Nutrition Problems of Public Health

Importance
Mekelle University
College of Health Sciences
Department of public health
Introduction
• Nutrition related health problems
– Developing countries
• Macronutrients
– Protein-Energy (Calorie) Malnutrition (PEM/PCM)
• Micronutrients
– Iron, iodine and vitamin A (and of course Zn) are the
nutrients most lacking.
• Developed countries and countries in transition
– Non-communicable diseases
• Include
– Hypertension, CVDs, Stroke, Diabetes (Non insulin
dependent), Obesity, Dental carries, Carcinomas,
Osteoporosis, etc
• Nutrition Problems of Public Health Importance in Ethiopia
includes
– Protein Energy Malnutrition (PEM)
– Vitamin A deficiency (VAD)

– Iron deficiency anemia (IDA)

– Iodine deficiency disease (IDD)
– Zinc deficiency
1. Protein Energy Malnutrition

• Other terms are

• Multi-deficiency syndrome
• Failure to thrive

• The term PEM/PCM/PED has been used to describe

– A range of disorders primarily characterized by growth
failure or retardation in children
• Growth deficit is catagorized as
– Clinical forms
– Marasmus

• Retarded growth with wasting of subcutaneous fat

– Kwashiorkor
• Growth failure with wasting of muscles and
preservation of subcutaneous fat and pitting type
edema
– Mixed: Marasmus-Kwashiorkor (MK)
• Edema of kwashiorkor with wasting of marasmus
• Kwashiorkor
– Characterized by symmetric edema
– Sparse hair
– Flaky paint rash on the buttocks, legs and arms
• Marasmus
– Shows a characteristic muscle wasting particularly
– Generally thought to be the result of cumulative, usually
slow, inadequate energy and protein intake
• Mixed
– Commonly coexist
Marasmus
• Characteristics
• Occurs in children < 2
yrs of age
• Severe deprivation
• Develops slowly
• Severe weight loss
• Severe muscle wasting
• No edema
• Anxiety, apathy
• Possible good appetite
• Dry skin
• “Old Man“ face,
wrinkled appearance
Kwashiorkor
• Characteristics
• 1st to 3rd yrs of life
• Edema;
• Low protein, infections
• Rapid onset
• Some weight loss
• Some muscle wasting
• Apathy, irritable
• Loss of appetite
• Hair dry
• Dermatosis (skin lesions)
• Milder forms
– Wasting
• Thinness using weight for height (W/H)
– Stunting
• Linear growth retardation using height for age (H/A)
– Underweight
• A result of wasting and/or stunting
• Using weight for age (W/A)
 Classification of moderate and severe
malnutrition

Malnutrition
Moderate Severe
Symmetric edema (bilateral No Yes (edematous malnutrition or
pitting edema) kwashiorkor)
Weight for age
• SD Score • –2 to – 3 • < -3 severe wasting
• % Median • 70 to 79 • < 70 or Marasmus
Length (Height) for age
• SD Score • –2 to – 3 • < -3 severe stunting
• % Median • 85 to 89 • < 85
 Causes of PEM
• Multifactorial
• Having a number of factors operating simultaneously
• Three causes
• Basic causes

• Underlying causes
• Immediate causes
Global Conceptual framework for malnutrition
 Stunting by Region
Percent of children under age 5 who are too short for their age (based on WHO standards)

Ethiopia total
44%
– Underweight (UNICEF 2009)
– 129 million (nearly one in four) under five
children (UFC) from the developing world are
underweight
– 10 percent of the UFC from the developing world
are severely underweight
– The prevalence of underweight among children is
higher in Asia than in Africa
– Asia – 27%
– Africa – 21%
• Wasting
– Children who suffer from wasting face a markedly
increased risk of death
– 13 percent of UFC in the developing world are wasted
– 5 percent (26 million) are severely wasted
Prevention of PEM
1. Dietary diversification
• Production of food stuffs at the backyard garden and
intensification of horticultural activities
2. Nutrition education
• Focuses on educating mothers/care givers on the
importance of having a balanced diet through
diversification of food
3. Economic approach
• Aims at improving the incomes of the target
community as a solution to their nutritional problems
• Different methods in this approach
– Food for work, food subsidy, income generating
projects
4. Dietary modification
– Focuses on modifying the energy, protein and
micronutrient content of the complementary foods.
5. Supplementation
– Could also be considered based on the local needs
Treatment of PEM
Admission criteria
Admission procedure
Implementation modalities
• Phase I
– F75 is used for treatment
– Rapid weight gain is dangerous
• Transition phase
– F100 is used
– RUTF is introduced
• Phase II
– RUFT
– F100
Routine medicines
• Vitamin A

