xx Micronutrient malnutrition: The hidden hunger Dr. Maria Andersson Department of Health Sciences and Technology, ETH Zürich

Transcription

1 xx Micronutrient malnutrition: The hidden hunger Dr. Maria Andersson Department of Health Sciences and Technology, ETH Zürich Maria Andersson

2 Daily dietary requirements during pregnancy: Energy: + 20% Iron Iodine +50% Folate Maria Andersson

3 Energy & iron + x >2 Maria Andersson

4 Energy +20% Maria Andersson

5 Energy & iron Iron content low Poor bioavailability Maria Andersson

6 Food quality is as important as food quantity for optimal nutrition Hidden Hunger: Micronutrient malnutrition lack of essential vitamins and minerals Maria Andersson

7 Numbers (millions) Children <5 years with stunted growth 40% 26% Prevalence (%) Maria Andersson Black et al., Lancet

8 Numbers (millions) Children <5 years with overweight 7% 10% Prevalence (%) Black et al., Lancet Maria Andersson

9 Micronutrient deficiencies Folic acid Vitamin A Maria Maria Andersson

10 Iron deficiency Iron deficiency anemia Anemia Maria Andersson

11 Consequences of iron deficiency anemia Pregnancy risk for preterm labor risk low birth weight risk infant mortality Predicts iron deficiency in infants after 4 mo maternal and perinatal mortality and reduces work capacity Children Cognitive and motor development All susceptibility to infections risk for chronic lead poisoning Zimmermann & Hurrell, Lancet 2007 Maria Andersson

12 Percent anaemic WHO estimates of anemia, by age group Global prevalence of anaemia (%) million billion 24.8% 24.8 PreSAC PW NPW SAC Men Elderly Global Population group WHO Global Database on Anemia, WHO, 2008 Maria Andersson

13 Anemia prevalence in pregnant women WHO Global Database on Anemia, WHO, 2008 Normal (<5.0%) Mild ( %) Moderate ( %) Severe ( 40.0%) No data Maria Andersson

14 Anemia prevalence in pregnant women Anemia in non-pregnant and pregnant women: Highest proportion affected in Africa (48-57%) But the greatest number affected in SE Asia = 200 million Prevention during child bearing age - before pregnancy WHO Global Database on Anemia, WHO, 2008 Normal (<5.0%) Mild ( %) Moderate ( %) Severe ( 40.0%) No data Maria Andersson

15 15 From : IDA remains the number 5-6 cause of DALYs in young women Global Burden of Disease Project

16 16 - Greater health burden than all other IDA: nutrient %DALYS deficiencies and combined YLDs in - women Greatest burden by region in Central in and 2010 South Asia, EMRO, SubSaharan Africa

17 Micronutrient deficiencies: When do they rise to public health attention? K West, 2013 Pathology Classic clinical signs Micronutrient deficiency disorders Epigenetic effects -> Altered metabolism Biomarkers Altered tissue nutrient levels Chronic dietary lack of micronutrients Dietary measures Maria Andersson

18 Expert Panel of world renowned economists Identified the smartest ways to allocate money to respond to ten of the world s biggest challenges. Agreed that fighting malnutriton should be the top priority for policy-makers & philanthropists 1. Bundled micronutrient interventions to fight hunger and improve education Maria Andersson

19 Global strategies to prevent micronutrient malnutrition Maria Andersson

20 Dietary diversification Maria Andersson

21 Dietary diversification Advantages Sustainable No addition to foods, no medication Disadvantages Food availability (eg animal source foods) Change of food habits, customs, beliefs Comments Might not be sufficient for all population groups Requires great investment in information and education Long term strategy Maria Andersson

22 Dietary supplementation A child receiving a vitamin A capsule Iron supplementation to pregnant women Maria Andersson

23 Dietary supplementation Advantages Disadvantages Coverage Compliance Sustainability difficult to achieve Often perceived as medication Costs Tailored to specific needs and population groups Comments Short term strategy for highly deficient population groups Therapeutic approach Maria Andersson

24 Food fortification Maria Andersson

25 Food fortification Dietary goal To provide most (97.5%) of individuals in the population group(s) at greatest risk of deficiency with an adequate intake of specific micronutrients - - without causing a risk of excessive intakes in other groups WHO Guidelines 2006 Maria Andersson

26 Food fortification Advantages Coverage high For specific groups or all population Most cost-effective Disadvantages One level might not be suitable for all groups Limited consumer choice Availability of knowledge and techniques Comments Long term flexible strategy Preventive approach Maria Andersson

27 Types of food fortification Mass fortification cereal flours pasta milk salt, sugar, condiments cooking oil regulated by government sector Targeted fortification infants and young children: complementary foods children and adolescents: breakfast cereals, chocolate drinks, snacks pregnant women: drinks, biscuits emergency feeding (Food Aid) government or industry driven, mandatory or voluntary In-home fortification powders or fat-based spreads added to gruels at time of consumption at present mostly government driven (NGOs, organizations) Maria Andersson

28 Levels of coverage and compliance General population Voluntary Mandatory Specific groups WHO Maria Guidelines Andersson

29 Legal considerations Public health significance of deficiency Food industry Population level of knowledge (consumer choice) Political environment Maria Andersson

30 Steps for food fortification Identify micronutrient deficiencies Select a food vehicle and measure its daily intake Measure the prevalence of inadequate intake Select a fortificant considering the bioavailability Define the acceptable prevalence of inadequate intake (goal) Set the fortification level and simulate the effect Maria Andersson

31 Selection of food vehicle and fortificant Main criteria for the selection of a food vehicle Main criteria for the selection of a fortificant Population consuming food Regular consumption Central processing Low cost technologies for fortification Consumption rapidly after production (small overage) Sensory changes: color, flavour, texture Bioavailability Costs Interactions Safety (e.g. vitamin A, β- carotene) Maria Andersson

