MICRONUTRIENT DEFICIENCIES CONTROL AND CHILD SURVIVAL IN NIGERIA1 By Francis Taiwo AMINU, PhD Country Coordinator, Micronutrient Initiative

(MI), Nigeria Office 1.0 PREAMBLE It is a pleasure most honoured to join all of you at this important meeting with greetings from MI. I know that each of us is deeply committed to tackling the serious problem of malnutrition including micronutrient deficiencies in Nigeria. We are here to discuss why micronutrient deficiencies control (MNDC) should have a higher profile in the Millennium Development Goals with emphasis on MDG 4, which is to ensure child survival. Therefore this paper will focus on MNs whose deficiencies are a risk factor in child survival. However, when you take a closer look at the link between MNDC and the MDG 4, the question almost begins to answer itself. We have heard many of the statistics so often that they tend to become background noise, but the numbers regarding micronutrient deficiencies bear repeating, because they are, simply, so incredible as shown later in this paper. More so, the connection between suffering, death and malnutrition is a very real one: the child dying from a common childhood illness who is a casualty of vitamin A deficiency; the girl not in school because of a poorly developed learning ability suffers because of lack of iodine; the baby emaciated from diarrhea because she was not breastfed; and the young mother who dies in childbirth because of anemia. These statistics, these tales of human suffering, make it unimaginable to question the importance of micronutrient to child survival and development. Around the world, millions of individual tragedies are adding up to serious economic and social burdens. Diseases are ravaging communities, classrooms are half-full, millions of children will never reach their full potential. In 2005, heads of state gathered to account for progress made toward the Millennium Development Goals that were set in 2000. The world has collectively promised to make real headway on issues including child mortality, maternal deaths, low education rates, poverty and inequality. But we are clearly not where we should be, and malnutrition makes every strategy for health, education and prosperity an uphill struggle. So let me discuss where we go from here, drawing on lessons we have learned. 2.0 WHAT ARE MICRONUTRIENTS?

These are vitamins and minerals that cannot be synthesized by the human body. They must be provided by the diet. The amounts needed are small - micrograms or milligrams a day - so they are called micro nutrients. They are necessary for the regulatory systems in the body, for efficient energy metabolism and for other functions (cognition, immune system, reproduction). Out of these 21 main micronutrients, three used to be of public health significance: vitamin A, iron and iodine. Of recent are zinc and folate. They are so qualified because they are known to be deficient widely in developing countries including Nigeria; we know how to treat them, and we can measure progress unambiguously. Deficiencies of these nutrients cause illness, death, learning disabilities, and impaired work capacity.

A key paper presented at the Seminar on Micronutrient Deficiencies Control and Child Survival in Nigeria organized by the Olu Akinkugbe Foundation Child Nutrition Centre, Friesland Foods WAMCO Nigeria October 30, 2007

-1-

3.0

MICRONUTRIENT DEFICIENCIES: CAUSES, PREVALENCE AND CONSEQUENCES

People may look healthy and their diets may provide adequate energy and proteins but lack vital nutrients that the body needs to grow and function properly. This may have devastating effects on millions of people throughout the world. It can blight the development of entire communities causing death and widespread disability. Despite their enormous consequences for economic growth and human development, these nutritional problems are often hidden and silent. The warning signs are not always recognized and the victims themselves are often not aware of the problem. Hence they are referred to as a hidden hunger. 3.1 Vitamin A Deficiencies (VAD)

VAD is one of the most important nutritional diseases among young children because most children with VAD also lack energy, protein, and other nutrientsthey may have protein-energy malnutrition (PEM). VAD occurs when a child or older person does not eat enough to cover her needs, and when the store of vitamin A in her liver is finished. Vitamin A deficiency rates in children are higher than 31% in some regions of Nigeria. PROFILES analysis shows that if no effective action is taken to prevent and control vitamin A deficiency, about 80,000 Nigerian children will die every year. This is about 240 child deaths every day! 3.1.1 VAD and Child Survival

