Emorn Wasantwisut

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Role of Zinc and Vitamin A in Child Health
Emorn Wasantwisut Institute of Nutrition Mahidol
University
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Millennium Development Goals
Eradicate extreme poverty and hunger Achieve
universal primary education Promote gender
equality and empower women Reduce child mortality
Improve maternal health (75 of MMR by
2015) Combat HIV/AIDS, malaria, and other
diseases Ensure environmental sustainability Dev
elop a global partnership for development
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5
6
2
7
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4
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Millennium Summit, Sep.2000
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Selected major risks to health Childhood and
maternal undernutrition
Risk factor Measured adverse outcomes (of
exposure) Underweight Mortality and acute
morbidity from infectious diarrhoea, malaria,
measles, pneumonia and other infectious
diseases. Perinatal conditions from maternal
underweight Iron deficiency Anaemia, maternal
and perinatal causes of death Vitamin A
deficiency Diarrhoea, malaria, maternal
mortality, vitamin A deficiency disease Zinc
deficiency Diarrhoea, pneumonia, malaria
Source World Health Report 2002
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Summary of selected risk factors

• Risk Factor South - East Asia West-Pacific
• Child/Adult Mortality Low High
  Very Low Low
• Under weight 26 46 4 16
• (lt 2 SD W/A)
• Iron def 11.0 10.4 12.5 11.0
• (Mean Hb in g/dl)
• Vitamin A def. 28 18 0 9
• ( VADNB)
• Zinc def. 34 73 4 9
• ( inadequate intake)

World Health Rep2002
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Leading 10 selected risk factors as percentage
causes of disease burden measured in DALYs
Developing countries High mortality
countries Under weight 14.9 Unsafe
sex 10.2 Unsafe water, sanitation and
hygiene 5.5 Indoor smoke from solid fuels
3.7 Zinc deficiency 3.2 Iron
deficiency 3.1 Vitamin A deficiency
3.0 Blood pressure 2.5 Tobacco
2.0 Cholesterol 1.9
World Health Rep2002
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Burden of Disease - Loss of healthy life years

• DALYS (million)
• Underweight 138
• Iodine Deficiency 2.5
• Iron Deficiency 35
• Vitamin A Deficiency 22.5
• Zinc Deficiency 28

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Vitamin A Deficiency

• Xerophthalmia blindness
• limit growth
• Weaken host defenses
• infection risk of death
• morbidity mortality during
  pregnancy and early post partum
• disadvantaged newborn

Childhood
Women of Reproductive age
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Vitamin A Supplementation
Prevention
Treatment at Diagnosis
Age
Dosage Frequency
lt 6 mo 50,000 IU 6, 10,14 wks with
DPT/Polio
lt 6-11 100,000 IU Every 4-6 mo
gt 1 yr 200,000 IU Every 4-6 mo
Women 200,000 IU lt 8 wks after (?
400,000 IU) delivery
Refs WHO/UNICEF/IVACG 1997, IVACG 2000
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Impact of Vitamin A on child Mortality
Reduction

• Indonesia
• Aceh 34
• Bogor 45
• Nepal
• Sarlahi 30
• Jumla 29
• India
• Tamil Nadu (wkly dose) 54
• Hyderabad 6
• Sudan 6
• Ghana 19

Source Sommer West 1996
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Global Prevalence - Maternal VAD
(In millions) Serum VA BM-VA
Night- lt0.70 umol/L lt1.05 umol/L
Blindness
Africa 2.4 5.4 1.1 E. Mediterranean 1.8 3.8
0.5 S/SE Asia 2.2 8.8 3.9 W.Pacific 1.2 2
.7 0.5 Americas 0.4 0.8 0.4
Ref K. West, J Nutr 2002 132 2857S-2866S
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VA and mortality related to pregnancy 12 wks
Post partum
Placebo VA -carotene VA or - C
b
b
Pregnancies 7,241 7,747 7,201 14,948
Deaths 51 33 26 59 Mortality 704
426 361 395 (per 100,000
pregnancies) RR 1.0 0.60
0.51 0.56 (95CI) (0.37-0.97) (0.30-0.86) (0.37
-0.84)
Refs West et al 1999
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Clinical signs of severe zinc deficiency

