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Innovations and Interventions in Iron Nutrition


									        Jordan’s Micronutrients Issue:
The Dilemma of Search for Effective Intervention

       Ibrahim M.D Khatib    (MSc , PhD)

Over many years, countries in the East Mediterranean
consistently overlooked under-nutrition as a probable health
threat to the community.

Today, few of these countries have discovered that no single
developing community may claim to be off the hook of
malnutrition, particularly hitting at the risk groups level.

Jordan has been one of those few EM-countries
        Combat Against Malnutrition
           The Partners Triad

Leading Role : For the MOH – Nutrition Division

Complementary Role : University Academics

Supportive Role : International organizations
                                   Facts About UnderNutrition *

       The most common health problem in developing countries
       Even in milder forms, it weakens the immune system
       Cause of diarrhea / ARI frequent / severe attacks
       Increases mortality in childhood (60 % of Global Rate)
       Causes are :
                       1. Direct   - inadequate access to food
                                   - inadequate intake of micronutrients,
                       2. Indirect - inadequate health care of mothers and children,
                                   - inadequate health services, and
                                   - unhealthy environments / poor hygiene

(Robert E Black, Saul S Morris and Jennifer Bryce. Where and why are 10 million children dying every year? (review). The Lancet, June 2003.
Vol. 361:2226- 2234 pp )
Jordan - Public Nutrition
 Facts and Chalenges
                  Adulthood Problems

Type 2-diabetes
    prevalence in middle age is above 20 %

CVD : Cardio-Vascular Disease
    prevalence is on the rise
                    Childhood Problems

Jordan is free from primary Malnutrition ( p-PEM)
Only secondary Malnutrition (s-PEM) prevails;
s-PEM signals inadequate tissue metabolization of nutrients
s-PEM is commonly attributed to:
  - Disease : e.g. frequent diarrheas / malabsorption / infections
   - Micronutrients – deficiencies (MNDs)
                      In Jordan…
         MNDs Are No Longer a Hidden Hunger

MNDs are significant causes of s-PEM in Jordan

Iodine, Iron, Zinc, and Vitamin A deficiencies : endemic

Stunting: remains the devious face of s-PEM

Anemia due to IDA and / or VAD : prevalent
              Significance in Childhood

Frequent diarrheas and infections / suppressed immunity
Stunting / Subnormal child growth pattern
Low IQ / compromised cognitive development
Poor performance / school achievement
Weak muscles / decreased work potential
Increased risk of death
            MNDs : Selected Outcomes

Iodine Deficiency Disorders (IDD)
  - mental deficiency
  - Physical anomalies
Poor Learning

Non-ocular VAD
Depressed immunity: infections / diarrhea & ARI
Physical growth deficiency
Predisposition to IDA
Ends with visual impairment / Nutritional blindness
            VAD, IDA, IDD
         International Reports

  Reduced learning capacity / intelligence
Population loss estimate = 10–15 I.Q. points

     Accomplished Surveys

Community Research For Advocacy
          Zinc Deficiency and Stunting [1,2]

Supplementation at infancy prevented growth stunting
                         MOH- IDD Surveys   [3,4]

IDD Prevalence
- by goiter assessment : 37.7 %
- by urinary iodine excretion > 50 %
   (median iodine excretion = 4 mcg/l)
IDD is a public health problem in Jordan;
Severity is highest in south / lowest in middle areas;
Intervention by salt-iodization started in 1996;
Program evaluation result (in 2000): satisfactory.
           MOE- Year 2000 School Surveys    [5,6]

Baseline prevalences among poor young school children:
 - 19.9 % for stunting,
 - 18.8 % for anemia,
 - 21.8 % for VAD.
Supplement: a daily snack + one 200,000 i.u.vitamin A capsule
Intervention improved all, EXCEPT stunting

Conclusion: VAD in school children is a public health problem.
               AlSaafi Schools Study, 2002 [7]

Approach : controlled interventional study ( 3 study groups)
Poorer villages of the disadvantaged AlSaafi district.
VAD prevalence : 35.3 %
Snack meal together with VA capsule made growth improvement;
A National Vitamin A Program should phase in.
             Conclusions on School Nutrition

Poverty linked-sub-clinical - VAD is confirmed as a public health emergency and
seems to be endemic in under-developed districts.

Impact of high domestic consumption of vegetables and fruits offset by
households concentrating on the carotenoids-poor items.

Statuses of vitamin A and E correlate strongly, suggesting a common defect in
fat solubles - absorption mechanism .

For poor young school children, the snack is essential for the VA capsule to
induce a significant improvement of serum VA levels.
Surveys on U5y - children
   North Badia survey - Year 2001 [8]

Prevalences Among Bedouin U5y – Children:

    Stunting ≈ 20%,
    anemia ≈19 %, ,
    non-ocular VAD ≈ 22%
Jordan Population and Family Health Survey   [9]
               DoS- Year 2000

 Anemia is prevalent at rates of :

   34% in U5y - children.