• Folic acid
• Antibiotics
• Malaria
• Measles

• Deworming
Treatment of complications
• Dehydrations

• Septic shock
• Heart failure
• Hypothermia
• Sever anemia
• Hypoglycemia

• HIV
• Other
Public Health Consequences
– Susceptibility to mortality (death)
• Undernutrition is associated with greater mortality
rates from most childhood diseases.
• Undernutrition accounts for 33-60% child deaths world
wide
• Mild, moderate and severe undernutrition increases
the risk of death from common childhood illnesses by
relative risk of 2.5, 4.6 and 8.4, respectively
– Susceptibility to acute morbidity (disease)
• Compared with people with adequate nutrition, those
with poor nutritional status (determined by
anthropometry) are more likely to contract diarrheal,
malarial and respiratory infections and more likely to
suffer from these illnesses for longer duration
– Decreased cognitive development
• Specific nutrient deficiencies also impaired cognitive
development (e.g. iodine)
– Decreased economic productivity
• People of larger stature and musculature are more
efficient and accomplish more physical labor
– Susceptibility to chronic diseases in later life

• There is early appearance and greater prevalence and

severity of obesity, hypertension, stroke and cardiac
ischemia and diabetes in people with low birth weight
and nutritional problems in early life
31
End!
Vitamin A Deficiency Disorders
 Introduction
• What is Vitamin A?
– Vitamin A is a fat-soluble vitamin
– It is provided in the diet in two forms
• Retinoids (preformed vitamin A)

• Carotenoids (provitamin A)
– VADD is a major health problem in the world
Food sources
– Egg yolks, butter, milk, liver, fish liver oil
– Carotenoids
– Red, orange, yellow, pigments
– Bright red, orange and yellow fruits &
vegetables generally provide carotenoids
– Liver is rich in vitamin A
– White foods are typically low in β-carotene.
 Functions
• Essential for numerous metabolic processes
including
– Vision
– Growth
– Epithelial integrity
– Cellular differentiation
– Immunity
– Reproduction
– Regulation of gene expression
– Embryonic (bone) development
Vitamin A Deficiency Disorders(VADD)

• A comprehensive term that covers all effects of the deficiency

state including those on health, survival and vision
– VADD are public health consequences attributable to vitamin A
deficiency
– “Vitamin A deficiency” (VAD) is defined as liver stores of
vitamin A
• <10 μg/dL (0.35 μmol/L) – Deficient
• < 20 μg/dL (0.7 μmol/L) – Low

• >= 30 μg/dL (1.05 μmol/L) – Normal

– Clinical signs of VAD appear when the average intake of
the vitamin is very low, which corresponds to negligible
liver reserves
– Plasma retinol concentrations of less than 10 µg/dL are
usually associated with Bitot’s spots and other signs of
deficiency or can be found in a vitamin A sufficient child
often plagued with infections
• Vitamin A Deficiency Disorders
– Xerophthalmia (mild to severe)
– Corneal blindness
– Anemia

– Stunted growth
– Impaired immunity
– Increased severity to infection (e.g. measles, diarrhea, etc)

– Mortality
– Vitamin A deficiency is a leading cause of
preventable childhood blindness, morbidity and
mortality among preschool age children.

