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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Emorn wasantwisut institute of nutrition mahidol university

Role of Zinc and Vitamin A in Child Health

Emorn Wasantwisut

Institute of Nutrition

Mahidol University


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


Emorn wasantwisut institute of nutrition mahidol university

Selected major risks to health : Childhood and maternal undernutrition

Risk factorMeasured adverse outcomes (of exposure)

UnderweightMortality and acute morbidity from infectious

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

Perinatal conditions from maternal underweight

Iron deficiencyAnaemia, maternal and perinatal causes of death

Vitamin A deficiencyDiarrhoea, malaria, maternal mortality,

vitamin A deficiency disease

Zinc deficiencyDiarrhoea, pneumonia, malaria

Source : World Health Report 2002


Emorn wasantwisut institute of nutrition mahidol university

Summary of selected risk factors

  • Risk Factor South - East AsiaWest-Pacific

  • Child/Adult Mortality Low High Very LowLow

  • Under weight 26 46416

  • (%< 2 SD W/A)

  • Iron def 11.0 10.4 12.511.0

  • (Mean Hb in g/dl)

  • Vitamin A def. 28 180 9

  • (% VAD+NB)

  • Zinc def. 34 734 9

  • (% inadequate intake)

World Health Rep:2002


Emorn wasantwisut institute of nutrition mahidol university

Leading 10 selected risk factors as percentage causes

of disease burden measured in DALYs

Developing countries

High mortality countries

Under weight14.9%

Unsafe sex10.2%

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

DALYS (million)

Underweight138

Iodine Deficiency2.5

Iron Deficiency35

Vitamin A Deficiency22.5

Zinc Deficiency28


Emorn wasantwisut institute of nutrition mahidol university

Vitamin A Deficiency

  • 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


Emorn wasantwisut institute of nutrition mahidol university

Vitamin A Supplementation

Prevention

Treatment

at Diagnosis

Age

Dosage Frequency

< 6 mo 50,000 IU6, 10,14 wks with

DPT/Polio

< 6-11100,000 IU Every 4-6 mo

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

Women200,000 IU < 8 wks after (? 400,000 IU)delivery

Refs : WHO/UNICEF/IVACG 1997, IVACG 2000


Emorn wasantwisut institute of nutrition mahidol university

Impact of Vitamin A on child Mortality

% Reduction

  • Indonesia

    • Aceh34

    • Bogor45

  • Nepal

    • Sarlahi30

    • Jumla29

  • India

    • Tamil Nadu (wkly dose)54

    • Hyderabad 6

  • Sudan+6

  • Ghana19

Source : Sommer & West 1996


Emorn wasantwisut institute of nutrition mahidol university

Global Prevalence - Maternal VAD

(In millions)

Serum VA BM-VA Night-

<0.70 umol/L <1.05 umol/L Blindness

Africa2.45.41.1

E. Mediterranean1.83.80.5

S/SE Asia2.28.83.9

W.Pacific1.22.70.5

Americas0.40.80.4

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


Emorn wasantwisut institute of nutrition mahidol university

VA and mortality related to pregnancy 12 wks Post partum

Placebo VA -caroteneVA or - C

b

b

# Pregnancies7,2417,7477,20114,948

# Deaths51 33 2659

Mortality 704 426 361 395

(per 100,000 pregnancies)

RR1.0 0.60 0.510.56

(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

  • Reduced appetite, taste acuity

  • Reduced growth velocity

  • Skin lesions

  • Diarrhea, other infections

  • Delayed sexual maturation, reduced fertility


Emorn wasantwisut institute of nutrition mahidol university

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

  • 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


Emorn wasantwisut institute of nutrition mahidol university

Mean + 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


Emorn wasantwisut institute of nutrition mahidol university

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 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

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)


Trial of zinc or vitamin iron supplementation in sga infants on mortality

Trial of Zinc or Vitamin/Iron Supplementation in SGA Infants on Mortality


Emorn wasantwisut institute of nutrition mahidol university

Prevention

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


Emorn wasantwisut institute of nutrition mahidol university

Treatment

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


Emorn wasantwisut institute of nutrition mahidol university

  • Maternal IDD

    • 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


Emorn wasantwisut institute of nutrition mahidol university

Iron and its effects

Infants Cognition, growth&

development

Children Cognition/physical

Adolescent Cognition/Fe store/

physical

Non-pregnant Productivity

Iron store

Pregnant Pregnancy outcome

Lactate Lactation

newborns

Immunity


Emorn wasantwisut institute of nutrition mahidol university

SUPPLEMENTATION WHEN ?

  • 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


Emorn wasantwisut institute of nutrition mahidol university

KEY TO CHANGES

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


Emorn wasantwisut institute of nutrition mahidol university

Baby - LBW/Undernutrition

Child growth failure

Early pregnancy

Low Wt & Ht teenagers

Small adult women

Small adult men


Emorn wasantwisut institute of nutrition mahidol university

Urine I

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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