dual, or multiple micronutrients are

normally targeted toward foods that are eaten by specific population groups. For school children, for example, a MMN-fortified foods (beverages, milk products, biscuits, seasoning powder) for child growth and improved cognitive domains and reduced morbidity

• Mass fortification – the focus is on foods that are widely consumed by the

majority of the target population. For example of fortified foods in developing countries are salt (with iodine) and wheat or maize flour (with several micronutrients), folic acid-fortified flour, traditional condiments and seasonings (eg, soy and fish sauces or curry powder) have been proposed as fortification vehicles, mainly in countries where they are widely consumed.

• In Vietnamese women, for example, consumption of fortified fish oil was shown to improve

iron status and reduce the prevalence of anemia (Van Thuy et al, 2003 &2005)

• In Guatemala, fortification of sugar with vitamin A has led to a dramatic reduction in the

prevalence rates of vitamin A deficiency (Dary & Mora, 2002)

• In Uganda, vegetable oil is fortified with vitamin A. In Brazil, fortifying potable water with

iron has been shown to be efficient in reducing iron deficiency and anemia in infants and small children, and feasible and can be done at community level

• MMN – Multiple micronutrient

+ Tackling Micronutrient Deficiencies: Causes and solutions

Biofortification

Is the process of enhancing the nutrient content of staple crops through traditional breeding and modern technology

• Biofortified varieties of rice, wheat, maize, cassava, pearl millet, beans,

and sweet potato are currently being developed with conventional breeding being the primary focus to increase the content of iron, zinc, and provitamin A carotenoids

• The amount of micronutrients that can be provided by biofortified

staple foods is much lower than the amount that can be achieved by supplementation or food fortification

• The benefit of biofortification depends on the amount of the staple food

consumed per day

• Currently, dissemination of biofortified crops is limited to orange sweet

potato, which is high in provitamin A

+ Tackling Micronutrient Deficiencies: Causes and solutions

Approaches to Combat Micronutrient Deficiencies

Local production of micronutrient rich foods through home gardens, livestock, and small fish – co-strategy to increase dietary diversity

• Nutrition-sensitive agricultural interventions, when community-based,

culturally acceptable, and economically feasible, have the potential to be the most sustainable long-term intervention of all for preventing multiple micronutrient deficiencies

• A systematic review showed that most agricultural studies, including home

gardens, with or without animal production strategies were associated with increased dietary diversity

• Agricultural interventions can complement supplementation and fortification
• programs. In contrast to supplements and fortified foods, agricultural

interventions deliver macro- and micronutrients, fiber, and phytochemicals. Additional non-nutritional benefits include empowerment of women through production for sale in markets

• Some small fish species in developing countries are rich sources of vitamin A,

iron, and zinc, and are more affordable and accessible than the larger fish. These locally available small fish have potential as a cost-effective food-based strategy to enhance micronutrient intake; however, only a few studies are available, and more research is needed (Kawarazuka and Bene, 2011)

+ Tackling Micronutrient Deficiencies: Causes and solutions

Food-based Approaches

+ Tackling Micronutrient Deficiencies: Causes and solutions

Food-based Approach

• The importance of food-based strategies to combat micronutrient

deficiencies was advocated by FAO (Rome) back in 1992, at the International Conference on Nutrition and reiterated in 2nd ICN in 2014.

• Food Security should address the issue of quantity, as well as quality of the

diet, in terms of food groups: cereals and millets, pulses and legumes, milk and meat products, fruits and vegetables and fats and sugars.

• This strategy promotes dietary diversification, using locally available

foods to satisfy local food habits and facilitates recommended nutrient intakes.

• Unlike supplementation or fortification, which can address the deficiency
• f only select nutrients, dietary diversification is a more holistic and

balanced approach with little or no danger of toxicity.

• It demands creating an enabling environment of awareness, and ensuring

access at affordable cost to a variety of foods, within and across food groups to obtain adequate micronutrients

Source: Bamji MS and Nair KM, 2016

+ Tackling Micronutrient Deficiencies: Causes and solutions

Common Pulses

Pulses are the dried seeds of the legume plants. Hundreds of different varieties of pulses are grown around the globe.

Dry beans Lentils Faba beans Dry peas Chickpeas Cow peas Bambara beans Pigeon peas Lupins Vetches

+ Tackling Micronutrient Deficiencies: Causes and solutions

Conclusion

• Micronutrient deficiencies can undoubtedly have profound influences on

the health of at-risk populations. Poor households are the most vulnerable to micronutrient malnutrition, and more permanent solutions are still required. For example, anemia remains a public health problem

• f huge magnitude, yet little progress in controlling it has been achieved

in the developing world.

• Both dietary and non-dietary factors, such as; access to clean drinking

water and sanitation, health care, purchasing power, women’s education and empowerment, contribute to micronutrient inadequacy

• To be successful, fortification and supplementation programs must have

high-level government involvement. Fortification programs, for example, require political support, adequate marketing, and long-term commercial commitment.

• Supplementation which is a short term strategy expected to produce

quick remediation provided for combating anaemia, and vitamin A deficiency, it has now become a long term strategy for many governments.

• Food-based strategies need to be promoted vigilantly by all stakeholders

and the link between agriculture, nutrition, and health and local environment need to be highlighted prominently

+ Tackling Micronutrient Deficiencies: Causes and solutions

References

Girard AW, Self JL, McAuliffe C, Olude O (2012). The effects of household food production strategies on the health and nutrition outcomes of women and young children: a systematic review. Paediatr Perinat Epidemiol. 26(Suppl 1):205– 222. Dary O, Mora JO (2002). International Vitamin A Consultative Group. Food fortification to reduce vitamin A deficiency: International Vitamin A Consultative Group recommendations. Journal of Nutrition 132(Suppl 9): 2927S–2933S Zaiton Daud (2018). Program Pemakanan Di Malaysia, Putrajaya: Bahagian Pemakanan, Kementerian Kesihatan Malaysia Bee Koon Poh, Boon Koon Ng, Mohd Din Siti Haslinda, Safii Nik Shanita, Jyh Eiin Wong, Siti Balkis Budin, Abd Talib Ruzita, Lai Oon Ng, Ilse Khouw and A. Karim Norimah (2013). Nutritional status and dietary intakes of children aged 6 months to 12 years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia) British Journal of Nutrition, 110, S21–S35 doi:10.1017/S0007114513002092 Thompson B and Amoroso L (2011). Combating Micronutrient Deficiencies: Food-based Approaches. Rome: FAO Bamji MS and Nair KM (2016). Food-based Approach to Combat Micronutrient Deficiencies. Proc Indian Natn Sci Acad 82 No. 5 December pp. 1529-1540 DOI: 10.16043/ptinsa/2016/48885 Van Thuy P, Berger J, Nakanishi Y, Khan NC, Lynch S, Dixon P (2005). The use of NaFeEDTA-fortified fish sauce is an effective tool for controlling iron deficiency in women of childbearing age in rural Vietnam. Journal of Nutrition ,135(11):2596–2601. Van Thuy P, Berger J, Davidsson L, et al. (2003) Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces the prevalence of anemia in anemic Vietnamese women. American Journal of Clinical Nutrition, 78(2):284–290 Kawarazuka N, Béné C (2011). The potential role of small fish species in improving micronutrient deficiencies in developing countries: building evidence. Public Health Nutr. 14(11):1927–1938.

+ Tackling Micronutrient Deficiencies: Causes and solutions