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Vitamin A Deficiency By Caroline Delori and Shira Lipsky Malnutrition Millions of mothers and children die each day from malnutrition. 83% of children die due to mild or moderate malnourishment. 1/3 rd of world’s population is micronutrient deficient

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Vitamin A Deficiency

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Vitamin a deficiency l.jpg

Vitamin A Deficiency

By Caroline Delori

and Shira Lipsky


Malnutrition l.jpg

Malnutrition

  • Millions of mothers and children die each day from malnutrition.

  • 83% of children die due to mild or moderate malnourishment.

  • 1/3rd of world’s population is micronutrient deficient

  • The global economy produces enough food to feed the entire world population.

  • Result of several factors combined.

    www.info.usaid.gov/pop_health/nmh


What is vitamin a l.jpg

What is Vitamin A?

  • Organic compounds that are present in small amounts in foods that are not digested, but absorbed through small intestine.

  • VA Functions; metabolic, photosensitive pigments of retinal cells, differentiation of epithelia.

  • Fat soluble and any excess cannot be excreted in the urine.

  • Most common preformed vitamin found in food is retinol.

    • Found in animal products, such as fish oils, milk, and butter.

  • Carotenoids are converted by the body into retinol.

    • Found in dark leafy vegetables, such as sweet potatoes and yellow fruits and palm oil, and in red chili. It is the red pigment present in carrots.

    • Half of biological activity of VA because of low conversion rate.


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The VAD Story!

  • 230 million children are at risk for VAD.

  • Over one million VAD childhood associated deaths in one year.

  • VAD is prevalent in over 75 countries distributed in S.E. Asia and Africa

  • VAD leads to

    • Infant and child mortality

    • Keratinization- dry skin and cracking of mucous membranes

    • Xerophthalmia- dryness of the eye, blindness

    • Diarrheal disease and respiratory infections

  • Strong link between VAD and infection.


What is va good for l.jpg

VA is most beneficial for infants, young children, pregnant and lactating mothers.

VA programs have shown to impact

Xerophthalmia

Measles

Child Survival

Growth

Other infections

What is VA good for?


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Estimated Numbers of People At-risk and Affected by VAD

RegionVA At RiskVA Affected (Xerophthalmia)

Africa521.0

Americas160.1

South East Asia1251.5

Eastern Mediterranean160.1

Western Pacific420.1

Total (millions)2512.8

http://www.sph.emory.edu/PAMM/Ih552/Jan28fortification/


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A Little History

  • 1904- First epidemic of xerophthalmia in Japan

  • 1947- Industrial VA synthesis

  • 1964- First global survey of VAD

  • 1980’s- Importance of VA in child survival was shown

  • 1990- Summit for children

  • 1991- Ending Hidden Hunger Conference

  • 1992- International Conference on Nutrition

    www.sightandlife.or/info/slides/slidesp16-30.pdf

    www.worldbank.org/html/extdr/hnp/nutrition


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How to Combat VAD


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Supplementation

  • Short-term solution

  • Therapeutic, targeted, or universal

  • Liquid filled gelatin capsules

  • Given orally or intravenously

  • .02 cents each capsule

  • $1.64- 2.20 per child for VA program


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VA Distribution Schedule

AgeRecommended DosageSchedule

0-6 mo.25, 000 IUevery 4 weeks

6-11 mo.100, 000 IUevery 3-6 mo.

1-6 yrs.200, 000 IUevery 3-6 mo.

Pregnant women10, 000 IUevery day during gestation

Lactating mothers200, 000 IUonce

www.sightandlife.org/info/manual/salManchap10.pdf


Food fortification l.jpg

Food Fortification

  • Medium-term solution

  • Increase nutrients in specific foods

    • Margarine, milk, sugar

  • Identify food vehicle & fortificant

  • Requires commitment from government, food industries, legislation, consumers, and research facilitation.

  • .36 cents per person

    http://www.jsi.com/intl/omni/sugr_pt1.htm


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Selecting a VA Food Vehicle

  • Must be consumed by a large proportion of the population.

  • “Little day to day and inter-individual variation occurs in the amount of the food vehicle consumed” which will ensure VA intake remains within a safe range.

  • Food vehicle must go through a process in which VA can be added under controlled conditions and at a minimum cost.

  • Must be able to track the delivery of fortified food.

    www.jsi.com/intl/omni/sugr_pt1.htm


Selecting a va fortificant l.jpg

Selecting a VA Fortificant

  • Miscible in the food vehicle

  • Must not change the smell, color or taste of the food

  • No chemical interaction with the food resulting in damage of the original food

  • Stable

  • No significant increase in cost of food to the consumer.

    www.jsi.com/intl/omni/sugr_pt1.htm


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Process of Food Fortification


Slide16 l.jpg

www.jsi.com/intl/omni/sugr_pt1/htm


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Diet Diversification

  • Long-term solution

  • Should run parallel with other short-term solutions

  • Increases the variety and frequency of micronutrient rich food sources

  • Modifies food production, consumption and distribution

    • Red palm oil

    • Sweet potatoes, 1998

  • Cost effective and won’t lead to hypervitaminosis.

  • Through nutritional education, home gardens and improved methods of food preparations, preservation and cooking.

  • No medicalization of food

    www.jsi.com/intl/omni/sugr_pt1.htm


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Nutrition Education

  • Long-term commitment from the participants.