It was shown by Sommer et al2. that there is a clear association between symptoms of VAD and mortality. The association between mild xerophthalmia and the risk of mortality was strong and dose-responsive. That is, children with Night blindness experienced about a 3-fold higher risk of dying; those with Bitots spot had about a 6-fold higher risk; and those children with the two conditions combined had a 9-fold higher risk of dying compared to children with healthy eyes. Severe vitamin A deficiency (keratomalacia) has very high fatality rates (60%) but even subclinical deficiency is associated with a 23% increase in preschooler mortality in areas with endemic vitamin A deficiency. In fact, one-quarter of early childhood deaths can be prevented in many countries by ensuring that children receive adequate amounts of vitamin A. This is the conclusion of an important "metaanalysis" of studies on the effects of vitamin A supplementation. Emerging evidence of slow progress towards MDG 4 sparked calls in 2003 for renewed efforts to be made to improve child survival. Controlling one aspect of malnutrition, Vitamin A Deficiency (VAD), has long been recognized as a highly cost-effective way to improve child survival. For children to be fully protected from VAD, they need to consume sufficient vitamin A to meet their physiological requirements. In other words, VAD can be controlled if dietary intake of Vitamin A can be improved sufficiently and sustainably. But while widespread poverty persists, prospects for achieving this in the short to medium term are limited, with the poorest and most vulnerable often the last to benefit. Where VAD is a public health problem, twice yearly provision of Vitamin A Supplements (VAS) to all children aged 6-59 months is a highly cost-effective way of improving intake, and has been associated with a reduction in all-cause mortality of 23% among children aged 659 months.

Sommer A, Tarwotjo I, Djunaedi E et al (1986). Impact of vitamin A supplementation on childhood mortality. A randomised controlled community trial. Lancet 1: 1169-1173
2

-2-

In 1998, the World Health Organization (WHO) recommended delivering VAS during National Immunization Days (NIDs) and so integrating its provision with other health services. As polio NIDs became widespread, increasing numbers of children under five received at least one high-dose of VAS each year. The % coverage achieved became a key indicator of progress towards improved child health, and is reported annually in UNICEFs State of the Worlds Children. In 2001 it was informally adopted as an additional core intermediate indicator of progress towards MDG1 (eradicating extreme poverty and hunger), and as an additional optional indicator of progress towards MDG 4 (reducing child mortality), and is a key part of the arsenal of effective interventions against childhood killers. 3.1.2 Benefits from Improving VA Status Studies have shown that improving the vitamin A status of children aged 6 59 months dramatically increased their chance of survival by; Reducing all-cause mortality by 23 %i Reducing measles mortality by 50 %ii Reducing diarrhoea disease mortality by 33 %iii Improving vitamin A status of deficient children reduces the severity of children illnesss: Less strain on clinic and outpatient services Fewer hospital admissions Contributes to the wellbeing of children and families. Improving vitamin A status also: Prevents night blindness, xerophthalmia, corneal destruction and blindness May reduce birth defects May prevent epithelial and perhaps other types of cancer Improving vitamin A status may reduce maternal mortality: Improves resistance to infection Helps reduce anaemia Improving vitamin A status is very cost-effective: Just a few cents (kobo) per capsule Reduces health costs by lessening hospital and clinic visits Easily integrated into existing public health/ immunization programmes 3.2 Zinc Deficiency and Child Survival

Zinc is now recognized as an essential micronutrient of public health significance. Given the diverse array of biologic functions of zinc, it is not surprising that multiple physiologic and metabolic functions, such as physical growth, immuno-competence, reproductive function, and neuro-behavioural development are all affected by zinc status. When supply of dietary zinc is insufficient to support these functions, biochemical abnormalities and clinical signs may develop. Clinical syndromes associated with zinc deficiency includes growth retardation, male hypogonadism, skin changes, mental lethargy, hepatosplenomegaly, iron deficiency anaemia, and geophagia In Nigeria, 20% of children under 5 are zinc deficient, ranging from 6.3% in the humid forest to 36.5% in moist savannah agro-ecological zones. 3.3 Iron Deficiency and Child Survival

The commonest cause of anaemia is iron deficiency, or lack of the nutrient iron. Iron is needed to make haemoglobin, a protein in red blood cells that carries oxygen to the brain, muscular system, immune system and other parts of the body. Lack of adequate oxygen reduces the physical and mental capacity of -3-