– VADDs are an increasingly recognized problem

among women of reproductive age in many
developing countries as well.
 Vitamin A Supplementation
• Dietary diversification alone is deemed inadequate to
normalize vitamin A status
– The bioavailability of beta carotene, the primary
provitamin A source in plants is only half that previously
assumed
– Supplementation of mothers and young children remains
an essential intervention in VAD populations
Causes of Vitamin A deficiency
– Inadequate intake
• Poor bioavailability
• Low fat diets
– Reduced fat intake
– Infections
• Mal absorption
– HIV, Measles, parasitic infections
• Confounding effect of RBP
– May cause low serum retinol as a result of transient
decreases in the concentration of RBP even in the
presence of adequate liver vitamin A stores
– Increased needs
• Age
• Physiologic status
– Socio cultural factors
– Interaction with other nutrients
• Vitamin E
• Iron
• Zinc
• Copper
• Lipids
• Proteins
– Age
• However, as a public health problem, VAD particularly
severe deficiency affects children of preschool age.
– This is because the requirements for growth in
these children are high while the dietary intake of
vitamin A is low with the added burden of a greater
exposure to infection.
• The incidence of corneal xerophthalmia is most
prevalent among children age 2-4 years
• In children under 12 months of age, corneal disease is
relatively a rare event largely because breast feeding is
protective
– Physiologic status
• As VA needs are increased during periods of rapid
growth, younger children are the most vulnerable
group.
• The demands of VA are also increased during gestation
and lactation and so pregnant and lactating women in
underprivileged populations may be unable to meet
the increased needs during those periods.
• Breast milk of women with poor vitamin A status
frequently is low in VA and could subsequently
contribute to increased susceptibility of the infants
• Diet
– The basic underlying cause of vitamin A deficiency is a diet
lacking adequate amounts of VA (preformed or provitamin
A) to meet the requirement

– In poor living conditions, the diet relies on less expensive

plant foods in which the vitamin A (as carotenoid) is less
bioavailable

– Intake of yellow fruit (mango and papaya) is strongly

protective in the second and third years of life
– Disease
• VAD increases the risk of infectious morbidity and
conversely infections predispose to vitamin A deficiency
• Several infections such as diarrhea, respiratory
infections and measles are associated with some form
of VAD
• The presence of PEM increases the subsequent risk of
xerophthalmia
– RBP may be reduced in PEM, reducing the
availability of circulating vitamin A
• Socio cultural factors
– Culture specific food habits and taboos for feeding
children, adolescents and pregnant and lactating women
often restrict consumption of potentially good food
sources of vitamin A
• Gender
– In healthy human adults, both retinol and plasma RBP are
found at levels 20% higher in males than females
– Nevertheless males have generally been found to be at
higher risk of night blindness and Bitot’s spots than
females during the preschool and early school age years.
– Socioeconomic conditions
• VAD is confined largely to relatively impoverished
countries
• Public health consequences of VAD
– Xerophthalmia
• Severe form of vitamin A deficiency
• Include
– Night blindness
– Conjunctival xerosis
– Bitot’s spots
– Corneal xerosis
– Corneal ulceration
– Corneal necrosis/Keratomalacia
– Immunocompetence
– Susceptibility to infection
– Morbidity
– Growth

– Associations with PEM

– Mortality (infants)
• Elimination (control) of VAD
– Four key strategies have been recommended

1. Nutrition education
– Creates micronutrient awareness

– Aims at improving practices related to consumption

of vitamin A rich sources
2. Diet diversification (eating a variety of foods)
• Natural way to obtain the nutrients needed for health
• It requires people to change their eating habits
• Agricultural research is trying to diversify the sources and
improve the yields of foods rich in provitamin A.
• Eg. Genetic engineering has made possible the
development of rice with high quality protein, improved
bioavailability and provitamin A
3. Supplementation
• Protect individual vitamin A deficiency by building
stocks in the liver
• Protection for 3 – 6 months
• Vitamin A is safe, effective and cost effective

