national perspective on micronutrient deficiencies and their impact on health and productivity...
TRANSCRIPT
National Perspective on Micronutrient Deficiencies and
Their Impact on Health and Productivity
Professor & Head, Centre for Community Medicine,
All India Institute of Medical Sciences,
Regional CoordinatorInternational Council for Control of
Iodine Deficiency disorders (South Asia)
Dr. Chandrakant S Pandav
New Delhi, India
Contributors • Dr. Kapil Yadav
Senior Program Officer, ICCIDD, c/o CCM, AIIMS, New Delhi
• Dr. P. StalinJunior Resident, CCM, AIIMS, New Delhi
• Dr. Ravi UpadhyayJunior Resident, CCM, AIIMS, New Delhi
Outline • Take Home Messages• Nutrition – A link between food & health • Micronutrients – Public health importance• Micronutrient Deficiencies
– Burden– Health consequences– Impact on productivity
• Copenhagen Consensus• Take Home Messages
Take Home Messages
Micronutrient deficiencies Public Health Problem Burden is heavy Health consequences
Serious & irreversible
Productivity loss – Significant
The Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower
women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Build a global partnership for development
Need for Equity Focus
• To leave the poorest and marginalized– Strategically short-sighted
• With resources depleted, • Political will exhausted and • A public that has moved on
– By 2015, it will be a big challenge to reach the most deprived
“The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition.” - Thomas Edison (1847 – 1931), American Inventor, Scientist & Businessman
“However much a mother may love her children, but impossible for her to provide quality child care if she herself is poor, illiterate, anemic and unhealthy”. -Dr. V. Ramalingaswami (1921 - 2001), Director (AIIMS) & Director General (ICMR)
Main factors for good health and quality of life
• Genetics
• Nutrition
• Mental well being
• Physical activity and exercise
• Avoidance of toxicants i.e. tobacco, alcoholic consumption and drug abuses
• Environment: physical, biological, chemical, social, economic & political
• Agriculture• Food supply• Service
Nutrition is a link between food and health
Food Nutrition Health• Promotion• Protection• Treatment
Ultimate Goals:
Nutrition Security and wellbeing for AllNutrition Security and wellbeing for All
• Food quality• Food safety
• Nutrient needs• Dietary intakes• Nutrition wellbeing• Nutrition literacy
• Free from food borne illness
• Good health
Food SecurityFood Security
Food and Nutrition EducationFood and Nutrition Education
Food CultureFood Culture
Food and Nutrition Challenges
• Continuing and persistent undernutrition Undernourished (Protein and energy
deficiency) in children and adults Micronutrient deficiencies: of iron, iodine,
vit. A and others• Overnutrition and diet related diseases
Overweight & obesity Diabetes mellitus, high blood lipids, High blood pressure Cardio-vascular diseases Cancers
• Food safety and quality
Food and Nutrition Challenges
• The pandemic of hunger and obesity, both are increasing
• FAO estimated in 2009 that over 1,000 million people were undernourished.
• Paradoxically, WHO estimated that1,600 million adults are overweightand 400 million are obese.
Macro-nutrients Proximate principles, Sources of energy & body building
Micronutrient Must be provided in food
& enable the body to use other nutrients
Air, Water & Energy
(3)
Protein
(amino acids)
(9)
Lipids-Fat
(fatty acids)
(2)
Macro-Minerals
(7)
Trace Elements
(17)
Vitamins
(13)
Oxygen
Water
Carbohydrates
Histidine
Isoleucine
Leucine
Lysine
Methionine
Phenylalanine
Threonine
Tryptophan
Valine
Linoleic acid
Linolenic acid
Na
K
Ca
Mg
S
P
Cl
Fe
Zn
Cu
Mn
I
F
Se
Mo
Co (in B12)
B
Ni
Cr
V
Si
As
Li
Sn
A
D
E
K
C (Ascorbic acid)
B1 (Thiamin)
B2 (Riboflavin)
B3 (Niacin)
B5 (Pantothenic acid)
B6 (Pyroxidine)
B7/H (Biotin)
B9 (Folic acid, folacin)
B12 (Cobalamin)
The Known 51 Essential Nutrients for Sustaining Human Life**
*Numerous other beneficial substances in foods are also known to contribute to good health.