individuals. Iron deficiency anaemia (IDA) is a nutritional anaemia. Nutritional anaemia means that the body cannot make enough haemoglobin and healthy red blood cells because it lacks the necessary nutrients Childhood anaemia starts if the mothers have anaemia before and during pregnancy. The infant is born with low iron stores, which when used and is not replenished (through iron absorbed from food or from drops or tablets) will develop iron deficiency anaemia. The bodys stores supply the various sites in the body including the bone marrow where red blood cells are formed. Iron losses occur due to bleeding and routine wear and tear of tissues. The amount of circulating red blood cells is a good indication whether the body has enough stores of iron. Iron deficiency is often made worse by blood loss from the gut caused by feeding infants with formula or other forms of animal milk, or in young children and women by infection with hookworm and whipworm. In many programs, supplements will bring little or no improvement in the iron status of women and children unless parasites are also controlled. In Nigeria, 20%3 of children under 5 years of age are iron deficient. This situation represents a handicap for the intellectual development of our children whose optimal school performance is vital for the future of our country. Iron deficiency anaemia also affects 28% of Nigerian women of reproductive age. As many as 34% of women are affected in some regions of the country. Iron deficiency has been associated with mortality4. Severe anaemia has been shown to cause heart failure. It is estimated that 20% of maternal mortality is due to anaemia, directly (heart failure) or indirectly (inability to tolerate haemorrhage). In addition, fatality rates in children hospitalized with severe anaemia have been estimated to be 31 % unless they receive immediate blood transfusions. Approximately 100,000 Nigerian infants are risk of death immediately before or after birth Approximately 9,000 severe birth defects annually, including infantile paralysis due to folate deficiency. PROFILES analysis shows that if no action is taken, about 64,480 Nigerian mothers will die between now and the next ten years because they were anaemic. This is about 18 maternal deaths per day, every day, for the next ten years. 3.4 Iodine Deficiency and Child Survival

Iodine is a very essential micronutrient necessary for the production thyroxina hormone produced by the thyroid gland. It is used for a number of vital body functions, such as maintaining body temperature, brain function, growth, and reproduction. The most important cause of iodine deficiency is lack of iodine in food, which continues for a long for a long time. Iodine deficiency disorders (IDD) are a group of disorders that iodine-deficient people may develop. Which type of disorder a person has and how severe it is depends on how much iodine is available to the thyroid gland, and how much the person needs. IDDs include: Preventable brain damage with a range of nervous system disorders Disability to work Hearing disorder Intellectual skills disorders Neonatal skills disorders

National Food Consumption and Nutrition Survey (NFCNS), 2001-2003 Viteri, F. 1997. The Consequences of Iron Deficiency and Anaemia in Pregnancy on Maternal Health and the Foetus and the Infant. SCN News, No. 11, pp. 1418.
3 4

-4-

In Nigeria, a total of 28% of children suffered various degrees of iodine deficiency (4.2% severe, 8.7% moderate, 14.6% mild). About 31% of mothers had varying degrees of iodine deficiency (4.2% severe, 8.8% moderate, 17.8% mild), while 11% of pregnant women had varying degrees of iodine deficiency (3.1% severe, 7.4% moderate, 16.0% mild)5. Iodine deficiency can be lethal too.. Evidence exists that maternal iodine deficiency is responsible for high rates of still birth and neonatal mortality - on the order of 0.5 to 1% of pregnancies in endemic areas. In addition, foetal iodine deficiency can result in severe, irreversible mental retardation and neurological disorders (cretinism) and limited lifespan. In addition to increasing their chances of survival iodized salt contributes to improved mental development and learning capacity, reduced school failure rates, and increased productivity. Iodine is essential for the development of a childs brain from conception. Results from several studies show that 3% of babies born to iodine deficient women suffer from cretinism and present severe mental and physical retardation, 10% suffer from moderate-to-severe mental retardation and the remaining 87% suffer from some form of mental impairment. It is also well known that in populations where iodine deficiency is endemic, the average IQ is reduced by 13.5 points6. The damage to cognitive development in children caused by iodine deficiency is permanent. 4.0 PROGRAMMATIC APPROACHES TO CONTROL MND

The options for addressing micronutrient deficiencies directly include: 1. Supplementation: Tablets, capsules, injections and oral tonics. In the case of vitamin A, megadose preparations provide protection for prolonged periods (4-6 months). While recognizing that improved diets are the ideal long-term solution, there is a need to help close damaging deficiency gaps quickly through the use of vitamin and mineral supplements and food fortification. 2. Fortification of food: Adding nutrients to foods including, flour, noodles, salt, sugar, vegetable oils, dairy products, weaning foods, monosodium glutamate and bouillon cubes. 3. Dietary change: Encouraging the consumption of nutrient-rich foods - red palm oil, dark green leaves, mangoes and various wild fruits - which may be available but underutilised by the deficient population. 5.0 ESSENTIAL ACTIONS TO REDUCE/ELIMINATE MND