• Vitamin A supplementation reduced the prevalence of

diarrhea by 36%
• Critical contact points for vitamin A supplementation
– Pregnancy
– Delivery
– Postnatal care and family planning
– Well baby clinic and growth monitoring
– Immunization
– Sick child contacts
– Others
• National immunization days, EOS/CHD, school health
programs, informal community contacts with mothers
and children (idir, market days, etc) can be used as an
opportunity to address vitamin A deficiency
4. Food fortification
– Addition of vitamins, minerals and trace elements to
staple foods)
• Is an effective public health measure to correct nutritional
deficiencies in whole population or specific segments at
risk.
• It does not require the active participation of the
consumer
• Traditional food consumption patterns can be maintained.
• Costs are negligible compared with the medical and public
health costs associated with malnutrition
– Several advantages
• It is affordable
• It is effective
• High population coverage can be achieved
• The risk of toxicity is negligible
• It is sustainable
• Complementary public health interventions
– Immunization, adding VAS to national NIDs
– Promotion of breast feeding
– Treatment of infectious diseases
– Community Health Days
END!?
Iron Deficiency Anemia
Introduction
• Iron
– One of the essential trace elements for life
– Found in the body in two different forms, namely the
functional or essential and storage forms
– Functional iron
– Serves metabolic or enzymatic function
– Mediates its physiological function through iron
containing proteins including iron containing
nonenzymatic proteins (hemoglobin and
myoglobin)
• Storage iron
– Primarily as ferritin and hemosiderin
– Responsible for the maintenance of iron
homeostasis
• Physiological functions
– Iron plays a vital role in
• Binding and transport of oxygen
• Electron transfer reactions
• Gene regulation
• Regulation of cell growth and differentiation
• Immune function
• Energy metabolism and
• Cognitive function
• Dietary sources of iron
– Despite its abundance in the earth’s crust, iron deficiency
is a common occurrence in both the developing and
developed world
– Iron in the diet comes from
• Contaminant iron
• Plants
– Non heme iron
– Leafy green vegetables, meat, egg, legumes, and
whole and enriched grains are good sources of non-
heme iron
• Animal sources
– Heme iron
– Meat, poultry and fish are good sources of heme
iron
• Forms of iron
– Heme iron (eg: hgb and mgb)
• From animal products
• Absorbed into the enterocytes and is little affected by
the composition of meals and the GI secretions
– Non-heme iron (eg: Ferric form, Fe3+)
• From plant products & dairy food
• Enriched products
• Must be solubilized and ionized by the acid gastric juice
and reduced to the ferrous form (Fe2+) prior to
absorption from the luminal to the mucosal phase
• Non heme iron absorption is affected by many factors
– Inhibitors
• Phytic acid (phytates), polyphenols, tannins, heavy
metals, fibers, low altitude, replete stores, achlorhydria
– Enhancers
• MFP, ascorbic acid, amino acids, high altitude, HCl,
fermentation, alcohol, deficient stores
• Causes of iron deficiency
– The main causes for failure to meet iron needs could be
• Dietary
– Inadequate intake of both heme and non-heme iron
rich diets
– Regular consumption of high phytate plant-based
meals
– Inadequate intake of iron absorption enhancers
– Inadequate intake of vit A, B- 12, folic acid, &
possibly B-6
• Non dietary
– Increased physiological requirements such as
menstruation
– Frequent parasitic infections including
» Malaria, Hookworm, Trichuriasis,
Schistosomiasis, Abnormal blood cell
production (sickle cell)
• Who is at the greatest risk?
• Children 6-24 months
• Special risk infants: low birth weight, premature, and/or
from anemic mothers
• Women of reproductive age, especially pregnant women
• Adolescents (especially females)
• PLWHA
Assessment of Iron Nutritional Status
• Iron nutritional status can be assessed by the following