32 Steps for food fortification Efficacy studies, Effectiveness studies Implement and scale up Maria Andersson

33 Monitoring and evaluation Monitoring of the fortified food The purpose of monitoring is to ensure that the fortified product, of desired quality, is accessible and available to consumers at sufficient amounts. Impact evaluation of nutrition status Assessment of the efficacy and effectiveness and the impact of a fortification programme on the target population Maria Andersson

34 Risk of inadequacy Preventing Hidden Hunger also means knowing when it is not there Deficiency Adequacy Excess Risk of excess 0.0 Increasing daily micronutrient intake 0.0 Maria Andersson

35 Iron fortification of rice Extruded rice

36 Iron fortification of rice Minimal differences with natural rice Food technological properties Color sensory qualities Iron compound Decrease prevalence of ID Iron bioavailability Fe abs. Food matrix Processing

37 Extruded rice premixes with different iron fortification compounds Extruded, not fortified Reagent grade Ferric Pyrophosphate Sunactive Fe SP80 FCC Ferric pyrophosphate 2.5 m FCC Ferric pyrophosphate 21 m Encapsulated FeSO 4 FeSO 4 Elemental Fe (electrolytic) Concentration: 1 g Fe/100g

38 Dual fortification of salt Micronized ground ferric pyrophosphate MGFePP Encapsulated ferrous fumarate EFF Control Iodized salt IS Iron: 2 mg Fe/g salt ~12 mg/day Iodine: 30 µg I/g salt ~180 µg/day

39 Prevalence (%) 39 Fortification of Atta flour with NaFeEDTA improves iron status of Indian School children (Muthayya et al, 2012 J Nutr) 7 mo RCT in 6-13 yrs old children (n=400) of low Fe status (SF <20 g/l) 100 g atta flour containing 6 mg Fe as NaFeEDTA fed as chapatis with vegetable dishes 6 d/w monitor Hb, SF and TfR ID IDA Control Iron fortified P<0.001 P< Time (mo)

40 Lack of progress in control of IDA in the developing world: contributing factors Low compliance with iron supplementation Poorly designed food fortification programs Insufficient targeted interventions for infants and young children Lack of integration of nutritional interventions with other public health and development programs Recently, safety of certain iron interventions has been questioned Maria Andersson

41 Biofortification Biofortification has been defined as the process of increasing the bioavailable concentrations of essential elements in edible portions of crop plants through agronomic intervention or genetic selection White et al

42 Biofortification Two major goals: 1. Increase the concentration of relevant nutrients in the edible part of the plant 2. Increase the bioavailability of relevant nutrients How? Agronomic approach Traditional plant breeding Transgenic approach 42

43 43

44 44

45 The iodine deficiency disorders One of the most common human diseases One of the most common causes of mental retardation Iodine deficiency remains a major global problem Simple, inexpensive salt iodization can eliminate IDD Zimmermann et al. Lancet 2008

46 Iodine deficiency has major adverse health effects throughout the lifecycle In utero iodine deficiency damages the developing brain 46

47 Maria Andersson

48 Hypothalamus TRH Pituitary gland TSH Thyroid Iodine T3 & T4 Maria Andersson

49 Universal salt iodization KI or KIO mg I/kg salt Cost effective: 0.05 USD/child/year Maria Andersson

50 50 Salt as the preferred vehicle for the delivery of iodine is based on many factors: one of few commodities consumed by everyone; consumption stable throughout the year importation/production often limited to a few producers iodization technology easy to implement and available at a reasonable cost throughout the developing world the addition of iodine to salt or iodized salt to processed foods does not affect color, taste or odor the quality of iodized salt can be easily monitored

51 51 Cost-effectiveness of iodized salt Estimated annual potential costs attributable to IDD in the developing world: $35.7 billion / yr prior to widespread salt iodization vs. $0.5 billion /yr cost for salt iodization 70:1 cost benefit ratio Horton S. The economic impact of micronutrient deficiencies. NNWSPP Vol.54. Geneva: Karger; 2004, and J. Nutr. 2006:136:

52 Switzerland the first country to introduce salt iodization, in 1920s Maria Andersson

53 Iodine status in the Swiss population Iodized salt Iodized (mg/kg) salt (mg/kg) Maria Andersson

54 Voluntary iodine fortification Federal decree: mg I/kg Plain Iodine Iodine & fluoride >80% consume iodized salt 7% 6% 87% Maria Andersson

55 Tons per month Decreased sales of iodized salt to food industry and canteens 1200 Iodized Non-iodized Schweizer Rheinsalinen AG Maria Andersson

56 As of Jan 2014 all iodized salt for human consumption contains 25 mg iodine/kg Maria Andersson

57 Household coverage of iodized salt 128 countries Iodized salt is available in households of 71% of the global population, up from 20% in 1990 <50 % % 90 % No data UNICEF, Child Info Database, 2012 Maria Andersson

58 1993 Severe Moderate Mild Adequate No data 110 countries iodine deficient WHO 1993

59 2013 Moderate Mild Adequate Excess No data 31 countries iodine deficient Zimmermann & Andersson, Curr Op Endo & Diab, 2012 Pearce et al. Thyroid, 2013

60 Number of countries Steady decrease in number of countries with iodine deficiency %

61 Adequate iodine intake in 123 countries! Median UIC 100 µg/l Zimmermann & Andersson, Curr Op Endo & Diab, 2012 Pearce et al. Thyroid, 2013

62 Future challenges 25 mg I/kg salt Convince the food industry to use iodized salt in food production to ensure adequate iodine status in all population groups Maria Andersson

63 Double burden of disease: Overweight obesity & hidden hunger Intervention strategies should be combined Maria Andersson