Role of Zinc and Vitamin A in Child Health
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Role of Zinc and Vitamin A in Child Health. Emorn Wasantwisut Institute of Nutrition Mahidol University. Millennium Development Goals. Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality.

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Role of Zinc and Vitamin A in Child Health

Emorn Wasantwisut

Institute of Nutrition

Mahidol University


Millennium Development Goals

Eradicate extreme poverty

and hunger

Achieve universal primary

education

Promote gender equality and

empower women

Reduce child mortality

Improve maternal health

(75% of MMR by 2015)

Combat HIV/AIDS, malaria,

and other diseases

Ensure environmental

sustainability

Develop a global partnership

for development

1

5

6

2

7

3

4

8

Millennium Summit, Sep.2000


Selected major risks to health : Childhood and maternal undernutrition

Risk factor Measured adverse outcomes (of exposure)

Underweight Mortality and acute morbidity from infectious

diarrhoea, malaria, measles, pneumonia and other infectious diseases.

Perinatal conditions from maternal underweight

Iron deficiency Anaemia, maternal and perinatal causes of death

Vitamin A deficiency Diarrhoea, malaria, maternal mortality,

vitamin A deficiency disease

Zinc deficiency Diarrhoea, pneumonia, malaria

Source : World Health Report 2002


Summary of selected risk factors undernutrition

  • Risk Factor South - East Asia West-Pacific

  • Child/Adult Mortality Low High Very Low Low

  • Under weight 26 46 4 16

  • (%< 2 SD W/A)

  • Iron def 11.0 10.4 12.5 11.0

  • (Mean Hb in g/dl)

  • Vitamin A def. 28 18 0 9

  • (% VAD+NB)

  • Zinc def. 34 73 4 9

  • (% inadequate intake)

World Health Rep:2002


Leading 10 selected risk factors as percentage causes undernutrition

of disease burden measured in DALYs

Developing countries

High mortality countries

Under weight 14.9%

Unsafe sex 10.2%

Unsafe water, sanitation and hygiene 5.5%

Indoor smoke from solid fuels 3.7%

Zinc deficiency 3.2%

Iron deficiency 3.1%

Vitamin A deficiency 3.0%

Blood pressure 2.5%

Tobacco 2.0%

Cholesterol 1.9%

World Health Rep:2002


Burden of disease loss of healthy life years
Burden of Disease - Loss of healthy life years undernutrition

DALYS (million)

Underweight138

Iodine Deficiency 2.5

Iron Deficiency 35

Vitamin A Deficiency 22.5

Zinc Deficiency 28


Vitamin A Deficiency undernutrition

  • Xerophthalmia blindness

  • limit growth

  • Weaken host defenses

  • infection & risk of death

  • morbidity & mortality during pregnancy and early post partum

  • disadvantaged newborn

Childhood

Women of Reproductive age


Vitamin A Supplementation undernutrition

Prevention

Treatment

at Diagnosis

Age

Dosage Frequency

< 6 mo 50,000 IU 6, 10,14 wks with

DPT/Polio

< 6-11 100,000 IU Every 4-6 mo

> 1 yr 200,000 IU Every 4-6 mo

Women 200,000 IU < 8 wks after (? 400,000 IU) delivery

Refs : WHO/UNICEF/IVACG 1997, IVACG 2000


Impact of Vitamin A on child Mortality undernutrition

% Reduction

  • Indonesia

    • Aceh 34

    • Bogor 45

  • Nepal

    • Sarlahi 30

    • Jumla 29

  • India

    • Tamil Nadu (wkly dose) 54

    • Hyderabad 6

  • Sudan+6

  • Ghana19

Source : Sommer & West 1996


Global Prevalence - Maternal VAD undernutrition

(In millions)

Serum VA BM-VA Night-

<0.70 umol/L <1.05 umol/L Blindness

Africa 2.4 5.4 1.1

E. Mediterranean 1.8 3.8 0.5

S/SE Asia 2.2 8.8 3.9

W.Pacific 1.2 2.7 0.5

Americas 0.4 0.8 0.4

Ref: K. West, J Nutr 2002; 132: 2857S-2866S


VA and mortality related to pregnancy 12 wks Post partum undernutrition

Placebo VA -carotene VA or - C

b

b

# Pregnancies 7,241 7,747 7,201 14,948

# Deaths 51 33 26 59

Mortality 704 426 361 395

(per 100,000 pregnancies)

RR 1.0 0.60 0.51 0.56

(95%CI) (0.37-0.97) (0.30-0.86) (0.37-0.84)

Refs : West et al 1999


Clinical signs of severe zinc deficiency
Clinical signs of severe zinc deficiency undernutrition

  • Reduced appetite, taste acuity

  • Reduced growth velocity

  • Skin lesions

  • Diarrhea, other infections

  • Delayed sexual maturation, reduced fertility


Mean (± SD) daily per capita absorbable zinc as percent of requirement, and estimated percent of population at risk of low intake, by region


Prevalence of growth stunting
Prevalence of growth stunting requirement, and estimated percent of population at risk of low intake, by region