biochemical and hematological tests
– Hemoglobin
– Hematocrit
– Serum iron concentration
– Total iron binding capacity
– Transferrin saturation
– Protoporphyrin
– Serum ferritin
– Transferrin receptors
• Clinical features of IDA
• Shortness of breath
• Lethargy
• Fatigue
• Headache
• Tinnitus
• Disturbance in taste
• Pallor of the conjunctiva, tongue, nail beds and soft palate
• Papillary atrophy of the tongue
• Nails become spoon shaped (koilnychia)
• Enlargement of the spleen (splenomegally)
• Behavioral changes
• Impairment of cognitive function
• Short attention spans
• Public health implications of IDA
– IDA is associated with
• Poor reproductive performance
• High proportion of maternal death (10 – 20% of total
deaths)
• High incidence of LBW (< 2500 g at birth)
• Intrauterine malnutrition(IUGR)
• Impaired scholastic performance (impaired
psychomotor development and intellectual
performance)
• Decreased resistance to infection
• Reduction of work capacity/productivity
• Consequences of Anemia:
• Has massive consequences for maternal & child health,
educability, & productivity
• Adults
– Adult productivity reduced
– 10% decrease in hemoglobin = 15% decrease in
productivity
• Women
• Increased risk of maternal mortality
• Reduced ability to survive bleeding during & after
childbirth
• Severe anemia is direct cause of 3-7% of maternal deaths
worldwide (others estimate it is direct or indirect cause of
20-40 percent maternal deaths)
• Even with mild/moderate anemia there is an associated
increased risk of dying
• Increased risk of:
– Premature birth
– Inter-uterine growth retardation
– Low birth weight
• Children
– Increased infant mortality (thru low birth weight)
– Learning deficits (iron deficiency anemia lowers IQ by 10
points)
– Fatigue & poor growth
– Iron deficiency affects iodine uptake, thus increasing risk of
Iodine Deficiency Disorders
• Risk factors for anemia
– Poor iron stores
• When the infants are born with poor iron stores iron,
deficiency is aggravated in infants who are solely breast
fed for prolonged periods
– Dietary inadequacy
• The major determinant of IDA, particularly in the
developing countries, is inadequate dietary consumption
• Many people are dependent on plant based foods in
which the iron absorption is poor and several substances
in the diet interfere with iron absorption
– Increased demands
• There is increased demand for iron during pregnancy
• Rapid growth during infancy and childhood increases iron
requirements
• Iron requirements increase considerably during puberty; in
girls the onset of menstruation imposes a double burden
– Mal absorption and increased losses
• Repeated episodes of diarrhea, resulting from unhygienic
practices, can result in malabsorption
• Infestations especially hookworm infestation and
ascariasis, result in iron loses and malabsorption of iron
• Repeated malaria attacks can lead to IDA
• In women, postpartum hemorrhage due to poor
obstetric care, repeated and closely spaced
pregnancies, prolonged periods of lactation and the use
of intrauterine contraceptive devices for birth control
are important contributory factors
– Drugs and other factors
• Radiation therapy, anticancer and anticonvulsant drugs
are some of the risk factors.
• Among the elderly, IDA is associated with chronic
inflammatory conditions such as arthritis,
gastrointestinal blood loss from long term use of drugs
such as aspirin and tumors
• Special case –Infants
• Infants are born with high iron stores
• Human milk has low iron content but bioavailability is high
• First 6 months of life, exclusively BF infant is in positive
iron balance
• Prevention and control of IDA
– There are four main approaches
• Provision of iron supplements
• Fortification of commonly consumed foods with iron
• Nutrition education
• Horticulture based approaches to improving the iron
bioavailability of common foods
 Anaemia in Children
Percent of children age 6-59 months classified as having anemia

