Micronutrient%20deficiencies

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Micronutrient deficiencies

• Prof. Pushpa Raj Sharma
• Department of Child Health
• Institute of Medicine

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• Nutrients, such as vitamins, iron, copper, and
  zinc,
• that are required in very small amounts by
  humans
• in order to survive, as distinguished from the
• macronutrients such as water, carbohydrate,
  protein
• and fat, that are needed in large quantities.

• Micronutreints are essential to the body in small
  
• amounts because they are either components of
• Enzymes (the minerals) or act as coenzymes in
• managing chemical reactions.

• Essential dietary elements required only in small
  
• quantities. They are present in the body in
  amounts
• less than .005 of body weight.

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If we could give every individual the right
amount of nourishment and exercise, not too
little and not too much, we would have found the
safest way to health. Hippocrates
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Commonest micronutrient deficiencies

• The World Health Report published recently by WHO
  cites iron, vitamin A and iodine deficiencies as
  three of the most prevalent and critical nutrient
  deficiencies in the world.

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Burden of the disease

• Globally
• Between 100 and 140 million children are vitamin
  A deficient
• Anemia, mostly due to iron deficiency, affects
  some 2 billion people
• About 41 million infants are born every year
  unprotected from losses in IQ or more severe
  mental retardation due to iodine deficiency.

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• Nepal
• Vitamin A deficiency (VAD) causes an estimated
  14,000-20,000 Nepalese children to die of
  infections annually.
• Iodine deficiency disorders (IDD) affect an
  estimated 10 million Nepalese nationwide
• A Goiter prevalence of 41.5 among females and
  38.4 among males among school-aged children 6-14
  years
• The anaemia prevalence was highest among infants
  aged 6-11 months (90) and during the second year
  of life (87.2), and decreased linearly with age
  to 59.2 in the 48-59 month age group.

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• United Nations General Assembly Special
• Session on Children convened in May 2002
• set the following targets
• The sustainable elimination of iodine
  deficiency disorders by 2005
• The sustainable elimination of vitamin A
  deficiency by 2010
• Reducing anemia prevalence, including iron
  deficiency by a third by 2010
• Accelerating progress towards the reduction of
  other micronutrient deficiencies through dietary
  diversification, food fortification and
  supplementation.

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Iodine Micronutrient

• Iodide uptake is a critical first step in thyroid
  hormone Synthesis.10 to 25 of radioactive tracer
  (e.g., 123I) is taken up by the normal thyroid
  gland over 24 h
• Iodine deficiency, there is an increased
  prevalence of Goiter.
• when deficiency is severe, hypothyroidism and
  cretinism develops.
• Iodine deficiency remains the most common cause
  of preventable mental deficiency

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Iodine deficiency world wide
WHO Regions a Proportion of population with UI lt 100 ?g/L () Population with UI lt 100 ?g/L (in millions) b
Africa 47.6 48.342
The Americas 14.1 9.995
Eastern Mediterranen 55.4 40.224
Europe 59.9 42.206
South East Asia 39.9 95.628
Western Pacific 19.7 36.082
Total 36.9 272.438
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Iodine Deficiency prevalence in Nepal
Iodine deficiency disorders (IDD) affect an
estimated 10 million Nepalese nationwide A
Goiter prevalence of 41.5 among females and
38.4 among males among school-aged children 6-14
years
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Estimated Goiter Prevalence Note  The prevalence in the sample was assessed for grades, 1, 2, as well as TGR (total goiter rate) Estimated Goiter Prevalence Note  The prevalence in the sample was assessed for grades, 1, 2, as well as TGR (total goiter rate)  


Group Sample Size Indicator Prevalence in Sample Prevalence in Sample Prevalence in Sample Population Affected
Group Sample Size Indicator G1 G2 TGR Population Affected
Women 15,540 Visible or palpable goiter (grades 1 and 2) 48.1 1.3 50.0 2,887,515
Children 6-11 yrs  (school aged children) 15,542 Visible or palpable goiter (grades 1 and 2) 40.5 0.0 40.5 1,328,648  The Nepal Micronutrient Status Survey was completed in 1998. 

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Iodine requirement

• To meet iodine requirements, the current
  recommended daily iodine intakes are
• 50mg for infants (first 12 months of age)
• 90mg for children (2-6 years of age)
• 120mg for school children (7-12 years of age)
• 150mg for adults (beyond 12 years of age)
• 200mg for pregnant and lactating women

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Prevention of Iodine Deficiency
There is legislation governing IDD in Nepal.  It
was passed in 1955 and has been revised since. 
Salt iodization is mandatory at the level of
20-60 ppm.
The estimated percent of households consuming
salt with some iodine is 91.  The estimate of
households consuming adequately iodized salt
(15ppm or above) is 63.  Sourced from the
Between Census Household Information, Monitoring
and Evaluation System 2000- BCHIMES.
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Iron Micronutrient