Micronutrients: Public Health Importance
• Iron
• Vitamin – A
• Iodine
• Zinc
• Folic Acid
India
• Burden of Micronutrient Deficiencies
• Health Consequences of Micronutrient Deficiencies
• Impact of Micronutrient Deficiencies on Productivity
The Ugly Face of The Ugly Face of “Hidden Hunger”“Hidden Hunger”
Zinc DeficiencyVitamin A Deficiency Iodine Deficiency
Iron DeficiencyFolic Acid Deficiency
3/4th of young children, ½ of women & 1/4th of married men are anemic
(NFHS 3, 2005 – 06)
Anemia in women (15-49
yrs)
Urban rich
49%
Urban poor
59%
Rural
57%
Preschool children(NNMB 2006)
Bitot’s spot
0.6%
Night Blindnes
s
0.2%
Burden of IDD(National Iodine Deficiency Disorders Control Programme,
Annual Report (2009-10) M/o Health & FW, Govt. of India, New Delhi.)
Goitre
70 million
Mild neurological deficits
6.6 million
Cretins
2.2 million
Proportion of households with adequately iodized salt – 51%
(NFHS 3, 2005-06)
Non-iodized salt Iodized salt
Burden of zinc deficiency No data
Burden of Folic Acid Deficiency
2,00,000 babies born with neural tube defects per year
India
• Burden of Micronutrient Deficiencies
• Health Consequences of Micronutrient Deficiencies
• Impact of Micronutrient Deficiencies on Productivity
Impact of Micronutrient Deficiencies on Health
• Iron• Vitamin A• Iodine • Zinc • Folic Acid
Iron deficiencyNutritional anemia: Indirect Cause of Maternal Mortality (20%),
Cognitive impairment & decreased immunity
Vitamin A deficiencyXerophtalmia, infections & growth failure
Iodine DeficiencyDecreased IQ, mild neurological deficits, cretinism, goitre
stillbirths & neonatal deaths
Zinc DeficiencyLow birth weight, preterm deliveries, spontaneous abortions
& congenital malformations
Folic Acid DeficiencyNeural tube defects, Megaloblastic Anemia
India
• Burden of Micronutrient Deficiencies
• Health Consequences of Micronutrient Deficiencies
• Impact of Micronutrient Deficiencies on Productivity
Question:
How much is : 2G + 3G = ?
MATHEMATICIAN : 2G + 3G = 5G
ACCOUNTANT : 2G + 3G = 5G……
……..On an average 5G;
……..Give or take 10%
ECONOMIST ……….?
JOB INTERVIEW
COMPONENTS OF ECONOMIC EVALUATION
HEALTH CARE PROGRAM
RESOURCES CONSUMED
HEALTH IMPROVEMENT
Cost Consequences
Cost
Direct Capital - (Land, Building, Equipment)
Operating - ( Staff, Overheads)
Indirect Production loss - (Patients, caregivers)
Transportation
Boarding & lodging
Intangible Pain
Suffering
Grief
Consequences
Physical functioning Mortality
Morbidity
Disability
Resources use Cost averted by health care system in the form of treatment.
Productivity loss averted.
Social & emotional functioning
Pain
Suffering
Grief
Changes in quality of life Friends
Family
COST OF MALNUTRITION – 3 ScenariosProgramme Health consequences Identification,
Measurement & Valuation of health consequences
No Programme
(no resource allocation)
Due to malnutrition very high
Mortality
Morbidity
Disability
Cost averted by health care system in the form of treatment.
Productivity loss averted.
Pain, Suffering, Grief
QOL: family & friends
Existing programme
(Resource allocation)
Decrease in prevalence of malnutrition
Effective programme (100%)
Minimal malnutrition
Calculating Costs: contd..
Productivity loss-
a proxy to cost of health consequences.
To measure productivity loss: 3 parameters• Productive life expectancy.• Average annual wage for an adult.
• Average rate of employment.
Source: National strategy to reduce childhood malnutrition: Final Report; Min of HR&D: GOI, Administrative staff college of India, Hyderabad. Dec, 1997.
