HIDDEN HUNGER. Dr. Mohamed Sultan Ibrahim, MD, DIP Senior Regional Medical Affairs and R&D Manager Wyeth Nutrition Middle East

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1 HIDDEN HUNGER Dr. Mohamed Sultan Ibrahim, MD, DIP Senior Regional Medical Affairs and R&D Manager Wyeth Nutrition Middle East

2 DEFINITION The lack of vitamins and minerals such as vitamin A, Iodine and Iron, is the main cause of hidden hunger and malnutrition in the world today. 2

3 Macro-nutrients Sources of energy & body building

4 Micronutrient Must be provided in food & enable the body to use other nutrients

5 Global Micronutrient Deficiencies > 3 billion people afflicted (Map from USAID)

6 UNICEF Controlling Vitamin and Mineral Deficiency is an affordable opportunity to improve the lives of two billion people and to strengthen the pulse of economic development. 6

7 7

8 Micronutrient Deficiencies

9 Why Micronutrient? Micronutrient play a vital role throughout the lifecycle for disease prevention, good health and wellness

10 Why Micronutrients? Required in small amounts by humans in order to survive Either components of: - enzymes (the minerals) - act as coenzymes in chemical reactions Amounts less than 0.005% of body weight

Micronutrient Deficiencies: Impact on Children Worldwide, 165M children are stunted More than 90% of stunted children live in developing countries Malnourished children: Never reach their full

11 Micronutrient Deficiencies: Impact on Children Worldwide, 165M children are stunted More than 90% of stunted children live in developing countries Malnourished children: Never reach their full height or cognitive potential Are less able to fight diseases such as malaria, TB and pneumonia Do worse in school Earn at least 10% less as adults Are at higher risk of chronic diseases later in life

12 Infant nutrition is a public health issue and not only a lifestyle choice AAP Policy Statement 2012

13 Micronutrient Deficiencies: Affecting the Wealthiest Countries United States Germany

14 Percent of People in USA Not Eating Adequate Intakes of Various Nutrients Riboflavin Niacin Se Fe Thiamin P Cu Moshfegh et al., NHANES Folate 8 Zn Vitamin B Vitamin C 31 Vitamin A 44 Mg 56 Vitamin E Inadequate Intakes < EAR (%)

15 Micronutrient Deficiencies: The Impact in Numbers 1.1 million children go blind or die each year from vitamin A deficiency 40-75% of world population estimated to be vitamin D deficient 600,000 stillbirths due to iron deficiency women estimated to be affected by osteoporosis worldwide 18 million babies born mentally impaired due to maternal iodine deficiency 36 million 16 July 22, 2012 Footer text here

16 Some Major World Risk Factors Causing Deaths Some WHO Major Risk Factors Causing World Deaths in 2000 Occupational safety Risk Factor Unsafe water, sanitation, hygiene Alcohol Unsafe sex Tobacco Malnutrition 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 Number of Deaths (X1000) (World Health Report, 2002) Malnutrition accounts of 30 million deaths per year (about 1 death per second)

17 (WHO-2009)

Micronutrient Deficiencies: Link to Noncommunicable Diseases 36 of the 57 million global deaths in 2008 were due to NCDs Worldwide: 366 million people have diabetes 200

18 Micronutrient Deficiencies: Link to Noncommunicable Diseases 36 of the 57 million global deaths in 2008 were due to NCDs Worldwide: 366 million people have diabetes 200 million people have osteoporosis 1.6 billion people are overweight 80% of premature heart disease, stroke & diabetes can be prevented Diet is an important modifiable factor

Thomas Edison (1847-1931) The doctor of the future will no longer treat the

19 Thomas Edison ( ) The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition

20 What Should We Expect from our Food? Vitamins Vitamin A Vitamin E Vitamin C Vitamin D Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Carotenoids B-carotene Lutein Zeaxanthin Enzymes Phytase Omegas DHA EPA ARA Amino acids Methionine Lysine Fibers Minerals Calcium Magnesium Iron Zinc Iodine Selenium

The Power of Micronutrients Throughout Life Pregnancy Infants & Toddlers Adults Seniors Pre-natal Health Optimal Development Staying Healthy Longer, Healthier

risk of chronic diseases Higher achievements in school Increased productivity as adults Prevention of diabetes, heart disease and stroke Multivitamins, along

