Nutritional Deficiencies in Children: Panama

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Nutritional Deficiencies in Children Panama

• Penni Davila Hicks, PhD, RD, LD
• Steven A. Abrams, MD
• USDA/ARS Childrens Nutrition Research Center
• Baylor College of Medicine

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Malnutrition Worldwide
174 million children under 5 yrs are
moderate/severe underweight. 230 million children
under 5 yrs are stunted.
In some regions, such as sub-Saharan Africa and
south Asia, stagnation of nutritional improvement
combined with a rapid rise in population has
resulted in an actual increase in the total
number of malnourished children.
SourceWHO fact sheets1996/1998
http//www.who.int/inf-fs/en/fact119.html
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Malnutrition - Children
Normal gt -1 SD Mild -1.1 to -2
SD Moderate -2.1 to -3 SD Severe lt -3 SD
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Background
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Comparison of changes in malnutrition in Costa
Rica and Panama
Costa Rica Panamá
Percent
Fuente Encuestas Nacionales de Salud, Sitios
centinelas (Panama)
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Growth Faltering

• A delay in the onset of the childhood growth
  phase at 6-12 months
• WHO reports that long-term growth faltering can
  be measured by height-for-age (linear growth)
• Causes
• Sub-optimal fetal endowment of nutrients
• Diarrhea, infections (e.g. chronic malaria,
  parasites)
• Environmental (poor hygiene, overcrowding,
  contaminated food)
• Complementary food practices during weaning are
  inadequate in timeliness, quality, quantity, and
  safety (e.g. use of coffee as weaning food in
  Guatemala

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Timeline of Growth Faltering

• The major impact of malnutrition and the greatest
  response to therapeutic intervention occurs
  before 18 months of age

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Nutrition education
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Pill supplementation programs

• Extreme difficulties with all supplementation
  programs
• Too-costly supplements - far beyond most
  governments ability or desire to provide
• Poorly distributed, limited assessment of actual
  need
• Not accepted by population - Do you remember to
  take a vitamin pill daily? Would you walk several
  miles to pick up a monthly supply?
• Therefore, not a sustainable long-term approach
  for most populations
• In some cases (e.g. vitamin A every 6 months) can
  protect against most severe deficiencies - but
  needs well-organized distribution process

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Agricultural changes

• Agricultural enhancement of micronutrient content
  of foods
• Great idea - but difficult and expensive to
  implement
• Must overcome problems including soil depletion
  of nutrients, traditional dietary patterns, and
  presence of inhibitors of nutrient absorption
• Development of super vegetables, etc. an active
  area of agricultural research
• Currently there is major political activity both
  pro and con the use of genetically modified
  foods. Outcome of this debate is uncertain. Use
  of natural selection is non-controversial but
  likely less effective.

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Food and beverage fortificationA global approach

• In the US food is routinely fortified - we dont
  usually think about
• Iodized salt
• Iron-fortified flour
• Folate-fortified flour
• Calcium-fortified orange juice
• Vitamin D-fortified milk
• Vitamin C-fortified apple juice
• Multiple nutrient-fortified breakfast cereal

• Cost of these fortificants is a small part of
  the product cost

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Pitfalls in food fortification programs

• Fortificant has to be bioavailable nutrient
  nutrient interactions must be considered (e.g.
  ironzinc)
• Nutrients must be carefully selected for the
  population
• Has to be well-tolerated, i.e. it cant harm the
  taste or shelf-life of the food. NO ONE will add
  castor oil (or iron drops) for long!
• Has to be inexpensive and readily distributed.
  Usually, it must be mandated by law in developing
  countries with adequate monitoring to be
  effective.

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Mexico Progresa (Oportunidades)

• Large scale welfare program, targeted at rural
  areas begin in 1998
• Components of education, health, nutrition
• Nutritional supplements for 4 to 23 mo old
  children
• Overall tremendous benefits. But nutritional
  programming needed evaluation

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Prevalence of iron deficiency (transferrin
saturation) in children under 5 years of age
after one year of intervention, 1999
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Progresa Prevalence of anemia lt5 years of age
after one year of intervention, 1999
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Progresa

• We demonstrated extremely low bioavailability of
  the elemental iron in Progresa in a study in
  Mexico
• Because of our findings, iron source changed to
  ferrous fumarate compromise of bioavailability
  and sensory tolerance
• Not simple to find the best micronutrient sources
  that are effective, safe, inexpensive and mix
  well with the other nutrients in the food

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Panama Background

• 2003- Estudio de Niveles de Vida evaluated the
  nutritional status of children lt5 y in the
  national, rural and indigenous populations.
• Chronic Malnutrition
• 13 Urban
• 19 Rural
• 57 Indigenous

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Background

• 2000 Census found that school aged children (6-9
  y) were stunted
• 8 Urban
• 21 Rural
• 64 Indigenous
• Children in indigenous population
• 3X greater risk of being stunted than rural
  children
• 8X greater risk of being stunted than urban
  children

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Specific Nutritional Deficiencies

• 2000 - Vitamin A deficiency children lt5y
• 2 Nationaly
• 24 Indigenous
• 1999 Iron deficiency children 6-12 y
• 47
• Assumed to be iron deficiency anemia with no
  other supporting information

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Consequence of micronutrient deficiencies

• Fe
• Development delays - lifelong effects
• Attention/concentration School performance ?
• Zn
• Can cause growth failure
• Linked to increased rates of illness and
  mortality from pneumonia and infectious diarrhea
• Low levels cause immune dysfunction
• Vitamin A
• Decrease immunity
• Night blindness or xerophthalmia

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Objective

• To evaluate the nutritional status of children
• 1 to 3 years
• 6 to 12 years
• Districts
• Mirono in the territory of Gnobe Bugle
• Santa Fe in the province of Veraguas

