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Dr. Ferdousi Begum Associate Professor , OBGYN, DMC Obstetrical & Gynecological Society of Bangladesh
Contents
Evidences Bangladesh Cochrane Database WHO Recommendations Retail Costs for Selected Calcium Supplements Calcium: Food Sources of Bioavailability Govt. of Bangladesh Operation Plan on National Nutrition Services Pathway to Implement Calcium Supplementation At Scale
Overall rickets prevalence among children-4% Rickets in Chakaria (Coxs Bazar, Bangladesh) is of the Ca-deficiency type
Gerald F. Biol Trace Elem Res (2008) 121:193204
Dietary calcium intake in premenopausal Bangladeshi women: Do socio-economic or physiological factors play a role?
Dhaka city area and the Betagair Union, Nandail, Mymensingh 47% of subjects of High SE Gr failed to meet even the lowest level (400 500mg=day) of WHO recommended dietary allowances (RDA) of calcium for adult women. No subject in low SE Gr was found to meet the RDA level. Moreover, 63% of the women in group L had calcium intake lower than 200mg=day. These figures could be more critical in both groups if we consider the recent USA-RDAs of calcium for adult women (1000mg=day). The difference of socio-economic status on calcium density of the diet is significant(P<0.001) .
MZ Islam et al. European Journal of Clinical Nutrition (2003) 57, 674680
The mean daily intake of calcium in sub-groups of the two groups MZ Islam et al
In High Income Group Fish - 42% (main source) Milk -19% of the total daily calcium intake (second highest source)
The mean calcium density (mg Ca=1000 kcal) in the subgroups of the two groups
Clinical and radiographic improvement of rickets in Bangladeshi children as a result of nutritional advice
Five-component nutritional advice: (i) The routine addition of 1 g limestone/kg rice, (ii) Consuming small fish (including bones) instead of large ones, (iii) Daily consumption of 5 g ground sesame seeds, (iv) 100 g leafy vegetables and, if possible, (v) 100 ml of milk. CONCLUSIONS -in mild calcium-deficiency active rickets, nutritional advice may be a cost-effective treatment and possibly a valuable long-term solution to the problem.
Arnaud J, Ann Trop Paediatr. 2007 Sep;27(3):185-91.
Apparent Efficacy of Food-Based Calcium Supplementation in Preventing Rickets in Bangladesh Gerald F. Biol Trace Elem Res (2008) 121:193204 1-to 5-year-old children who did not present with rickets but ranked in the upper decile of plasma alkaline phosphatase (AP) activity. 158 children were randomized to a milkpowder-based dietary supplement given daily, 6 days/week, and providing either 50, 250, or 500 mg Ca, or 500 mg Ca plus multivitamins, iron, and zinc.
Mean serum calcium and zinc levels were significantly (p<0.001) lower in study group than those of control group. Again, serum calcium and zinc showed significant negative correlation with SBP and DBP in preeclamptic women. Therefore, early detection and supplementation to treat this deficiency may reduce the incidence of preeclampsia.
Serum calcium levels were determined in 30 normal non-gravid women and 30 women with normal pregnancies during third trimester with age range of 17-35 years. The mean serum calcium levels were found to be significantly lower in normal pregnant woman in third trimester than that of normal non-pregnant controls.
whereas the largest risk reduction (78%) was recorded among those at high risk of hypertensive disorders.
(five trials, 587 women; RR 0.22, 95% CI 0.120.42)
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059
Eclampsia
(three trials, 13 425 women; RR 0.73, 95% CI 0.411.27);
Maternal death (one trial, 8312 women; RR 0.17, 95% CI 0.021.39); Maternal intensive care unit admission
(one trial, 8312 women; RR 0.84, 95% CI 0.661.07);
In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at doses of 1.5 2.0 g elemental calcium/day) is recommended for the prevention of pre-eclampsia in all women, but especially those at high risk of developing pre-eclampsia.
Moderate
Strong
WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.