21 The Power of Micronutrients Throughout Life Pregnancy Infants & Toddlers Adults Seniors Pre-natal Health Optimal Development Staying Healthy Longer, Healthier Lives Iron ensures healthy deliveries and improves birth weight of babies Folate helps prevent neural tube defects in babies Power to fight off diseases Lower risk of chronic diseases Higher achievements in school Increased productivity as adults Prevention of diabetes, heart disease and stroke Multivitamins, along with a balanced diet, have the potential to reduce the risk of cancer by 8% Reduced cognitive decline Lower risk of dementia Lower risk of agerelated macular degeneration

22 Iron Deficiency Rickets Folic Acid Deficiency Vitamin A Deficiency Iodine Deficiency Zinc Deficiency

23 24 Importance of the At-Risk Nutrients

24 25

25 IRON

26 Iron: How much do we need? Preterm infants: 2-4 mg/kg/day Full term infants: 1 mg/kg day Children 1-3 years old: 7 mg/day Children 4-8 years old: 10 mg/day Children 9-13 years old: 8 mg/day Males 14-18: 11 mg/day Females 14-18: 15 mg/day Food and Nutrition Board of the Institute of Medicine. Iron in: Dietary reference intakes for Vitamin A, Vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. National Academy Press, Washington DC, 2000; p. 339.

27 Newborn Iron Stores Endowed with 75 mg/kg of iron at birth Minimally dependent on maternal iron status Depleted by 3 months in low birth weight infants without supplementation Delayed cord clamping (by 2 minutes) leads to higher ferritin and iron stores at 6 months of age

28 Iron and ascorbic acid Ascorbic acid aids the absorption of non haem iron (non meat sources of iron) when eaten at the same time. This is particularly important for people following strict vegan or vegetarian diets.

29 Risk factors for Iron Deficiency in Infants and Children Prematurity or low birth weight Exclusively breastfeeding beyond 4-5 months without iron supplementation Cows milk before 1 year Malnutrition Chronic illness or special health needs Brotanek et al. Iron Deficiency in Early Childhood in the United States: Risk Factors and Racial/Ethnic Disparities. Pediatrics 2007;120;568 Pizzaro et al. Iron status with different infant feeding regimens: relevance to screening and prevention of iron deficiency. J Pediatr May;118(5):687-92

30 . Cows milk and iron deficiency Poor source of iron Poor absorption (5-10%) Reduces consumption of other foods, especially with overconsumption Can cause microscopic GI bleeding Cow Milk for calves

31 Population at Risk of Deficiency - Global People (billions) Iodine Iron Vitamin A 32 Source: UNICEF (2002)

32 Prevalence of iron deficiency anemia Region 0-5 years 5-12 years South Asia 56% 50% Africa 56% 49% Latin Am 26% 26% Gulf Region 40% 36% Developed 12% 7% World 43% 37%

33 Clinical cases of IDA the tip of the ice-berg Clinical cases Non-clinical cases

34 Screening for iron deficiency AAP recommendations: Determination of hemoglobin concentration -Term infants - 12 months of age -Preterm infants - 9 months of age Assessment of risk factors for ID/IDA: -Inadequate iron intake, poor nutrition, feeding problems, poor growth Additional screening at months of age? Pediatrics 2010; 126:

35 AAP Guidelines for prevention of IDA : Breast fed Infants Formula-fed infants At 4 months of age, breastfed infants should be supplemented with 1mg/kg per day of oral iron First 12 months of life Iron demands can be met by a standard infant formula (iron content: 12 mg/dl). introduction of iron-containing complementary foods after 4 to 6 months of age, including iron-fortified cereals. NB. iron intake between 6 and 12 months of age should be 11 mg/day. Toddlers 1-3 years Iron intake should be 7 mg/day This can be achieved by either : 1-Eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C (increase Iron absorption). 2-liquid supplements Preterm infants -Formula fed should have 2 mg/kg per day through 12 months of age (amount already supplied by the formula). -Breastfed :2mg/kg per day by 1 month of age, continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.

36 Reducing the prevalence of iron-deficiency anemia by means of food supplements, in particular, has an exceptionally high benefit to cost ratio. The Copenhagen Consensus Project,

38 Vitamin D

39 Vitamin D: The Sunshine Vitamin

41 Vitamin D Critical for normal calcium absorption from diet Risk factors for deficiency: Inadequate diet Inadequate sunlight Obesity Malabsorption AAP 2008, recommendation = 400 IU 42

42 Dietary Sources of Vitamin D D3 in fatty fishes and fish (cod) liver oils Fortified milk and juice has approx 100 IU/8 oz. Survey of vitamin D content of milk samples in U.S. found: approximately 15% had no detectable vitamin D and >50% had <80% of vitamin D content stated on label (Chen et al. NEJM 1993) 43