   65% in the 10-11 months children
           MOH–National Nutrition Study [10]
                         Year 2002

           Women in the child bearing age

Anemia               > 30 % ; (Hb <12 g/dl)
Iron deficiency (ID) > 40 % ; (low ferritin)
ID anemia            > 20 % ; (low Hb & ferritin)
   MOH–National Nutrition Study    [10]
                Year 2002
              U5y - children

Anemia = 20.1 % ; (Hb <11 g/dl)
Iron deficiency (ID) = 26.1 % ;
Iron deficiency anemia (IDA) = 10.1 % ;
Vitamin A deficiency (VAD) = 15.1 %
              Jordan’s MNDs problem
                The Social Grounds

Other factors contribute to the national nutritional problem
VA status and anemia always correlated with:

 - Maternal education
 - Consumption of animal based food
 - Socio-economic status
                                        VAD - International Rates
                  Among Pre-School Children in Selected Developing Communities*

      Country                      Community                          VAD           References
      YEMEN                        Rural    1992                       62.4         [Pizzarello, 1993]
      PAKISTAN                               1990                      48.3         [Molla et al., 1993]
      PALESTINE                    National 2003                       22.0         [Present Study, 2004]
      OMAN                         National 1995                       20.8         [National study, 1995]
      JORDAN                       National 2002                       15.2         [Jordan-MOH Staff, 2003]
      BOLIVIA                      National 1991                       11.3         [Encuesta de vitamina A, 1991]
      DOMINICAN REP                Southwest 1991                      19.6         [WHO,1995]
      GHANA                        VAST      1991                      73.4         [Ghana VAST study team, 1993]
      MORROCO                      National 1996                       40.9         [Berraho et al., 2003]
      CHINA                        2000                               9.97*         VAD in China, 2000
      PHILIPPINES                  1986                                10.9         [WHO,1995]

* Adapted   from the draft report : Palestine Vitamin A Deficiency Survey among U5y-children . Maram Project, May 2004.
         Ongoing Interventional Programs
           An MOH - Story of Success

  Iodination of Table Salt (1996)
  Wheat Flour Fortification : (Iron and Folic acid; May 2002)

Monitoring System:
  MOH- Nutrition Division

  International Organizations
                    Upon a Royal Decree….

The Jordan-government implemented in February 2003, a national
program aiming at the universal distribution of a daily multi-vitamin
& mineral supplementary tablet for every school childr in Jordan


The Jordan- High Commission on Nutrition recommendation is for
the switching from tablet - supplement distribution to food (flour)
fortification to secure higher coverage for other risk groups
The Pending Questions

Shall Jordan continue expanding in wheat
flour fortification to include vitamin A ?
If not, what will be the alternative option?

Shall Jordan consider adding some other
micronutrients to the premix ?
If yes, what are these ?
                   Let Us not Forget the
                  Missed year 2000 –Targets*

    Eliminate iodine deficiency disorders (IDD)
    Eliminate vitamin A deficiency (VAD)
    Reduce iron deficiency anemia (IDA), by 1/3

1990 -World Summit for Children
   Immdiate Ambitions of Jordan Community

Eliminatation of VAD as a health risk factor

Prevention of unrecognized MNDs
                        The Elimination of VAD

                   Low serum retinol (< 0.70 µmol/L)

            Prevalence - Goal to Achieve
               < 5% in age 6-71 month

Source: WHO 1996
         Measuring Impact of Intervention
              Standard Indicators

Valid indicators are established to assess progress toward
achieving elimination of vitamin A and iodine deficiencies

In ID surveys, Hb and SF consitute a useful combination for
use as a tool to assess progress toward achieving alleviation
of iron deficiency anemia (IDA)

No single standard indicator exist for ID diagnosis
                                        Domestic Research: References

1. Khatib I, and Hijazi S. JUST-Percentiles : a cross-sectional study of the declination observed in the Jordanian child
    growth curve and its association with the local patterns of infant weaning. Jordan University of Science & Technology
    (JUST)-Publications,1992, Irbid-Jordan .
2. Khatib I, Hijazi S, and Aggett P. A longitudinal -interventional-study of the impact of zinc fortified weaning food on linear
    growth of infants in northern Jordan.The Higher Council for Science and Technology Publications,1995, Amman-Jordan.
3. The IDD National Committee: Iodine Deficiency in Jordan,1995 . A national baseline study. Report of UNICEF office-
    Amman, 1995.
4. The IDD National Committee: Iodine Deficiency in Jordan, 2000. A national baseline study. Report of UNICEF office-
    Amman, 2000.
5. Khatib I. High prevalence of subclinical vitamin A deficiency in Jordan: a forgotten risk Food Nutr Bull., September 2002,
    3; 23 (Supp. 228-236).
6. Khatib I and Hijazi S. Poverty – Linked vitamin A deficiency (VAD) in Jordan is endemic and coupled with compromised
    vitamin E Status. ( A report submitted to the MOE in 2002; currently under-modification for publication ).
7. Khatib I . Supplementation with vitamin A capsules along with iron fortified school meals can have positive impact on the
    growth of young school children: a controlled trial. (An abstract to be orally presented in the X Auxology Congress ,
    Florence-Italy , July 4-7, 2004)
8. Khatib I and Hijazi S. Nutritional status of the under 5 years beduin children. A study report submitted to the sponsor :
    the Jordanian Badia Development Program, December 31,2003 .
9. Department of Statistics. The 2002 Jordan Population and Family Health Survey. The ORC Macro Publications,2003.
10. The National Committee on Micronutrients. The year 2003 – National Nutrition Study of Anemia and VAD . MOH .
    (report in press).
Thank You

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