• Reduced appetite, taste acuity
• Reduced growth velocity
• Skin lesions
• Diarrhea, other infections
• Delayed sexual maturation, reduced fertility

?
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Mean ( SD) daily per capita absorbable zinc as
percent of requirement, and estimated percent of
population at risk of low intake, by region
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Prevalence of growth stunting

• Percentage of pre-school children with
  height-for-age lt -2 SD with respect to
  international reference data (data already
  available for most countries)
• Based on prior observations that stunted (but not
  non-stunted) children respond to zinc
  supplementation with increased linear growth

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Mean 95 C.I. for effect size of change in
height, by mean initial height-for-age z-score
Data from Brown KH et al, AJCN, 2002
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Risk of zinc deficiency, based on absorbable zinc
in food supply and prevalence of growth-stunting
Low Inter-mediate High
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Preventive Effect of Zinc Supplementation on
Diarrheal Prevalence in Continuous
Supplementation Trials
B.Faso
India
Mexico
PNG
Peru
Vietnam
Ethiopia
Guatemala
Jamaica
Pooled
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2
Odds Ratio and 95 CI
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Effect of Zinc Supplementation on Duration of
Acute Diarrhoea/Time to Recovery
India, 1988
Bangladesh, 1999
India, 2000
Brazil, 2000
India, 2001
Indonesia, 1998
India, 1995
Bangladesh, 1997
India, 2001
India, 2001
Nepal, 2001
Bangladesh, 2001
Pooled
1
Difference in mean and 95 CI Relative Hazards
and 95 CI
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Efficacy of Zinc in Therapy of Severe Pneumonia

• Bangladeshi children lt2y old with severe
  pneumonia
• 270 randomized to 20mg zinc/d or placebo along
  with standard antibiotics (amp./gent.)
• Zinc group had shorter duration of severe
  pneumonia (RH 0.81 0.67, 0.99) and of chest
  indrawing, elevated RR and hypoxia

Brooks et al, submitted
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Effect of Zinc Supplementation on Malaria in
Children
Reduction in Clinic Visits for Malaria
Location
32 (p0.09)
The Gambia
38 (plt0.05)
Papua New Guinea
36 (CI 9-55, plt0.05)
Combined
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Trial of Zinc or Vitamin/Iron Supplementation in
SGA Infants on Mortality
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Effective Child Survival Interventions
Cause of Under 5 death
Diarrhea Pneumonia Measles Malaria..

• Exc.BF 6 mo
• Cont.BF 6-11 mo

• Comp. feeding

• Zinc

?
?
?

• Vitamin A

Source Jones et al. Lancet 2003
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Effective Child Survival Interventions
Cause of Under 5 death
Diarrhea Pneumonia Measles Malaria..

• Oral Dehydration

• Antibiotic-Pneumonia

• Antimalarials

• Zinc

• Vitamin A

Source Jones et al. Lancet 2003
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• Maternal IDD
• stillbirth
• mild to severe brain damage
• fetal damage subcretins,
• neurological cretinism

• Childhood and adult hypothyroidism
• Neonatal Hypothyroidism
• high TSH in neonates
• Cerebral hypothyroidism
• Mental torpor and apathy

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Iron and its effects
Infants Cognition, growth
development Children
Cognition/physical Adolescent Cognition/Fe
store/ physical Non-pregnant
Productivity Iron store Pregnant
Pregnancy outcome Lactate
Lactation
newborns
Immunity
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Baby - LBW/Undernutrition
Child growth failure
Early pregnancy
Low Wt Ht teenagers
Small adult women
Small adult men
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Urine I TSH Hb/Hct TfR Bmilk-VA Dark Adapt.
Retinol
Urine I BLOOD SPOT (Hb/Hct TfR, Retinol)
Monitoring surveillance groups indicators
Hct TGR Urine I
Repro- ductive age women
Mothers (PL) fetus
Neonate infants (0-2 yr.)
Pre- school age
School age
Adults
Iodized salt
Quality of I- salt
Iodine

Preventive supplem. Fd based
Iron
Food Industry
weekly
weekly
weekly
daily
Fortified food
Food based
Periodic vitamin A capsule
Vit A
Indigenous foods