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Mirono and Santa Fe

• Classified as high priority districts
• Mirono Indigenous
• Santa Fe Rural
• Representing the poorest and most vulnerable
  segments of the Panamanian population
• Important to know the nutritional deficiencies of
  the young children in this population

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Specific Objectives

• To evaluate nutritional status of the children
  1-3 y and 6-12y
• Weight for Age, Length for Age and Weight for
  Length
• To determine the prevalence
• iron, zinc and vitamin A deficiency
• To evaluate anemia through biochemical parameters

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Methods

• Descriptive, cross-sectional type
• N 350
• 75 school children (6-12y)
• 100 pre-school children (1-3y)
• From each district
• Sample selection
• Census of schools in the area
• Census of children 1-3y

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Methods

• Informed Consent was given by subjects parents
• Approved by
• El Comite Nacional de Bioetica de la
  Investigacion del Instituto Conmemorative Gorgas
  de Estudios de la Salud
• IRB of Baylor College of Medicine

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Measurements

• Height or length
• Weight
• Venous Blood Draw
• Hemoglobin
• Ferritin
• Proteina C reactiva
• Zinc
• Vitamin A

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Results
Mean SEM
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Results Malnutrition
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Results Vitamin A

• Vitamin A deficiency defines as lt0.70 µmol/L by
• Sight and Life Guidebook on Vitamin A
• Mild health issue if lt10 of population affected

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Results Zinc

• Zinc deficiency defines as lt0.70 µg/dL
• by IZiNC group
• Mild health issue if lt10 of population affected

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Results Iron
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Overall

• Iron and Zn deficiency are more common in
  preschool children than school aged children
• Anemia in pre-school children is primarily Fe
  deficiency
• Anemia in school aged children is likely
  associated with other issues such as parasite
  infection.

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PRESIDENCIA DE LA REPUBLICA SECRETARIA NACIONAL
PARA EL PLAN ALIMENTARIO NUTIRICIONAL
Programa de Bonos Familiares para Alimentos
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QUÉ ES EL PROGRAMA DE BONOS FAMILIARES PARA
ALIMENTOS? What is the family vouchers for
nurishement program A program that is part of
the Network of Opportunities, directed by the
national seceratary of food and nutrition plans.
The program provides vouchers to families in
extreme poverty to buy foods and other
supplies. The program is meant to establish a
mechanism to combat the problem of poverty and
marginalization by guaranteeing food and
nutrition security for families in district that
qualify according to their high leveles of
poverty as indicated by the Survey of Standards
of life of 2003.
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General Objective Reduction of poverty through
the improvement of food and nutrition security in
a population of extreme poverty
Specific Objectives ? To reduce the levels of
malnutrition of the participating families ? To
increase the cover of vaccination of children lt 5
years of the participating families ? To increase
the awareness/attention of sexual and
reproductive health of the members of the
participating families ? To reduce the school
drop out rate of the children with special
emphasis in the indigenous and the rural
communities of the participating families ? To
reduce the percentage of absenteeism of the
school children of the participating families ?
To increase the matriculation in the primary
centers in the participant districts? ? To
improve the availability and access to foods in a
sustainable way by means of programs of food
production ? To fortify and to harness the
abiliities of the local authorities in the
design, execution and management of programs
and/or projects of development
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How the program was developed
STAGE 1 Meeting with local, traditional
authorities (indigenous areas), civil employees
NGOs that operate in the district. To raise
the strategies of implementation of the
Program? signature of the local Letter of
undertaking between SENAPAN/ and local
authorities
STAGE 2 Conducting the Familiar Census in the
area. Finding census takers volunteers from the
community Conducting the Census Collection
and analysis of data
STAGE 3 Creation of commercial establishments
localized in the district that meet the criteria
for the program in operation 2 year or more,
peaceful, permission from the Ministry of Health
and commitment of fulfill the conditions of the
Program.
STAGE 4 Delivery of the nourishment vouchers to
the families of the participating districts
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Criteria for selecting the participating families
? Families with permanent residency in the
district ? Family was counted in the Census ?
Family is below the extreme poverty line ?
Conditions of the home Priority goes to families
that have children, elderly and handicapped
persons

• COMMITMENTS OF THE PARTICIPANT FAMILIES
• Attendance of children gt 6 years to school
  (MEDUCA)
• Up to date vaccines of the lt 6 years (MINSA)
• All the members of the family up to date with
  sexual and reproductive health visits
• An adult member of the family must participate
  in the programs of food production

• STRATEGIES OF CONTROL
• Proof of fulfillment of commitment
• The verification of fulfillment is made through
  the FAMILIAR CARD

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The vouchers have the name of the beneficiary, ID
number, and assigned census number. Each book
contains 7 vouchers worth 5.00 each. The date of
expiration and a bar code that contains detailed
information of when and where they are exchanged.
The vouchers are passed out in the school or a
communal house of the head of the area in the
presence of the authorities of the district and
SENAPAN civil employees.
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Delivery of Vouchers



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NETWORK OF COMMERCIAL ESTABLISHMENTS


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Summary perspectives

• Childhood malnutrition is widespread, with
  remarkably little improvement, especially in
  Africa and parts of Latin America and Asia in
  recent years.
• Strategies to resolve malnutrition need to be
  food-based rather than supplement-based
• Accurate assessment of the population is a key to
  intervention strategies
• Interaction of government and private sector is
  crucial in formulating effective programs
• Scientific questions must be resolved as to
  optimal strategy for food fortification and
  similar programs

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Thank youQuestions? sabrams_at_bcm.edu
pennih_at_bcm.edu

• Sri Lanka, June 2005