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The role of micronutrients in the first 1,000 days of life Information for Philippine Association of Nutrition (PAN), Inc. and Philippine Society of Nutritionist-Dietitians (PSND), Inc. Joint Convention, Manila 7 July, 2016 1 Presented by Regina Moench-Pfanner, PhD ibn360 Pte Ltd, Singapore SCALE OF MALNUTRITION IN 2016 2 Source: IFPR. 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, DC. NUMBER OF CHILDREN STUNTED IN ASEAN Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF PREVALENCE OF ANEMIA IN CHILDREN AND WOMEN Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF GLOBAL NUTRITION TARGETS Source: IFPR. 2016. Global Nutrition Report 2016: From Promise5to Impact: Ending Malnutrition by 2030. Washington, DC. THE FIRST 1000 DAYS Conception Birth Pregnancy -9 -6 -3 Adequate complementary feeding AND continued breastfeeding Exclusive breastfeeding 0 2nd Birthday 6 months 3 6 9 Months 12 15 18 21 24 MICRONUTRIENT MALNUTRITION (VMDS) WHAT IS IT? ►Micronutrient Malnutrition: Deficiencies in essential vitamins and minerals required in small amounts by the body including : • Iron • Vitamin A • Iodine • Zinc • Folic Acid ►Deficiencies caused by: • Insufficient, poor or unvaried diets • Losses or poor absorption (due to infections like HIV/AIDS, malaria, diarrhea and parasites) THE HEALTH SIGNIFICANCE OF VITAMINS AND MINERALS (MICRONUTRIENTS) Micro Nutrients • needed in small amounts • vitamins and minerals are needed by the body to perform hundreds of roles • body cannot manufacture on its own in sufficient amounts • must be consumed Some of the roles of micronutrients VITAMINS – FAT SOLUBLE AND WATER SOLUBLE Vitamin A (retinol) Vitamin B6 (pyridoxine) Vitamin B2 9 (riboflavin) WHAT FOODS ARE RICH IN MICRONUTRIENTS? Water soluble vitamins (vitamin C and B complex) are rich in fruits and vegetables. Fat soluble carotenes – vitamin A precursors and others – are responsible for some of the colours of fruit and vegetables. Trace minerals are found in many foods but bioavailability is low from most plant sources. Vitamin D is found in few foods (cheese, margarine, butter, fortified milk, fortified cereals, fatty fish) unless fortified. The body makes vitamin D when exposed to ultraviolet rays. Milk and fish bones are also rich in calcium. 10 RECOMMENDED NUTRIENT INTAKE 11 Source: World Health Organization, 2006. Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf KEY NUTRIENTS BEFORE AND DURING 1,000 DAYS ARE CRUCIAL FOR LIFELONG POTENTIAL Protein • amino acids are essential for building, maintaining, and repairing new tissues; manufacturing important enzymes, hormones, antibodies, and other components; and performing specialized functions in regulating body processes; • Quality protein from breast milk and/or complementary foods Lipids (EFAs) • The brain is made primarily of fat (50-60% of the adult dry brain is fat) with AA and DHA being among the most important FA in the brain. • The critical period for accretion of these fats into the infant’s brain is during the last trimester of gestation up to 2 years of age • Supplementation with omega-3 fatty acids reduced risk of preterm birth (<34 weeks gestation) by 31% in all pregnancies and by 61% in high-risk pregnancies Vitamin A • Needed before and during pregnancy to boost maternal vitamin A levels, immune system, and iron intake • Intake through breast milk can improve Vitamin A status of nursing infants and lower mortality by 11% • 40% reduction in vitamin A deficiency among 1-3 year olds Vitamin D • An essential fat-soluble vitamin that is required for proper formation of bones and utilization of calcium and phosphorous in the body 12 KEY NUTRIENTS BEFORE AND DURING 1,000 DAYS ARE CRUCIAL FOR LIFELONG POTENTIAL Vitamin E • A fat soluble vitamin that protects lipids and proteins from oxidation in the body, preventing the breakdown of tissues. Vitamin K • Anti-haemorrhaging agent (promotes blood clotting) and maintains bone health Folic acid • Adequate pre-pregnancy folate levels reduce incidence of spina bifida by 41% and reduce perinatal mortality due to NTDs by 66% Iodine • Needed for fetal brain development and IQ, WHO states ID as most common preventable cause of early childhood mental deficiency • Reduces risk of miscarriage and stillbirth Iron • Reduces pregnancy complications, perinatal and maternal mortality related to iron deficiency anemia (hemorrhage) • Can reduce anemia in <24 months by up to 62% Calcium • An important mineral with a role in bone and tooth development, blood clotting and maintenance of healthy nerves and muscles. 