• Most Abundant Trace element in body
• Functions
• Structure of hemoglobin Myoglobin O2 CO2
  Transport
• Oxidative Enzymes
• Cytochrome C
• Catalase
• Peroxidase
• MAO (neurotransmitters)

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Deficiency

• Causes
• Inadequate intake/ Poor bioavailability/
  Infections/ Chronic blood loss/Decreased
  absorption
• Increased Demand (young children/ preg.
  Lactation)
• Manifestations
• IDA End stage of long process Tip of iceberg

Stage Manifestation Diagnosis
Early Storage iron depletion N- Hb/Serum iron ? Ferritin/ marrow liver iron
Second Iron limited erythropoiesis N- Hb ? Ferritin/? TIBC
Third Iron Deficiency Anemia ? Hb/Ferritin/Serum iron, MC/HC Anemia
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The cutt-offs for haemaglobin and haemocrit which
are used to define anemia in people living at sea
level

• Population GroupHaemoglobin(g/dL) Haemocrit()
• Children 6 months to 5 years 11.033
  Children 5-11 Years 11.534
• Children 12-13 years 12.036
• Non-pregnant women 12.036
• Pregnant women 11.033
• Men
  13.039

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Prevalence of Anaemia in Nepal
MOH/USAID 1975 National 6-23 months 319 19.5
MOH/USAID 1975 National 24-71 months 946 25.7
Sharma PR, Baral MR, Khetan BK 1985 Kanti Childrens Hospital 0-1 1000 65.25
Sharma PR, Baral MR, Khetan BK 1985 Kanti Childrens Hospital 1-4 1000 59.44
Sharma PR, Baral MR, Khetan BK 1985 Kanti Childrens Hospital 5-14 1000 47.93
MOH, Child Health Division 1998 National 6-11 months 549 90
MOH, Child Health Division 1998 National 12-23 months 1220 87.2
MOH, Child Health Division 1998 National 24-35 months 978 74.9
MOH, Child Health Division 1998 National 36-47 months 637 70.2
MOH, Child Health Division 1998 National 48-59 months 515 59.3
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Prevention of Iron Deficiency

• Supplementation with medicinal iron
• - Pregnant women/ infants/ preschool children
• Increasing dietary intake
• - promoting breast feeding/ timely introduction
  of weaning foods
• Enhancing bioavailability
• ?- ? Vit. C, ? tannins phytates
• Control of infections
• - Feeding during illness/ Deworming
• Food fortification

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Iron doses
Oral iron therapy ( safe, cheap, effective) Dose
6mg/kg/d infants children 60-120
mg/d adolescents and adults - Parenteral
thearapy (not very safe but ensures compliance)
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Vitamin A Micronutrient

• First Vitamin Discovered (1913)
• Functions
• Maintenance of Normal Vision
• Growth, Repair and Cell Differentiation
• Health of Epithelial Cells
• Pregnancy and Fetal Development
• Protection Against Infection

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Deficiency

• Causes
• Inadequate intake/ Infections/ Measles
• Manifestations
• XN Night Blindness (Earliest manifestation)
• X1A Conjunctival xerosis
• X1B Bitots Spots
• X2 Corneal xerosis
• X3A Corneal ulcer/Keratomalacia lt 1/3
• X3B Corneal ulcer/Keratomalacia gt 1/3
• XF Fundal changes
• XS Corneal Scarring

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Prevalence of Vit A deficiency Nepal preschool
children
Age group number cases Number cases
6-11 0 0 0.00 1995 0 0.00
11-23 4457 3 0.07 4534 2 0.04
24-35 4305 8 0.19 4348 10 0.23
36-47 3455 18 0.52 3470 21 0.61
48-59 3084 14 0.45 3102 24 0.77
National 15307 42 0.27 17455 57 0.33
Nepal mocronutrient status survey 1998
Night blindness Bitots Spot
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Prevalence of Vit A deficiency Nepal school
children
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Burden of Disease in Nepal

• Vitamin A deficiency (VAD) causes an
• estimated 14,000-20,000 Nepalese children
• to die of infections annually.

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Vitamin A requirement
Infantslt 6-12 months of age only if not breastfed (breast fed children in this group should be protected by post partum supplementation of their mothers.)   50,000 IU orally
Infants 6-12 months of age  100,000 IU orally, every 4-6 months
Childrengt 12 months of age 200,000 IU orally, every 4-6 months
Mothers (post-partum, lactating)  200,000 IU orally within 8 wks of delivery

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Zinc Micronutrient

• In 1958, a 21 year old male patient in the
  Iranian city of Shiraz.
• In 1974 the Food and Nutrition Board of the US
  National Academy of Sciences
• The immunological effects of zinc deficiency
  during the late 1960s.
• BMJ 2003326409-410 ( 22 February )Ananda
  S Prasad Editorials

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Zinc

• 3rd most abundant trace element in body
• There are no zinc stores in the body to mobilize
  from, and in 16 hours an animal can be deficient
  with rapid effects.
• Functions
• Metabolism (functions in over 200 enzymatic
  reactions)
• Antioxidant function
• Immunity and Wound healing
• Fetal Growth and Development
• Production of brain neurotransmitters