43 44 Rickets is back! 1915 versus 2015

44 Vitamin D Deficiency

45 How do we define deficiency? Or is it insufficiency? And what about optimal levels? 11, 12 or 15 ng/ml = deficiency ng/ml = insufficiency > ng/ml = optimal Accepted definition (deficiency) 25(OH)D 3 < 20 ng/ml 46

46 What is the optimal serum level? RE: fracture prevention in adults, for 5/6 authors, the minimum desirable 25(OH)D clusters between 70 and 80 nmol/l (28-32 ng/ml) Considering all health endpoints (BMD, risk falls, fracture, colon cancer), nmol/l (30-40 ng/ml) optimal 47

47 How much is enough? Guidelines for Vitamin D Intake Institute of Medicine

48 49 Promoting healthy bones and identifying ones at risk!

49 What Should we Do as HCPs? Encourage: Regular exercise Maintenance of normal weight Good nutrition, with adequate calcium and vitamin D Wean of glucocorticoids as primary disease allows 50

50 Take Home Message Vitamin D is essential for optimal health Solar UVB is the primary source of vitamin D for most people on Earth Optimal serum 25(OH)D levels are >32ng/ml In the absence of solar UVB, supplements, food sources, and UVB lamps such as in tanning salons can supply vitamin D

51 52 Additional restrictions potentially mandated by local regulations are not considered for this presentations but need to still be followed locally

52 So, is there any solution? Nothing impossible

53 So what should we do? Team work

54 Summery and conclusion Hidden Hunger is a global health problem Major risk factors for include poor dietary intake, infection, disease and sanitation WHO is putting efforts to reduce the incidence of such deficiency. National efforts are needed to overcome this problem. Treatment include dietary diversification, supplementation, and food fortification PROPHYLACTIC approach will put us one step ahead of the problem

55 Optimising early nutrition will improve later outcomes

57 References: Sight & Life: Micronutrients; Macro Impact, the Story of Vitamins and a Hungry World[PDF MB], Investing in the future: A united call to action on vitamin and mineral deficiencies. Global Report 2009 p. 1 4.Investing in the future: A united call to action on vitamin and mineral deficiencies. Global Report 2009 p. 5 5.Stevens GA, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for : a systematic analysis of population-representative data[pdf - 408KB]. 6- The Lancet Global Health, Volume 1, Issue 1, Pages e16 - e25, July

58 References: 7.WHO Guideline: Intermittent iron and folic acid supplementation in menstruating women. 8.Copenhagen Consensus 2012: Solving the World s Challenges 9.UNICEF - Improving Child Nutrition: The Achievable Imperative for Global Progress [PDF-5.98MB]. 2013, pg23 10.WHO Guideline: Vitamin A supplementation for infants and children 6-59 months of age. nvesting in the future: A united call to action on vitamin and mineral deficiencies. Global Report 2009 p Zimmermann MB. Iodine Deficiency. Endocrine Reviews, June 2009, 30(4): Zimmermann MB; Andersson M. Assessment of iodine nutrition in populations: past, present, and future. Nutr Rev Oct; 70(10): Wessells KR, Brown KH. Estimating the Global Prevalence of Zinc Deficiency: Results Based on Zinc Availability in National Food Supplies and the Prevalence of Stunting. PLoS ONE (11): e

59 References: 14.Investing in the future: A united call to action on vitamin and mineral deficiencies. Global Report 2009 p Zimmerman, SL. Fifteen Years of Fortifying With Folic Acid. SIGHT AND LIFE; Vol. 25 (3) 16.US commerce department 17.UNICEF-state of the world nutrition,2009 WHO global data base on vitamin A deficiency 18-American Academy of pediatrics 2012 policy statement. 19-Micronutrients in health and disease, A Shenkin, Postgrad Med J 2006;82: doi: /pgmj Moshfegh et al., NHANES WHO 2010 report of mortality 22-UNICEF 2002 data on incidence of Iron deficiency 60

PROJECT WOMEN S ANAEMIA. by My HealthWorks. Associate Member. 125A, 2nd Floor, Shahpur Jat, New Delhi ,

PROJECT WOMEN S ANAEMIA. by My HealthWorks. Associate Member. 125A, 2nd Floor, Shahpur Jat, New Delhi , PROJECT WOMEN S ANAEMIA by My HealthWorks Associate Member 125A, 2nd Floor, Shahpur Jat, New Delhi-110049, Whatsapp: 8076964582, Phone No: 011-26496673-(74) info@myhealthworks.in INTRODUCTION Anaemia is