Low-dose acetylsalicylic acid (aspirin, 75 mg) is recommended for the prevention of preeclampsia in women at high risk of developing the condition.
Moderate
Strong
WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.
Low-dose acetylsalicylic Low acid (aspirin, 75 mg) for the prevention of preeclampsia and its related complications should be initiated before 20 weeks of pregnancy.
Weak
WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.
Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid Supps
Calcium Calcium carbonate pill citrate pill (1.5-2.0 g/d) (1.5-2.0 g/d) Calcium chewable pill-antacids
Cost of supplement /day /woman ($US) Cost of supplements/ Pregnancy($US) (from 20 wk GA)
0.0960.15
0.2640.375
0.0210.041
5.34/1,000 or 0.00534/ea
13.4421.00
36.9652.50
*In cases of severe anemia, the woman may require 120 mg of ferrous fumarate.
Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*
Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*
Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*
1.50 1.50 Other program cost per pregnancy (US$) 15.3238.38Total costs per 22.88 (by 54.38 sea/land) pregnancy 19.06(US$) 26.62 (by air)
1.50
1.50
4.84-7.62 2.00
(by land/sea) (by sea/land)
8.5611.36
(by air)
250 ml milk or 1 c. yogurt or 1.5 oz cheese Beans, dried Kale Spinach Tofu, calcium set
260
300
32
96
177 65 90 126
50 47 122 258
16 59 5 31
8 28 6 80
12 4 16 1
Adapted from Weaver, CM, et al., AJCN 70:543S-8S., 1999 (as shown in Shils, et al., Modern Nutrition in Health and Disease, 2006.)
Operation Plan for National Nutrition Services July 2011 - June 2016
Health, Population and Nutrition Sector Development Program (HPNSDP)
Directorate General of Health Services Ministry on Health and Family Welfare July 2011
10. (A) Priority Interventions and Activities of the National Nutrition Services
10.A.3 Micronutrient Supplementation a) Vitamin A supplementation b) Iron folate supplementation c) Iron supplementation and deworming of adolescent girls d) Zinc supplementation during treatment of diarrhoea
e) Vitamin D, Calcium Supplementation Very recently disability among children due to deficiency of calcium and/or vitamin D is also found in some pocket areas of Bangladesh which are suspected as Rickets cases. Special programs for Calcium and Vitamin D supplementation for specific cases will be undertaken.
Key NNS Activities with responsibilities at different levels of services in the health sector program
Activity Responsibility/service delivery and supervision/monitoring District level (DH/MCWC) Delivery and supervision: CS/DDFP TS & Logistics; LD-NNS Upazila health Complex Delivery and supervision: UHFPO/UFPO TS & Logistics: LD-NNS Union health facility Delivery and supervision: UHFPO/UFPO T S & Logistics: LD-NNS
Community clinics/community
Iron-Folic Acid Supplementation for pregnant and lactating women, and adolescent girls
Same service delivery, supervision, technical support and logistic channels for IFA and Calcium
D, calcium etc.