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Zinc and its effect
When pregnant mice were fed a diet moderately deficient in zinc, their offspring exhibited a malfunctioning immune system for the first six months of life. More alarming, the second and third generations also showed signs of poor immunity - even though they were fed a zinc-plentiful diet. Jean Carper, writing in Jean Carper's Total Nutrition Guide, in reference to zinc studies done at U.C. Davis
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Symptoms of Zinc Deficiency
Delayed skeletal maturation and defective
mineralization of bone (monkeys) Weight loss
Intercurrent infections Hypogonadism in males
Lack of sexual development in females Growth
retardation Dwarfism

• Delayed puberty in adolescents
• Rough skin
• Poor appetite
• Mental lethargy
• Delayed wound healing
• Short stature
• Diarrhea
• Pneumonia
• Stretch marks (striae)

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Symptoms of Zinc Deficiency

• White spots on fingernails
• Reduction in collagen turnover and synthesis (in
  chicks)
• Reduction in collagen (in humans)
• Poor Immune system
• Acne
• Cross-linking of collagen

• Hyaluronic acid abnormalities (in swine)
• Defective connective tissue
• Macular degeneration
• Cataracts (in salmon)

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Deficiency

• Severe Deficiency
• Acrodermatitis enteropathica
• Syndrome of hypogonadism, stunting, anemia,
  anorexia and hepatosplenomegaly
• Mild/Subclinical Deficiency
• True estimate currently not possible Lack of
  valid marker for nutriture
• ? common in children/women developing world
• ? susceptibility to infection/?wound-healing
  time.
• ? Growth retardation/? Pregnancy related
  complications and LBW

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Vitamin A and zinc are micronutrients known to be
important in the maintenance of normal immune
function
Zinc deficiency is associated with chronic
diarrhea, growth failure, and immune deficiency.
Supplementation resulted in a 23 percent
reduction (95 percent confidence interval, 12 to
32 percent) in the risk of continued diarrhea and
a 39 percent reduction (95 percent confidence
interval, 6 to 70 percent) in the mean number of
watery stools per day.
Tomkins A, Behrens R, Roy S. The role of zinc and
vitamin A deficiency in diarrhoeal syndromes in
developing countries. Proc Nutr Soc
199352131-142.
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Three Recommended Daily Allowances of zinc given
daily by caretakers or by field workers
substantially reduced theduration of diarrhea. .
Strand TA, Chandyo RK, Bahl R, Sharma PR,
Adhikari RK, Bhandari N, Ulvik RJ, Molbak K, Bhan
MK, Sommerfelt H. Pediatrics. 2002
May109(5)898-903.
An emphasis on the costs and economic benefits of
an alternative therapy is an important aspect of
health services research. The cost savings and
theattractive cost-effectiveness indicates the
need to further assess the role of
micronutrients such as zinc and copper in the
treatment of acute diarrhea in a larger and more
varied population Patel AB, Dhande LA, Rawat
MS. Cost Eff Resour Alloc. 2003 Aug 291(1)7.
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Zinc in growth and respiratory infection

• Zinc-deficient Bangladeshi infants showed
  improvements in growth rate and a reduced
  incidence of acute lower respiratory infection
  after zinc supplementation. In infants with serum
  zinc concentrations gt 9.18 micro mol/L,
  supplementation improved only biochemical zinc
  status.Osendarp SJ, Santosham M, Black RE, Wahed
  MA, van Raaij JM, Fuchs GJ.Am J Clin Nutr. 2002
  Dec76(6)1401-8.

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Safe Upper Limit of Zinc Intake

• 0.5 -1 yr 13mg/d
• 1 -6 yr 23mg/d
• 10 -12 yr 32mg/d Girls
• 34mg/d Boys
• Trace elements in human nutrition and health.
  Geneva. WHO 1996.

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Intestinal Diseases and micronutrients
Three months after treatment, significant
differences in serum copper, zinc and magnesium
were seen in patients with E. VERMICULARIS
infection, and in serum magnesium levels in
patients with G. LAMBLIA. Olivares JL, Fernandez
R, Fleta J, Rodriguez G, Clavel A. Serum mineral
levels in children with intestinal parasitic
infection Dig Dis. 200321(3)258-61 Children
with inflammatory bowel disease have abnormal
levels of the trace elements which is more marked
in those with Crohn's disease The reduced free
radical scavenging action of zinc and selenium as
a result of their deficiency may contribute to
the continued inflammatory process of IBD.
Ojuawo A, Keith L. The serum concentrations of
zinc, copper and selenium in children with
inflammatory bowel disease.Cent Afr J Med. 2002
Sep-Oct48(9-10)116-9.
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The doctor of the future will give no medication,
but will interest his patients in the care of the
human frame, diet and in the cause and prevention
of disease. Thomas A Edison Thank you