1. Ensure that the vitamin A requirements of the population are met. Specifically: Ensure that an adequate policy on vitamin A supplementation is developed and implemented; Ensure that all children 6-59 months of age are supplemented with vitamin A twice-yearly; Ensure the adequate integration of vitamin A supplementation into the primary health care system and IMCI;

5 6

National Food Consumption and Nutrition Survey (NFCNS), 2001-2003

Research evidence suggests that in communities where iodine deficiency is prevalent, mental impairment is widespread. A review of 18 studies in different countries found that in communities affected by iodine deficiency, the average IQ of children is - on a scale of 100 points 13.5 points lower than that of children living in communities without iodine deficiency. Source: Bleichrodt N. and Born M.P. (1994) A meta-analysis of research on iodine and its relationship to cognitive development. In J.B. Stanbury (ed.) The Damaged Brain of Iodine Deficiency. New York: Cognizant Communication Corporation.

-5-

Ensure that all women receive two doses of vitamin A as soon as possible after delivery, at 24 hour intervals, and not later than 8 weeks post delivery; Promote the consumption of locally produced vitamin A rich foods, including fortified foods. 46.

2. Ensure that the iron and folic acid requirements of the population are met. Specifically: Ensure that all pregnant women receive adequate iron and folic acid supplements as well as counseling on the use of such supplements; Explore the effectiveness of supplements for pregnant women that contain multiple micronutrients; Ensure that all children are de-wormed at least once a year; Ensure that all health workers provide appropriate counseling for malaria prevention, treatment and control; and Promote the consumption of iron-rich foods, including foods fortified with iron 3. Ensure that the iodine requirements of the population are met. Specifically: Ensure that all table salt is adequately fortified with iodine; and Ensure that the promotion and consumption of iodized salt is sustained. 6.0 STRATEGIES FOR ACHIEVING THE ACTIONS Addressing micronutrient malnutrition is consistent with the vision of the Federal Government of Nigeria, who is signatory to the commitments stemming from the world summits on poverty, nutrition, food, and the rights of children and women, among others. Despite this political disposition, however micronutrient malnutrition, with poverty as an underlying cause, remains a major barrier to development in Nigeria. To help government achieve these goals will not be easy. It will require the combined efforts of governments, international organizations, NGOs and private industry. The central focus of activity should be on the following strategies: Improving the effectiveness and coverage of supplements delivery systems including exploitation of new outreach mechanisms, better logistics, and improved client counselling. Maximizing industry compliance with fortification mandates through incentives to private industry, and through building objective, competent and respected regulatory enforcement institutions. Raising consumer demand for micronutrients from natural food, fortified food or supplements through policy advocacy, social marketing, and commercial advertising. 6.1 Returns on Investment The costs of these programs are important but we will see that their benefits far outweigh their costs. Every dollar invested would bring about a benefit of 8-20 US dollars. Given the conservative nature of our estimates and the omission of numerous other benefits, the real value of the benefits resulting from this investment is clearly underestimated.

-6-

7.0

CONCLUSION

In conclusion, the policy choices and investment decisions made now will profoundly influence the number and location of micronutrient deficient children in the future! Nigeria is one of the most endowed countries in Africa with outstanding human and natural resources, yet, it is one of the poorest nations in the world with poor social, rural, institutional infrastructures with one of the highest malnutrition and under five mortality rates in the continent. This situation must change. Few people make change happen. We are the agents of change to make nutrition a priority in the development agenda of Nigeria. You are the ones who can ensure sustainable investment for the improvement of the nutrition situation of children and women in Nigeria. The time for action is now! References
i Beaton G. H., Martorell R, Aronson K. J., et al (1993). Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality

in developing countries. ACC/SCN State of the Art Series Nutrition Policy Discussion Paper, No 13. December 1993, Geneva. ii Maclaren D. S, and Frigg M. (1997). Vitamin A supplementation and infectious morbidity. In Sight and Life Manual on Vitamin A Deficiency Disorders (VADD). Task Force Sight and Life, Switzerland. iii Maclaren D. S, and Frigg M. (1997). Vitamin A supplementation and infectious morbidity. In Sight and Life Manual on Vitamin A Deficiency Disorders (VADD). Task Force Sight and Life, Switzerland.

-7-