44

21 20

3
 Anaemia in Children by Region
Percent of children age 6-59 months classified as having anemia

Ethiopia total
44%
75
69
63
56
51 52
47
35 37 38
33
 Anaemia in Women
Percent of women age 15-49 classified as having anemia

17
13

3
<1

Any anemia Mild anemia Moderate anemia Severe anemia

 Trends in Anaemia in Women
Percent of women age 15-49 classified as having anemia

2005 EDHS 2011 EDHS

27

17 17

8
3 3
<1 <1

Any anemia Mild anemia Moderate anemia Severe anemia

 Anaemia in Women by Region
Percent of women age 15-49 classified as having anemia

Ethiopia total
17%
44

35
29

19 19 19 19
17
11 12
9
Iodine Deficiency Disorders (IDD)
Introduction

• Iodine
– Was second to iron to be recognized as an
essential trace element for health
– Iodine has been used in the treatment of goiter
since 1820
– Its deficiency was shown to be the causative agent
for thyroid enlargement in 1917
– Was recognized to be an essential component of the
thyroid in 1895 for the first time (Kimball 1923)
– Nowadays it is well accepted that iodine is an integral
constituent of the thyroid hormones
• 3,5,3’,5’-tetraiodothyronine (thyroxine, T4)
• 3,5,3’-triiodothyronine (T3)
– These hormones regulate numerous functions
» Biochemical reactions (e.g., protein synthesis,
enzyme activities)
» Influence early organ development (e.g., brain)
• Physiological functions of iodine
– Iodine is an essential micronutrient for the
biosynthesis of thyroid hormones produced by the
thyroid gland (Zimmermann 2009)
– Thyroid hormones are essential for maintaining the
body’s metabolic rate by controlling cellular energy
production and oxygen consumption, for normal
growth and for neural and sexual development (Ristic-
Medic, Piskackova et al. 2009)
• Dietary sources of iodine
– The richest dietary sources of iodine are seafood,
seaweed and iodized salt
– Foods of animal origin including meat and milk can
also constitute a significant source of iodine if
animals have grazed on iodine sufficient soils
– Similarly, crops from iodine sufficient soils may
supply some dietary iodine
– Iodine fortified foods like salt, bread and milk
• Iodine deficiency disorders (IDDs)
• Encompass the wide spectrum of the effect of
suboptimal iodine nutrition on health, including
– Physical impairment and
– Mental retardation
• Epidemiology of iodine deficiency disorders
• Globally, iodine deficiency still remains a public health
problem in many countries
• Two billion people are estimated to be at risk of iodine
deficiency disorders due to suboptimal iodine nutrition
(de Benoist, McLean et al. 2008)
• Based on the survey data from 192 WHO member
states, 36.5% (285.4 million) of school age children are
at risk of iodine deficiency
• The largest numbers of school age children with low
iodine intake are from Southeast Asia (96 million) and
Africa (50 million)
• Causes of IDD
– Soil devoid of iodine
• Erosion of the land owing to the mountainous
topography especially in Ethiopia
• Crops growing in this type of soil are deficient in
iodine
• Animal products from animals grazing grass growing
in this soils are deficient in iodine
• Water will also be deficient
– Poor consumption of sea foods
– Increased consumption of goitrogens
• Foods that contain goitrogenic factors include
cabbage, cassava, beetroot, bamboo shoot
– Deficiency of other micronutrients (Iron, selenium, etc)
– Risk factors for IDDs in Ethiopia
• Marine foods are rarely consumed
• Staple diets are of plant origin
• Soils in the highlands are believed to be low in iodine as
it is leached out of the soil due to its solubility in water
• If soil is deficient in iodine, so are the plants grown in it,
including the grains and vegetables consumed by
people and animals
• Most of the Ethiopian cereals grow in iodine deficient
soils
• Health consequences of iodine deficiency
• Inadequate intake of iodine leads to iodine deficiency
disorders (IDD)
• The term IDD encompasses all consequences of IDD
which can be prevented by optimal iodine nutrition
• The most damaging effect of inadequate intake of
iodine is on the developing brain
• Cretinism is an extreme form of neurological damage
due to severe iodine deficiency or fetal hypothyroidism
– Cretinism is a congenital disease characterized by
mental and physical retardation and commonly
caused by maternal iodine deficiency during
pregnancy.
– Iodine deficiency alone lowered mean IQ scores by 0.9 SD
or 13.5 IQ points
– Iodine deficiency can induce thyroid enlargement at any
period in life.
• Goiter reflects an attempt of the thyroid gland to adapt to
increased need to produce thyroid hormones
– Impaired reproductive outcomes
– Child mortality
– High degree of apathy
– Reduced work productivity in the adult population living in
severely iodine deficient areas, leading to economic
stagnation of communities.
• Recommended intakes (WHO/UNICEF/ICCIDD, 2001)
Category Intake (µg/day)
Infants, 0 – 59 months 90
School children, 6 – 12 years 120
Children > 12 years and adults 150
Pregnant and lactating women 200

• At a level that assures 150 µg/day is safe for all

populations (WHO, UNICEF, FAO, ICCIDD)
• Intervention strategies
– One or a combination of strategies may be decided to
eradicate iodine deficiency
– Programs may include one or both of the following
strategies
• Food based approaches
• Fortification
• Nutrition education
• supplementation
• Fortification
– Fortification of salt
– Iodination of drinking water
• Iodination of irrigation water in China
– Fortification of infant formulas
– Fortification of foods consumed by animals
Salt fortification
– This recommendation assumes that 20% of the iodine will
be lost from the production site to the household and
another 20% lost during cooking and that the average salt
intake is 10 g per person per day
– Either KIO3 or KI may be used for fortification
– But KIO3 is more suitable in hot and humid climates
because of its greater stability
• Nutrition education emphasizing on
– The consequences of IDD
• IQ loss of 13.5
• Every year China loses 60-70 million IQ points due to
IDD
– Consumption of iodized salt
– Increased consumption of sea food when accessible
– Decreased consumption of goitrogenous foods and employ
food processing methods able to detoxify goitrogens
• Iodine status assessment Methods
– Urinary iodine excretion
– Thyroid size
– Thyroid size by palpation
– Cognitive function
– Incidence of cretinism
Thank You!!!