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Jordan s Micronutrients Issue: The Dilemma of Search for Effective Intervention

Background Misconception . Over many years, countries in the East Mediterranean consistently overlooked under-nutrition as a probable health threat to the community. Today, few of these countries have discovered that no single developing community may claim to be off the hook of malnutrition, particularly hitting at the risk groups level. Jordan has been one of those few EM-countries.

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Jordan s Micronutrients Issue: The Dilemma of Search for Effective Intervention

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    1. Jordan’s Micronutrients Issue: The Dilemma of Search for Effective Intervention Ibrahim M.D Khatib (MSc , PhD)

    2. Background Misconception Over many years, countries in the East Mediterranean consistently overlooked under-nutrition as a probable health threat to the community. Today, few of these countries have discovered that no single developing community may claim to be off the hook of malnutrition, particularly hitting at the risk groups level. Jordan has been one of those few EM-countries

    3. Combat Against Malnutrition The Partners Triad Leading Role : For the MOH – Nutrition Division Complementary Role : University Academics Supportive Role : International organizations

    4. Facts About UnderNutrition * The most common health problem in developing countries Even in milder forms, it weakens the immune system Cause of diarrhea / ARI frequent / severe attacks Increases mortality in childhood (60 % of Global Rate) Causes are : 1. Direct - inadequate access to food - inadequate intake of micronutrients, 2. Indirect - inadequate health care of mothers and children, - inadequate health services, and - unhealthy environments / poor hygiene (Robert E Black, Saul S Morris and Jennifer Bryce. Where and why are 10 million children dying every year? (review). The Lancet, June 2003. Vol. 361:2226- 2234 pp )

    5. Jordan - Public Nutrition Facts and Chalenges

    6. Adulthood Problems Type 2-diabetes prevalence in middle age is above 20 % CVD : Cardio-Vascular Disease prevalence is on the rise

    7. Childhood Problems Jordan is free from primary Malnutrition ( p-PEM) Only secondary Malnutrition (s-PEM) prevails; s-PEM signals inadequate tissue metabolization of nutrients s-PEM is commonly attributed to: - Disease : e.g. frequent diarrheas / malabsorption / infections - Micronutrients – deficiencies (MNDs)

    8. In Jordan… MNDs Are No Longer a Hidden Hunger MNDs are significant causes of s-PEM in Jordan Iodine, Iron, Zinc, and Vitamin A deficiencies : endemic Stunting: remains the devious face of s-PEM Anemia due to IDA and / or VAD : prevalent

    9. MNDs Significance in Childhood Frequent diarrheas and infections / suppressed immunity Stunting / Subnormal child growth pattern Low IQ / compromised cognitive development Poor performance / school achievement Weak muscles / decreased work potential Anemia Increased risk of death

    10. MNDs : Selected Outcomes Iodine Deficiency Disorders (IDD) Goiter Cretinism - mental deficiency - Physical anomalies IDA Anemia Poor Learning Non-ocular VAD Depressed immunity: infections / diarrhea & ARI Physical growth deficiency Predisposition to IDA Ends with visual impairment / Nutritional blindness

    12. Accomplished Surveys Community Research For Advocacy

    13. Zinc Deficiency and Stunting [1,2] Supplementation at infancy prevented growth stunting

    14. MOH- IDD Surveys [3,4] IDD Prevalence - by goiter assessment : 37.7 % - by urinary iodine excretion > 50 % (median iodine excretion = 4 mcg/l) IDD is a public health problem in Jordan; Severity is highest in south / lowest in middle areas; Intervention by salt-iodization started in 1996; Program evaluation result (in 2000): satisfactory.

    15. MOE- Year 2000 School Surveys [5,6] Baseline prevalences among poor young school children: - 19.9 % for stunting, - 18.8 % for anemia, - 21.8 % for VAD. Supplement: a daily snack + one 200,000 i.u.vitamin A capsule Intervention improved all, EXCEPT stunting Conclusion: VAD in school children is a public health problem.

    16. AlSaafi Schools Study, 2002 [7] Approach : controlled interventional study ( 3 study groups) Poorer villages of the disadvantaged AlSaafi district. VAD prevalence : 35.3 % Snack meal together with VA capsule made growth improvement; A National Vitamin A Program should phase in.

    17. Conclusions on School Nutrition Poverty linked-sub-clinical - VAD is confirmed as a public health emergency and seems to be endemic in under-developed districts. Impact of high domestic consumption of vegetables and fruits offset by households concentrating on the carotenoids-poor items. Statuses of vitamin A and E correlate strongly, suggesting a common defect in fat solubles - absorption mechanism . For poor young school children, the snack is essential for the VA capsule to induce a significant improvement of serum VA levels.

