National Perspective on Micronutrient Deficiencies and Their Impact

National Perspective on Micronutrient Deficiencies and Their Impact on Health and Productivity Dr. Chandrakant S Pandav Professor & Head, Regional Coordinator Centre for Community Medicine, International Council for Control of All India Institute of Medical Sciences, Iodine Deficiency disorders (South Asia) New Delhi, India

Contributors • Dr. Kapil Yadav Senior Program Officer, ICCIDD, c/o CCM, AIIMS, New Delhi • Dr. P. Stalin Junior Resident, CCM, AIIMS, New Delhi • Dr. Ravi Upadhyay Junior 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

Nutrition is a link between food and health • Agriculture • Food supply • Service • • Food quality Food safety Nutrition • • Nutrient needs Dietary intakes Nutrition wellbeing Nutrition literacy Health • • • Promotion • Protection • Treatment Free from food borne illness Good health Food Security Food and Nutrition Education Food Culture Ultimate Goals: Nutrition Security and wellbeing for All

Food and Nutrition Challenges • Continuing and persistent undernutrition Ø Undernourished (Protein and energy deficiency) in children and adults Ø Micronutrient deficiencies: of iron, iodine, vit. A and others • Overnutrition and diet related diseases Ø Ø Ø 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 that 1, 600 million adults are overweight and 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

The Known 51 Essential Nutrients for Sustaining Human Life* Air, Water & Energy (3) Protein (amino acids) (9) Lipids-Fat (fatty acids) (2) Oxygen Water Carbohydrates Histidine Isoleucine Lysine Methionine Phenylalanine Threonine Tryptophan Valine Linoleic acid Linolenic acid Macro. Minerals (7) Na K Ca Mg S P Cl Trace Elements (17) Vitamins Fe Zn Cu Mn I F Se Mo Co (in B 12) B Ni Cr V Si As Li Sn A D E K C (Ascorbic acid) B 1 (Thiamin) B 2 (Riboflavin) B 3 (Niacin) B 5 (Pantothenic acid) B 6 (Pyroxidine) B 7/H (Biotin) B 9 (Folic acid, folacin) B 12 (Cobalamin) (13) *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 “Hidden Hunger” Iron Deficiency Vitamin A Deficiency Iodine Deficiency Folic Acid Deficiency Zinc Deficiency

Anemia in women (15 -49 yrs) Urban rich 49% Urban poor Rural 59% 57% 3/4 th of young children, ½ of women & 1/4 th of married men are anemic (NFHS 3, 2005 – 06)

Bitot’s spot Night Blindness 0. 6% 0. 2% Preschool children (NNMB 2006)

Goitre 70 million Mild neurological deficits Cretins 2. 2 million 6. 6 million Burden of IDD (National Iodine Deficiency Disorders Control Programme, Annual Report (2009 -10) M/o Health & FW, Govt. of India, New Delhi. )

Non-iodized salt Iodized salt Proportion of households with adequately iodized salt – 51% (NFHS 3, 2005 -06)

Burden of zinc deficiency No data

Burden of Folic Acid Deficiency 2, 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 deficiency Nutritional anemia: Indirect Cause of Maternal Mortality (20%), Cognitive impairment & decreased immunity

Vitamin A deficiency Xerophtalmia, infections & growth failure

Iodine Deficiency Decreased IQ, mild neurological deficits, cretinism, goitre stillbirths & neonatal deaths

Zinc Deficiency Low birth weight, preterm deliveries, spontaneous abortions & congenital malformations

Folic Acid Deficiency Neural tube defects, Megaloblastic Anemia

India • Burden of Micronutrient Deficiencies • Health Consequences of Micronutrient Deficiencies • Impact of Micronutrient Deficiencies on Productivity

JOB INTERVIEW Question: How much is : 2 G + 3 G = ? MATHEMATICIAN : 2 G + 3 G = 5 G ACCOUNTANT : 2 G + 3 G = 5 G…… ……. . On an average 5 G; ……. . Give or take 10% ECONOMIST ………. ?

COMPONENTS OF ECONOMIC EVALUATION RESOURCES CONSUMED Cost HEALTH CARE PROGRAM HEALTH IMPROVEMENT 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 Scenarios Programme Health consequences No Programme (no resource allocation) Existing programme (Resource allocation) Due to malnutrition very Mortality high Morbidity Disability Decrease in prevalence Cost averted by health of malnutrition care system in the form of treatment. Productivity loss averted. Minimal malnutrition Pain, Suffering, Grief QOL: family & friends Effective programme (100%) Identification, Measurement & Valuation of health consequences

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 Iron Anemia 20% Iodine Mild iodine deficiency 5% Cretinism 50% Partial blindness 25% Total blindness 50% Vitamin A Assumed productivity loss% Source: *Assumptions made by Judith Mc. Guire 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 Productive life expectancy Years 15. 6 Average annual wage for adult Rs. Average rate of employment % Moderate High 20 25 3500 5000 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 annual productivity losses (2010) Nutritional deficiency Low scenario Moderate scenario High scenario 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 Vitamin A Iron and Folic Acid Iodine Zinc Multiple Management Total Yearly Additional Cost (Rs. in Billion) 4. 6 35. 9 3. 8 2. 6 11. 0 0. 8 58. 8

Imagine you had $75 bn 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. Education 5. Global Warming 6. Malnutrition and Hunger 7. Sanitation and Water 8. Subsidies and Trade Barriers 9. Terrorism 10. Women and Development

Expert panel Economists : 8 Challenge Paper Authors : 3 10 Challenges Costs and benefits analysis Rank Listing Solutions for challenges Policy Makers Decision Making on Money Spending Perspective Paper Authors : 2

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-fortification 9. 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 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 Prevent and 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)