Investing in Essential Vitamins and Minerals: A Critical Public Health Strategy for Tajikistan Greg S. Garrett 27 January 2017
Contents 1. Magnitude of problem: hidden hunger 2. Effects of hidden hunger 3. Ways to prevent hidden hunger 4. Costs benefit to Tajikistan by addressing hidden hunger
I. Magnitude of problem: global hidden hunger (micronutrient deficiency) Map looks at iron, folate, iodine, vitamin A and zinc deficiencies. Muthayya S, Rah JH, Sugimoto JD, Roos FF, Kraemer K, Black RE. The Global Hidden Hunger Indices and Maps: An Advocacy Tool for Action. PLOS ONE 2013
I. Prevalence of iron deficiency in children and women of reproductive age, by low serum ferritin levels in Tajikistan and region 60 Iron deficiency, % Children Iron deficiency, % Women 50 43.8 44.6 51.0 47.5 40 38.1 38.8 30 28.2 29.2 21.4 20 10 Kaz: NMNS-2011, n=1083 (Ch), n=1076 (Wom) Kyr: NNS-2009, n=1413 (Ch), n=1026 (Wom) Mon: NNS-2011, n=524 (Ch), n=867 (Wom) Taj: NMNS-2003, n=1252 (Ch), n=1415 (Wom) Uzb: NMNS-2008, n=2582 (Wom) NMNS National Micronutrient Survey NNS National Nutrition Study 4
I. The population at risk of inadequate zinc intake (ZnD,%) and neural tube defects (NTD, 10,000 births) in Tajikistan and region % 25 ZnD NTD 20 20 20 20 20 20.2 20 20.4 20 18.9 15 10 8.8 5 4.9 6.0 0 Kazakhstan Kyrgyzstan Uzbekistan Tajikistan Afghanistan Pakistan Source: www.ffinetwork.org/country_profiles/ 5
II. Effects of Hidden Hunger Poor brain development Poor immune function Various adverse physical outcomes (e.g. spina bifida) Decreased work productivity Within the first 1,000 days there is a window of opportunity of a child s life from conception to the age of 2 to ensure intakes of key micronutrients and improve physical and cognitive growth which in turn will have positive impacts for life McComb 1996, Horn 1999, 2004
II. EFFECTS OF HIDDEN HUNGER: THE VISIBLE & LESS VISIBLE CONSEQUENCES OF MICRONUTRIENT DEFICIENCY Visible: neural tube defects (from low folic acid intakes), anaemia (low iron), goitre (low iodine intakes) Less visible: Reduced immunity, increased incidence and severity of Infectious illness and mortality from diarrhea, measles, malaria and pneumonia. The consequences are not limited to health parameters alone but have far reaching effects on the economy through secondary physical and mental disabilities and altered work productivity.
II. APPROPRIATE PUBLIC HEALTH OBJECTIVE: SHIFT DISTRIBUTION OF MICRONUTRIENT INTAKES AT POPULATION LEVEL Distribution of intakes in population Distribution of adequate intakes Deficiency detected (biomarker/ symptom) Estimated average requirement (EAR) 0 5 10 15 20 25 30 35 40 45 50 55 Intake of essential micronutrient
II. APPROPRIATE PUBLIC HEALTH OBJECTIVE: SHIFT DISTRIBUTION OF MICRONUTRIENT INTAKES AT POPULATION LEVEL Current distribution of intakes 1 Distribution of adequate intakes 0 5 10 15 20 25 30 35 40 45 50 55 Intake of essential micronutrient 1 This curve is meant to be illustrative of the fact that many people in the population will have inadequate dietary intakes of micronutrients and with food fortification you can move that curve towards more adequate intake, as long as people are consuming that food. Actual increase in intake would not be symmetrical across the population and would depend on the pattern of consumption of the fortified food and other sources of the nutrient in the diet.
III. SOLUTIONS: EVIDENCE-BASED, COST EFFECTIVE INTERVENTIONS Food Fortification: Can cover entire population. Evidence of impact of large-scale food fortification include: - Only 25 countries today remain iodine insufficient at population level largely due to salt iodization, down from 54 only 13 years ago (2) - The prevention of hundreds of thousands of cases of NTDs in South Africa, USA, Canada (3) - A 2015 systematic evaluation of 76 studies concluded strong evidence of measurable improvements in micronutrient status and health outcomes in women and children in LMIC (4) - High return on investments, e.g. $30 for every $1 spent depending on micronutrient and delivery channel (5) 1) Mayo-Wilson E, et al Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMJ 2011, 343:d5094; 2) 2016 Iodine Global Network, Iodine Scorecard, available from www.ign.org; 3) Youngblood, et al. 2012 Update on Global Prevention of Folic Acid Preventable Spina Bifida and Anen; 4) GAIN, Micronutrient Forum and Sight&Life: The #Futurefortified global summit on food fortification - Events proceedings and recommendations for food fortification programs., July 2016. 5.. Horton S& J Ross (2003), The Economics of Iron Deficiency, Food Policy, 2003, 28: 51-75. Y Yi, M Lindemann, A Colligs, et al. (2011), 10
III. SOLUTIONS: WHEAT FLOUR FORTIFICATION WITH IRON AND FOLIC ACID 11 50 45 40 35 30 25 20 15 10 5 0 Neural Tube Defects (per 10,000): Pre and Post Fortification with Folic Acid Prefortification NTD per 10,000 Postfortification NTD per 10,000 Brazil, Canada, Chile, Costa Rica, Iran, Jordan, Peru, Saudi Arabia, South Africa, USA Adapted from FFI 2013. Folic acid in flour ranged from 1.2-2.2 mg/kg.
IV. TAJIKISTAN COST BENEFIT ANALYSIS: MALNUTRITION COST DRIVERS 12 Mortality and disability in children and consequent forgone income from future employment Deficits in child cognition, inferior school performance and depressed future productivity Depressed productivity in working but anemic adults Excess health care costs
13 IV. COST BENEFIT ANALYSIS: GENERAL ALGORITHM General Algorithm for Projection of Economic Losses Risk Group Population Prevalenc e of Condition Population with Deficit Economically A Population Average Annual Wage Coefficient Of Deficit or Loss Lost Productive Activity # National Statistics X % from NNS = By Indicator and Risk Group X % of total Population X Per Year X % or RR From Global Literature = $/year
14 IV. COST BENEFIT ANALYSIS: SCOPE Following, are the five health conditions covered: Neural tube defects (NTD) Neonatal deaths Maternal mortality Kids productivity loss due to ID anemia Adult productivity loss due to ID anemia Cost estimates for 10 year period starting from 2017 Fortification intervention covered Wheat Flour Fortification
15 IV. COST BENEFIT ANALYSIS: RESULTS The economic cost of doing nothing to address micronutrient deficiencies over ten years would be 6.9 billion Tajik Somoni* ($889 million US dollars) If all premium and first grade wheat flour consumed in Tajikistan is fortified with iron and folic acid, it will reduce the economic loss by 2.3 billion Tajik Somoni * ($289 million) over a 10 year period;] $1 investment will generate a return of $9 and significant social and other economic benefits for Tajikistan (* Currency rate from March 2016)
85 COUNTRIES MANDATE FORTIFICATION OF WHEAT, MAIZE FLOUR AND/OR RICE. TAJIKISTAN CAN EASILY BE NEXT August 2014. Source: Food Fortification Initiative. http://www.ffinetwork.org/global_progress/index.php
The reasons for investing in fortification is the potential of our children. It is both compelling and self-evident. 17 Thank you.
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