    18. Surveys on U5y - children

    19. North Badia survey - Year 2001 [8] Prevalences Among Bedouin U5y – Children: Stunting ˜ 20%, anemia ˜19 %, , non-ocular VAD ˜ 22%

    20. Jordan Population and Family Health Survey [9] DoS- Year 2000 Anemia is prevalent at rates of : 34% in U5y - children. 65% in the 10-11 months children

    21. MOH–National Nutrition Study [10] Year 2002 Women in the child bearing age Anemia > 30 % ; (Hb <12 g/dl) Iron deficiency (ID) > 40 % ; (low ferritin) ID anemia > 20 % ; (low Hb & ferritin)

    22. MOH–National Nutrition Study [10] Year 2002 U5y - children Anemia = 20.1 % ; (Hb <11 g/dl) Iron deficiency (ID) = 26.1 % ; Iron deficiency anemia (IDA) = 10.1 % ; Vitamin A deficiency (VAD) = 15.1 %

    23. Jordan’s MNDs problem The Social Grounds Other factors contribute to the national nutritional problem VA status and anemia always correlated with: - Maternal education - Consumption of animal based food - Socio-economic status

    25. Ongoing Interventional Programs An MOH - Story of Success Program: Iodination of Table Salt (1996) Wheat Flour Fortification : (Iron and Folic acid; May 2002) Monitoring System: MOH- Nutrition Division Supporters International Organizations

    26. Upon a Royal Decree…. The Jordan-government implemented in February 2003, a national program aiming at the universal distribution of a daily multi-vitamin & mineral supplementary tablet for every school childr in Jordan ~~~~~~~~~~~~~~~~~~~~~~~~ The Jordan- High Commission on Nutrition recommendation is for the switching from tablet - supplement distribution to food (flour) fortification to secure higher coverage for other risk groups

    27. The Pending Questions Shall Jordan continue expanding in wheat flour fortification to include vitamin A ? If not, what will be the alternative option? Shall Jordan consider adding some other micronutrients to the premix ? If yes, what are these ?

    28. Let Us not Forget the Missed year 2000 –Targets* Eliminate iodine deficiency disorders (IDD) Eliminate vitamin A deficiency (VAD) Reduce iron deficiency anemia (IDA), by 1/3 1990 -World Summit for Children 1 Frequently coexist 2 Similar risk factors 3 similar target populations1 Frequently coexist 2 Similar risk factors 3 similar target populations

    29. Immdiate Ambitions of Jordan Community Eliminatation of VAD as a health risk factor Prevention of unrecognized MNDs

    30. The Elimination of VAD Criteria Indicator Low serum retinol (< 0.70 µmol/L) Prevalence - Goal to Achieve < 5% in age 6-71 month

    31. Valid indicators are established to assess progress toward achieving elimination of vitamin A and iodine deficiencies In ID surveys, Hb and SF consitute a useful combination for use as a tool to assess progress toward achieving alleviation of iron deficiency anemia (IDA) No single standard indicator exist for ID diagnosis Measuring Impact of Intervention Standard Indicators

    32. Domestic Research: References Khatib I, and Hijazi S. JUST-Percentiles : a cross-sectional study of the declination observed in the Jordanian child growth curve and its association with the local patterns of infant weaning. Jordan University of Science & Technology (JUST)-Publications,1992, Irbid-Jordan . Khatib I, Hijazi S, and Aggett P. A longitudinal -interventional-study of the impact of zinc fortified weaning food on linear growth of infants in northern Jordan.The Higher Council for Science and Technology Publications,1995, Amman-Jordan. The IDD National Committee: Iodine Deficiency in Jordan,1995 . A national baseline study. Report of UNICEF office-Amman, 1995. The IDD National Committee: Iodine Deficiency in Jordan, 2000. A national baseline study. Report of UNICEF office-Amman, 2000. Khatib I. High prevalence of subclinical vitamin A deficiency in Jordan: a forgotten risk Food Nutr Bull., September 2002, 3; 23 (Supp. 228-236). Khatib I and Hijazi S. Poverty – Linked vitamin A deficiency (VAD) in Jordan is endemic and coupled with compromised vitamin E Status. ( A report submitted to the MOE in 2002; currently under-modification for publication ). Khatib I . Supplementation with vitamin A capsules along with iron fortified school meals can have positive impact on the growth of young school children: a controlled trial. (An abstract to be orally presented in the X Auxology Congress , Florence-Italy , July 4-7, 2004) Khatib I and Hijazi S. Nutritional status of the under 5 years beduin children. A study report submitted to the sponsor : the Jordanian Badia Development Program, December 31,2003 . Department of Statistics. The 2002 Jordan Population and Family Health Survey. The ORC Macro Publications,2003. The National Committee on Micronutrients. The year 2003 – National Nutrition Study of Anemia and VAD . MOH . (report in press).

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