  • Percentage of pre-school children with height-for-age < -2 SD with respect to international reference data (data already available for most countries)

  • Based on prior observations that stunted (but not non-stunted) children respond to zinc supplementation with increased linear growth


Mean requirement, and estimated percent of population at risk of low intake, by region+ 95% C.I. for effect size of change in height, by mean initial height-for-age z-score

Data from Brown KH et al, AJCN, 2002


Risk of zinc deficiency based on absorbable zinc in food supply and prevalence of growth stunting
Risk of zinc deficiency, based on absorbable zinc in food supply and prevalence of growth-stunting

Low

Inter-mediate

High


Preventive Effect of Zinc Supplementation on Diarrheal Prevalence in Continuous Supplementation Trials

B.Faso

India

Mexico

PNG

Peru

Vietnam

Ethiopia

Guatemala

Jamaica

Pooled

0

0.25

0.5

0.75

1

1.25

1.5

1.75

2

Odds Ratio and 95% CI


Effect of zinc supplementation on duration of acute diarrhoea time to recovery
Effect of Zinc Supplementation on Duration of Acute Diarrhoea/Time to Recovery

*India, 1988

*Bangladesh, 1999

*India, 2000

*Brazil, 2000

*India, 2001

Indonesia, 1998

India, 1995

Bangladesh, 1997

India, 2001

India, 2001

Nepal, 2001

Bangladesh, 2001

Pooled

1

*Difference in mean and 95% CI

Relative Hazards and 95% CI


Efficacy of zinc in therapy of severe pneumonia
Efficacy of Zinc in Therapy Diarrhoea/Time to Recovery of Severe Pneumonia*

  • Bangladeshi children <2y old with severe pneumonia

  • 270 randomized to 20mg zinc/d or placebo along with standard antibiotics (amp./gent.)

  • Zinc group had shorter duration of severe pneumonia (RH 0.81; 0.67, 0.99) and of chest indrawing, elevated RR and hypoxia

* Brooks et al, submitted


Effect of zinc supplementation on malaria in children
Effect of Zinc Supplementation on Malaria in Children Diarrhoea/Time to Recovery

Location

Reduction in Clinic Visits for Malaria

The Gambia

32% (p=0.09)

Papua New Guinea

38% (p<0.05)

Combined

36% (CI 9-55%, p<0.05)



Prevention on Mortality

Effective Child Survival Interventions

Cause of Under 5 death

Diarrhea Pneumonia Measles Malaria..

  • Exc.BF 6 mo

  • & Cont.BF 6-11 mo

  • Comp. feeding

………

  • Zinc

?

?

?

  • Vitamin A

Source : Jones et al. Lancet 2003


Treatment on Mortality

Effective Child Survival Interventions

Cause of Under 5 death

Diarrhea Pneumonia Measles Malaria..

  • Oral Dehydration

  • Antibiotic-Pneumonia

  • Antimalarials

………

  • Zinc

  • Vitamin A

Source : Jones et al. Lancet 2003


  • Maternal IDD on Mortality

    • stillbirth

    • mild to severe brain damage

    • fetal damage: subcretins,

    • neurological cretinism

  • Childhood and adult hypothyroidism

    • Neonatal Hypothyroidism:

      • high TSH in neonates

    • Cerebral hypothyroidism

    • Mental torpor and apathy


Iron and its effects on Mortality

Infants Cognition, growth&

development

Children Cognition/physical

Adolescent Cognition/Fe store/

physical

Non-pregnant Productivity

Iron store

Pregnant Pregnancy outcome

Lactate Lactation

newborns

Immunity


SUPPLEMENTATION WHEN ? on Mortality

  • 1. Treat Severe or Clinical Deficiencies

  • 2. Prevention in

    • endemic areas

    • high risk groups

3. NOT possible to meet requirements

from diet, e.g., pregnancy, lactation


KEY TO CHANGES on Mortality

Form, Dose, Safety

Bioavailability, Interaction,

SUPPLEMENTATION

Delivering System &

Compliance

Impact on Status

Choice of food vehicles &

fortification

Processing, sensory, shelf-life

QA system

FORTIFICATION

Bioavailability

Impact on Status

UPSCALE

INTERVENTION


Baby - LBW/Undernutrition on Mortality

Child growth failure

Early pregnancy

Low Wt & Ht teenagers

Small adult women

Small adult men


Urine I on Mortality

TSH

Hb/Hct

TfR

Bmilk-VA

Dark Adapt.

Retinol

Urine I

BLOOD

SPOT

(Hb/Hct

TfR,

Retinol)

Hct

TGR

Urine I

Monitoring &

surveillance:

groups &

indicators

Repro-

ductive

age women

Pre-

school

age

Mothers

(P+L)

&

fetus

Neonate

&

infants

(0-2 yr.)

School

age

Adults

“Iodized salt”

Quality of I- salt

Iodine

Preventive

supplem.

& Fd based

Food Industry

Iron

weekly

daily

weekly

weekly

Fortified food

Food

based

Periodic vitamin A capsule

Vit A

Indigenous foods


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