Productivity loss due to different deficiency disorders:- Assumptions*
Nutrient Deficiency disorder
Assumed productivity loss%
Iron Anemia 20%
Iodine Mild iodine deficiency
5%
Cretinism 50%
Vitamin A Partial blindness 25%
Total blindness 50%
Source: *Assumptions made by Judith McGuire et al National strategy to reduce childhood malnutrition: Final Report; Min of HR&D:GOI, Administrative staff college of India, Hyderabad. Dec, 1997.
Estimating the Annual Productivity loss
• Annual Productivity loss
= (n * p * w * e) + (d * pe * w * e)
n= No. of adults suffering from deficiency disorder P = Productivity loss due to the disorder. w= annual wage e = employment rate. d= death due to disorder pe= productive life expectancy.
Source:National strategy to reduce childhood malnutrition: Final Report; Min of HR&D:GOI, Administrative staff college of India, Hyderabad. Dec, 1997.
Assumptions used for analysis
Parameter Unit Scenario
Low Moderate High
Productive life expectancy Years 15.6 20 25
Average annual wage for adult Rs. 3500 5000 7500
Average rate of employment % 75 80 85
National Strategy to reduce childhood malnutrition: Final report; Ministry of Human Resource Development: Government of India, Administrative staff college of India, Hyderabad. December 1997
Estimated annualproductivity losses (2010)
Nutritional deficiency
Low scenario
Moderate scenario
High scenario
Rs. Billion Rs. Billion Rs. Billion
Iron 305.8 468.2 750.0
Vitamin A 16.4 31.9 63.64
Iodine 69.2 108.1 156.8
National Strategy to reduce childhood malnutrition: Final report; Ministry of Human Resource Development: Government of India, Administrative staff college of India, Hyderabad. December 1997
Total Annual productivity losses approximately Rs. 1000 billion (High Scenario)
Micronutrient Initiative:India Micronutrient National Investment Plan
L Lavialette & et al
Nutrient Category Yearly Additional Cost (Rs. in Billion)
Vitamin A 4.6
Iron and Folic Acid 35.9
Iodine 3.8
Zinc 2.6
Multiple 11.0
Management 0.8
Total 58.8
Imagine you had $75bn to donate to worthwhile causes.
What would you do, and where should we start?
Copenhagen Consensus : 10 Challenges
1. Air Pollution 2. Conflicts 3. Diseases 4. Education5. Global Warming6. Malnutrition and Hunger 7. Sanitation and Water 8. Subsidies and Trade Barriers 9. Terrorism 10. Women and Development
Expert panel Economists : 8
10 Challenges
Rank Listing Solutions for challenges
Challenge Paper Authors : 3
Perspective Paper Authors : 2
Costs and benefits analysis
Policy Makers
Decision Making on Money Spending
10 Challenges
30 Solutions
Ranking list
4 solutions related to Malnutrition in first 10 priorities
1. Micronutrient supplements for children (vitamin A and zinc) 3. Micronutrient fortification (iron and salt iodization)5. Bio-fortification9. Community-based nutrition promotion
Take Home Messages
Micronutrient deficiencies Public Health Problem Burden is heavy Health consequences
Serious & irreversible
Productivity loss – Significant
The Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower
women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Build a global partnership for development
Need for Equity Focus
• To leave the poorest and marginalized– Strategically short-sighted
• With resources depleted, • Political will exhausted and • A public that has moved on
– By 2015, it will be a big challenge to reach the most deprived
" We ourselves sometimes feel that what we do is just a drop in the ocean, But the ocean would be less because of that missing drop.“
- Mother Teresa
" We ourselves sometimes feel that what we do is just a drop in the ocean, But the ocean would be less because of that missing drop.“
- Mother Teresa
Thank You
Seven Challenges in Nutrition
1. Getting nutrition first on the top priority of the policy makers and keeping it there?
2. Doing the right things
3. Not doing the wrong things
4. Acting on scale
5. Reaching those in need
6. Data based decision making
7. Strengthening operational and strategic capacities
Source: Lancet series on Maternal and Child Under-nutrition 4
Strategies/Actions to Preventand Control of Malnutrition
Supplementation with micronutrients/food
Food fortification
Food regulation
Food and Nutrition education/communication
Right to food (and nutrition)
Food based approach: ensuring food security/consumption of safe and nutritious food
Public health measures: basic services, immunization, sanitation, water supply, deworming
Community based (integrated) approaches
Others: M&E, R&D, Capacity Building (CB)