  • Education of mother and children on how to eat a more well balanced diet filled nutrients

  • Improved local access to VA-rich foods

  • Economic and social payoffs are as high as 84 times the program costs

  • Requires economic, political, operational, behavioral sustainability.


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DEBATE

Which program would be most effective in the country you selected for your MCH proposal? Discuss the issues involved in implementing a program solution. Use the list of pros and cons.


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Different Programs Must Consider…

  • Survey the extent of the problem

  • Severity of the deficiency

  • Distribution of the deficiency

    based on; age, gender, urban, rural, agriculture, socioeconomic

  • Identifying target population

  • Screening for VAD

    www.jsi.com/intl/omni/sugr_pt1.htm


Program issues supplementation l.jpg

Program Issues: Supplementation

  • Most common vehicle is EPI

  • What will happen when polio is eradicated?

  • Timing of intervention and cost

  • Scope of population reached

  • Procurement or production VA capsules- UNICEF

  • Monitoring of VA program

  • Requires foreign currency

  • An efficient, sustainable distribution system

  • Shared responsibility by immunization and nutrition sectors.

  • National Micronutrient Day in Niger

    http://dcc2.bumc.bu.edu/IH887/IH887A~1.htm


Program issues food fortification l.jpg

Program Issues: Food Fortification

  • Identify food vehicle and fortificant; the high cost of fortificant

  • Field testing of fortificant must be done at many locations in one country due to differing environmental conditions.

  • There might not be a food vehicle, in which case, one must be created.

  • Need technologically developed food industry, field testing and appropriate monitoring.

  • Micronutrient losses may occur at each point in distribution chain and at household levels during storage and preparation.

  • Social marketing of the fortified food

  • Harmonization between different sectors involved

    • Sangkap Pinoy Seal Program in Philippines

    • Zambia, May 1998

    • Swaziland, June 1999


Program issues diet diversification l.jpg

Program Issues: Diet Diversification

  • Home gardening issues

    • available technology- seeds, assistance

    • cultural acceptability and sensitivity

    • land suitable for gardening

    • time

  • Requires community involvement

  • Requires nutritional education of consumers

    • Challenging to coordinate and requires much cooperation

    • Labor intensive operation

    • Costly economically and logistically

  • Results aren’t readily seen

    http://dcc2/bumc.bu.edu/IH887/IH887A~1.htm


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Cost Analysis of Programs

Summary of cost-effectiveness of three VA interventions in Guatemala, 1991.

ProgramPersons reachedHigh-risk person reached

Fortification 0.2870.653

Capsule Distribution1.5241.524

Food Production/Education1.1912.707

(long-term effect)

Phillips, M, Sanghvi T, Suarez R, McKingney J, and Fiedler J. The Costs and Effectiveness of Three Vitamin A Interventions in Guatemala. Soc Sci Med.1996.42(12):1661-1668


Controversy issues l.jpg

Controversy Issues

  • VA is a known teratogen

  • Difficult to evaluate if maternal mortality rate is effected by VAD

  • Side effects of hypervitaminosis:

    • Malformation

    • Schizophrenia

    • Head ache and loss of appetite

    • Bulging Fontanelle


More controversies l.jpg

More Controversies…

  • There are pros and cons to all interventions, therefore difficult to assess which one to implement.

  • Protection afforded by prophylactic large doses

  • Dosage amount

  • Associated with the increase in severity of the infection

  • Ghana Study

  • Selection of target population- high-risk, medium risk, and low risk populations

  • Multiple micronutrient fortification

  • Which food vehicles and fortificants to use

  • Reports that dark vegetables and fruits do not provide as much carotenoids as was assumed.


Biotechnology l.jpg

Biotechnology

  • You provide the idea and they’ll make it!

    • Genetically Engineered Rice

  • You can target very precisely the kind of crops needed

  • Increase agricultural production time

  • The potential benefits of VA in a grain of rice are greater than the possible risks.

  • Requires cooperation among scientists and funding institutions

  • Rarely managed correctly

  • Unforeseen negative effects

  • Risks range from human health effects through eating the foods to environmental impacts- spreading genes through cross pollination to other plants

  • Many people opposed to idea because of possible issues

  • Need global forum for governments, NGO’s and industries to discuss risks and benefits of biotechnology

    http://www.cgiar.org/ifpri/media/innews/2052099.htm


New technology l.jpg

New Technology

  • CIP (International Potato Center)- sweet potatoes varieties increase intake of VA

  • Swiss Federal Institute of Technology- genetically engineered rice

  • Plants that fortify themselves and deliver VA through their seeds.

  • MI and UNICEF- developing and testing new dropper to administer VA

  • WHO and UNICEF-

    • IMCI (Integrated Management of the Sick Child)- treat VAD to reduce diseases

    • IMCI- taking advantage of the contact made when a sick child comes in for care


Conclusions l.jpg

Conclusions

  • Different countries require various solutions, sometimes a combination of two

  • Middle income countries- Philippines, Zambia and other Latin Am. countries

    • Food fortification

  • Low income countries- Urban

    • Food fortification and government subsidies

  • Low income countries- Nepal, Bangladesh, and rural Indonesia

    • Supplementation used

    • Extreme measures

  • Evaluation of supplementation programs with a case control study.

  • Biotechnology is an option, but must look at the different environments to see what should be implemented

  • Must answer if should implement program even if not all at risk or unknown

  • Focus should be on reduction of infections improving primary health care, sanitation, water supply, and reducing poverty.


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