Child Nutrition ABCN, 6 Iron supplementation ICDP (micronutrient powder) 8 Other Nil Micronutrients (Vit D, Calcium etc.) Maternal and Newborn Nutrition Iron-folic acid ANC, supplementation PNC, for pregnant and ABCN lactating women
DGHS, DGFP
DGHS, DGFP
Sustainability / Institutionalization
Global Actions
Global advocacy and partnerships: Global action to support work to reduce PE/E
Global Actions
Global clinical and program approaches: Efficacy for calcium supplementation to prevent PE/E
Global Actions
Global programmatic guidelines for calcium supplementation developed and issued: Effective interventions for calcium supplementation demonstrated Some recommendations made This meeting can add to the guideline / recommendation
Global Actions
Global source of calcium supplements: UNICEF does not have a low cost calcium supplement for pregnant women on its drug list Need for exploration of development partners, funding
Program Design
Formative research: Demand and supply-side barriers to calcium supplementation determined (womens perceptions of PE/E as a problem and taking calcium to prevent it; supply and logistic gaps)
May need operations research Ma Moni Project may generate some evidences
Program Design
Drug supply procurement: Systems in place to ensure adequate forecasting and delivery of calcium supplies to health facilities and pregnant women
General system can be used Needs National planning and finance
Program Design
SBCC: SBCC strategy developed including counseling messages and materials to ensure compliance, social mobilization campaigns, and use of media to raise awareness
Some messages have been generated in MaMoni project area Needs further action & support
Early Introduction
Training and education: Pre-service and in-service training conducted on calcium supplementation To some extent Supervision and on the job training in place No
Early Introduction
Quality of care : Quality of care introduced at community and facility levels
Needs to be included in pre service and in-service training curriculum of all categories of HSP
Early Introduction
Community engagement: Community driven support for prevention of PE/E and Calcium supplementation community /facility linkages in place
Ma Moni project may explore & highlight the possible way May need operations research
Early Introduction
Monitoring and evaluation: Routine monitoring in place: National coverage surveys conducted 35 years
Needs strengthening
Early Introduction
Programmatic growth: Adding districts, partners, and financing
After operations research can be scaled up HPNSDP plans to cover all MC, DH/MCWC, UHC
Mature Implementation
Capacity development: Providers have complete knowledge and counseling skills on calcium supplementation
Incomplete knowledge and counseling skills
Mature Implementation
Quality of Care: Providers are self-assessing and supervisors provide supportive supervision Self assessment should be in built in the system General chain of supervision may be used Periodical especial study or survey may be conducted
Mature Implementation
Drug and supply availability: Calcium for all pregnant women available in community/facility
Long way to go
Mature Implementation
Clinical coverage: High coverage and uptake of calcium supplementation
Low Coverage
Sustainability/ Institutionalization
Prevalence Data
Outcome Data
Approaches fully adapted/implementation at scale Approaches introduced/implementation started but not at scale Approaches not yet introduced/adapted
Mature Implementation
Capacity development: Providers have complete knowledge and counseling skills on calcium supplementation Quality of care: Providers are selfassessing & supervisors provide supportive supervision
Sustainability / Institutionalization
Global advocacy and partnerships: Global action to support work to reduce PE/E
Global clinical and program approaches: Efficacy for calcium supplementation to prevent PE/E demonstrated and WHO recommendation issued
Maternal calcium supplementation policy: National policy/strategy sets reducing PE/E as priority and recommends calcium supplementation for all pregnant women Health system governance: Proactive financing of maternal health including calcium supplementation to prevent PE/E Service delivery capacity at sites: Presence of reliable infrastructure, personnel, and systems to deliver calcium supplementation
Formative research: Demand & supply-side barriers to calcium supplementation determined (womens perceptions of PE/E as a problem & taking calcium to prevent it; supply & logistics gaps) Drug supply procurement: Systems in place to ensure adequate forecasting & delivery of calcium supplies to health facilities & pregnant women SBCC: SBCC strategy developed including counseling messages & materials to ensure compliance, social mobilization campaigns, and use of media to raise awareness
Global programmatic guidelines for calcium supplementation developed and issued: Cost-effective, feasible and consumer-acceptable interventions for calcium supplementation demonstrated
Drug & equipment availability: Calcium for all pregnant women available in community/facility
Clinical coverage: High coverage & uptake of calcium
Global source of calcium supplements: UNICEF has available for programs sufficient supplies of lowcost calcium supplements for pregnant women
M&E
Prevalence Data
Outcome Data
Indicators in HMIS
Routine monitoring
INTRODUCING INNOVATION
Coverage of CA Supplementation
coverage (average) of CA supplementation schematic
The color filled in here is illustrative and needs to be adjusted based on country experience. Guidelines for filling in this box should be based on the following indicator: % of pregnant women receiving 1500 mg of calcium per day (or whatever the country recommendation is) from 20 weeks of gestation