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					    Flour Fortification Initiative
    Eurasia FFI Regional Group
      Leaders Group Meeting
  Istanbul, 12-13 November 2006

Vitamin and Mineral Deficiencies
  Public health Consequences
                  Bruno de Benoist

  Department of Nutrition for Health and Development
Over the last 20 years, increasing recognition of public
health importance of vitamin and mineral deficiencies as
a public health problem

•Widespread in industrialised and non-industrialized countries
    – Over 2 billion people affected by a micronutrient deficiency, usually
       more than one deficiency.
    – More prevalent in poor populations
•Pregnant women and young children more vulnerable
•Risk factor for many diseases and contribute to high rates of morbidity and
 mortality
    – Iron, iodine and vitamin A represent 7.3% of global burden of
       diseases and are responsible for 45 million deaths every year
    – Other V&M deficiencies common but less recognised
•Measures for prevention and control are known and cheap
Worldwide, the three most common forms of
vitamin and mineral deficiencies are iron,
iodine and vitamin A deficiencies


  – Iodine deficiency: 2 billion
  – Vitamin A deficiency: 254 million preschool children ; 20
    million pregnant women
  – Iron deficiency anemia: 2 billion
  – Zinc deficiency: 3 billion
Iron, Zinc and vitamin A deficiency are among 20
leading risk factors responsible for the Global burden
of disease
Iron, Zinc and Vitamin A are among the first
ten risk factors contributing to the Burden of
Diseases in Developing Countries
Other vitamins and minerals may to make a
substantial contribution to the global burden of
disease
• However, the scale and impact of deficiencies is more difficult to
  quantify because
    – There are few data on the prevalence of deficiencies in these micronutrients
    – Their adverse effects on health are sometimes non specific, and the public
      health implications are less well understood
• However some vitamin and mineral deficiencies are known to be of
  public health importance in specific situations/conditions e.g.:
    –   Folate during pregnancy
    –   Vitamins B, PP, C in refugees and displaced people
    –   Vitamin D in young children
    –   Multiple micronutrient supplements in pregnant women, young children
 Vitamin A, iodine, iron and zinc are responsible for the
 four main deficiencies in micronutrients

• Iodine deficiency              50

   – 2 billion                   45
                                 40
• Vitamin A deficiency           35
   – 254 million preschool       30
     children                    25
                                                      IDD
                                                      IDA
   – 20 million pregnant women   20                   ZDD
• Iron deficiency anemia         15
   – 2 billion                   10
                                 5
• Zinc deficiency                0
   – 3 billion                        IDD IDA ZDD
                  Anaemia in Pre-SAC
                     Iceland


                                                           Norway
                                                                               Finland
                                                             Sweden
                                                                                                                                 Russian Federation

                                                                           Estonia

                                                Denmark                       Latvia
                IrelandUnited Kingdom of Great Britain and Northern Ireland
                                                                          Lithuania
                                         Liechtenstein
                                    Netherlands                                     Belarus
                                                                 Poland
                                   Belgium    Germany
                                   Luxembourg                                                                                                         Kazakhstan
                                                     Czech Republic
                                                                Slovakia                  Ukraine
                            France Switzerland       Austria
                                                              Hungary         Moldova, Republic of
                                                     Slovenia
                                                                           Romania
                                                     Croatia
                                          San Marino                                                                                                                     Kyrgyzstan
                                               Italy      Serbia and Montenegro
                                                    Bosnia and Herzegovina                                                                               Uzbekistan
                                  Monaco                                   Bulgaria                               Georgia
Portugal   Spain                                                      The former Yugoslav Republic of Macedonia                                                       Tajikistan
                          Andorra                              Albania
                                            Holy See                                                              ArmeniaAzerbaijan             Turkmenistan
                                                                  Greece
                                                                                                   Turkey


                                                Malta
                                                                                           Cyprus
   Mild (5.0-19.9%)
   Moderate (20.0-39.9%)
                                                                                                Israel
   Severe (≥40.0%)
   No Data
    Anaemia in Pregnant Women
                     Iceland


                                                           Norway
                                                                               Finland
                                                             Sweden
                                                                                                                                 Russian Federation

                                                                           Estonia

                                                Denmark                       Latvia
                IrelandUnited Kingdom of Great Britain and Northern Ireland
                                                                          Lithuania
                                         Liechtenstein
                                    Netherlands                                     Belarus
                                                                 Poland
                                   Belgium    Germany
                                   Luxembourg                                                                                                         Kazakhstan
                                                     Czech Republic
                                                                Slovakia                  Ukraine
                            France Switzerland       Austria
                                                              Hungary         Moldova, Republic of
                                                     Slovenia
                                                                           Romania
                                                     Croatia
                                          San Marino                                                                                                                     Kyrgyzstan
                                               Italy      Serbia and Montenegro
                                                    Bosnia and Herzegovina                                                                               Uzbekistan
                                  Monaco                                   Bulgaria                               Georgia
Portugal   Spain                                                      The former Yugoslav Republic of Macedonia                                                       Tajikistan
                          Andorra                              Albania
                                            Holy See                                                              ArmeniaAzerbaijan            Turkmenistan
                                                                  Greece
                                                                                                   Turkey


                                                Malta
                                                                                           Cyprus
      Mild (5.0-19.9%)
      Moderate (20.0-39.9%)
                                                                                                Israel
      Severe (≥40.0%)
      No data
Vitamin A status in Europe-1995
Iodine status in the European region
                         Iceland


                                                                   Norway
                                                                                        Finland
                                                                    Sweden
                                                                                                                                     Russian Federation

                                                                                    Estonia

                                                     Denmark                        Latvia
                    IrelandUnited Kingdom of Great Britain and Northern Ireland Lithuania
                                              Liechtenstein
                                          Netherlands                                    Belarus
                                                                       Poland
                                       Belgium     Germany
                                        Luxembourg                                                                                                        Kazakhstan
                                                          Czech Republic
                                                                     Slovakia                Ukraine
                                France    Switzerland     Austria
                                                                   Hungary        Moldova, Republic of
                                                          Slovenia
                                                                                Romania
                                                          CroatiaBosnia and Herzegovina
                                               San Marino                                                                                                                     Kyrgyzstan
                                                    Italy       Serbia and Montenegro
                                                                                                                                                              Uzbekistan
                                      Monaco                                    Bulgaria                               Georgia
 Portugal   Spain                                                          The former Yugoslav Republic of Macedonia                                                       Tajikistan
                              Andorra                               Albania
                                                Holy See                                                               ArmeniaAzerbaijan              Turkmenistan
                                                                        Greece
                                                                                                       Turkey


  Moderate iodine deficiency (20-49 µg/l)               Malta
                                                                                                   Cyprus
  Mild iodine deficiency (50-99 µg/L)
  Optimal (100-199 µg/l)
  Risk of iodine-induced hyperthyroidism (200-299 µg/l)                                                Israel
  Risk of adverse health consequences (>300 µg/l)
  No data
Risk factors for micronutrient malnutrition

•   Monotonous diet resulting in low micronutrient intake and poor bioavailability,
    especially of minerals
•   Low intake of animal source foods
•   Low prevalence of breastfeeding
•   Low micronutrient density of complementary foods
•   Increased demand
     – for growth, pregnancy and lactation
     – for diseases, in particular acute/chronic infection
•   Malabsorption due to diarrhea or intestinal parasites
•   Increased excretion (schistomiasis)
•   Poor economic status, social deprivation (low education and illiteracy)
Health consequences of vitamin and mineral
deficiencies
• During pregnancy
    – Stillbirth
    – Birth defects,
    – Prematurity, low birth weight
•   During childhood
    –   Increased risk of morbidity and mortality
    –   Delay in physical growth
    –   Impaired mental/cognitive development and least performance at school
    –   Less resistance to infection
• Adults
    – Increased risk of morbidity
    – Reduced productivity
Health consequences associated with iodine, iron,
zinc and vitamin A deficiencies
•   Iodine deficiency
     – Birth defects: brain damage during fetal life resulting in impaired cognitive development in infancy
       and childhood
     – Increased risk of stillbirth and infant mortality
     – Hypothyroidism
•   Vitamin A deficiency
     – Ocular lesions (night blindness, xerophtalmia)
     – Increased risks of morbidity and mortality in children due to less resistance to infection
     – Increased risk of mortality in pregnant women
•   Iron deficiency anemia
     –   Increased risk of morbidity and mortality in children
     –   Increased risk of mortality in pregnant women
     –   Reduced cognitive performance and endurance
     –   anemia
     –   Reduced productivity in adults
•   Zinc deficiency
     – Increased risk of morbidity and mortality in children
     – Delayed physical growth and impaired physical development
Health consequences associated with other
vitamin deficiencies
•   Folate deficiency
     – Birth defects, especially neural tube defects
     – Impaired cognitive function
     – Heart disease and stroke
•   Vitamin B-12
     – Megaloblastic anemia
•   Vitamin B1
     – Beri beri
•   Vitamin B2, B6
     – Microcytic anemia
     – Dermatitis
•   Vitamin B3
     – Pellagra
•   Vitamin C
     – Scorbut
•   Vitamin D
•   Rickets
 Measures to control vitamin and mineral
 deficiencies
•Combined interventions to improve nutrient intake
    – Dietary approaches, supplementation, fortification and biofortification
    – Public health measures
    – These approaches should be regarded as complementary
•In practice current strategies focus on:
    – Supplementation
         • Quickest intervention to implement to reduce V&M deficiencies
         • For Vitamin A, more sustainable than originally thought (EPI), but for other V&M
           deficiencies, limited effectiveness
    – Fortification
         • Long history in developing countries
         • Universal salt iodization now widespread
         • Increasingly feasible in developing countries, e.g. sugar fortification with vitamin A in
           Guatemala, Zambia
WHO and UNICEF pledged to virtually eliminate vitamin
A, iodine deficiency deficiencies and to reduce
prevalence of iron deficiency anemia

•Impact of their adverse consequences on:
    – Health and development (increased morbidity and
      mortality)
    – Productivity, with loss of human capital formation
•As a response to this awareness
    – Mobilisation of the international community
    – Increased collaboration with the private sector

				
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