13 THE FIRST 1000 DAYS Conception Birth Pregnancy -9 -6 -3 Adequate complementary feeding AND continued breastfeeding Exclusive breastfeeding 0 2nd Birthday 6 months 3 6 9 Months 12 15 18 21 24 PREGNANCY AND NUTRIENTS Conception Birth Pregnancy 15 WHAT A PLATE SHOULD CONSIST OF • Many different foods • Colourful • Stomach filling • Low in salt, unhealthy fat and refined sugar • Pregnancy: increased micronutrient intake 16 WHAT A PLATE OFTEN CONSISTS OF 17 FOOD INADEQUACY 18 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 19 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf IRON AND FOLIC ACID SUPPLEMENTATION IN PREGNANT WOMEN 20 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF THE FIRST 1000 DAYS Conception Birth Pregnancy -9 -6 -3 Adequate complementar y feeding AND continued breastfeeding Exclusive breastfeeding 0 2nd Birthday 6 months 3 6 9 Months 12 15 18 21 24 LACTATION Birth 6 months Diversified nutritious adequate diet for lactating mothers Increased micronutrient intake Exclusive breastfeeding 22 PREGNANT AND LACTATING: IODINE SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 23 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf COVERAGE OF IODIZED SALT 24 Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN, Volume 2. Bangkok; UNICEF MULTIPLE MICRONUTRIENT SUPPLEMENTATIONI FOR PREGNANT AND LACTATING WOMEN Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 25 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf THE FIRST 1000 DAYS Conception Birth -9 -6 -3 Adequate complementar y feeding AND continued breastfeeding Exclusive breastfeeding Pregnancy 0 2nd Birthday 6 months 3 6 9 Months 12 15 18 21 24 LACTATION AND COMPLEMENTARY FEEDING 6 months 2nd Birthday Nutrient dense complementary foods as increased micronutrient needs for specific months of age Nutritious diversified diet for lactating mother Adequate complementa ry feeding AND continued breastfeeding Micronutrient increase in: • B-vitamins, vitamin A, C • Magnesium, calcium, phosphorus • Zinc, Copper • Iodine, Selenium (particularly for lactation beyond 4 months) 27 UK: VITAMINS – RNI FOR CHILDREN (0-2Y) AND WOMEN (19-50Y) 0-6m 7-9m 10-12m 1-3y Woman (19-50y) Pregnancy Lactation Vitamin A 350 350 350 400 600 700 950 Vitamin D 8.5 7 7 7 10 10 Vitamin K 5 10 10 15 55 55 55 Vitamin E 2.7 2.7 2.7 5 7.5 7.5 7.5 Vitamin C 25 25 25 30 40 50* 70 Vitamin B1 0.2 0.2 0.3 0.5 0.8 0.9* 1 Vitamin B2 0.4 0.4 0.4 0.6 1.1 1.4 1.6 Vitamin B3 3 4 5 8 13 13 15 Vitamin B5 1.7 1.8 1.8 2 5 6 7 Vitamin B6 0.2 0.3 0.4 0.7 1.2 1.2 1.2 Vitamin B7 5 6 6 8 30 30 35 Vitamin B12 0.3 0.4 0.4 0.5 1.5 1.5 2 Folic Acid 50 50 50 70 200 300 260 * For third trimester only Source: British Nutrition Foundation, Nutrition Requirements, 2015. 28 https://www.nutrition.org.uk/attachments/article/234/Nutrition%20Requirements_Revised%20Nov%202015.pdf FAO, Human vitamin and mineral requirements, Report of a joint FAO/WHO expert consultation, 2001. http://www.fao.org/3/a-y2809e.pdf UK: MINERALS – RNI FOR CHILDREN (0-2 YEARS) AND WOMEN (19-50 YEARS) All minerals needed in the body are essential nutrients. Bulk minerals 0-3m 4-6m 7-9m 10-12m 1-3y Woman (19-50y) Pregnancy Lactation Potassium (mg/d) 800 850 700 700 800 3500 3500 3500 Chloride (mg/d) 320 400 500 500 800 2500 2500 2500 Sodium (mg/d) 210 280 320 350 500 1600 1600 1600 Calcium (mg/d) 525 525 525 525 350 700 700 1250 Phosphorous 400 400 400 400 270 550 550 990 Magnesium 55 60 75 80 85 270 270 320 Trace minerals 0-3m 4-6m 7-9m 10-12m 1-3y Woman (19-50y) Pregnancy Lactation (≤4m) Lactation >4m) Iron (mg/d) 1.7 4.3 7.8 7.8 6.9 14.8 14.8 14.8 14.8 Zinc (mg/d) 4 4 5 5 5 7 7 13 9.5 Copper (mg/d) 0.2 0.3 0.3 0.3 0.4 1.2 1.2 1.5 1.5 Iodine (µg/d) 50 60 60 60 70 140 140 140 155 Selenium (µg/d) 10 13 10 10 15 60 60 60 75 Source: British Nutrition Foundation, Nutrition Requirements, 2015. 29 https://www.nutrition.org.uk/attachments/article/234/Nutrition%20Requirements_Revised%20Nov%202015.pdf FAO, Human vitamin and mineral requirements, Report of a joint FAO/WHO expert consultation, 2001. http://www.fao.org/3/a-y2809e.pdf ECONOMIC LOSS DUE TO MICRONUTRIENT MALNUTRITION 30 INTERNATIONAL RECOMMENDATIONS 31 PRE-PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 32 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf PREGNANCY: IRON AND FOLIC ACID SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 33 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf PREGNANCY: IRON AND FOLIC ACID (NON ANAEMIC) Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 34 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf PREGNANCY: VITAMIN A SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 35 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf CALCIUM SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 36 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf PREGNANT AND LACTATING: IODINE SUPPLEMENTATION Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 37 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf MULTIPLE MICRONUTRIENT SUPPLEMENTATIONI FOR PREGNANT AND LACTATING WOMEN Source: World Health Organization, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and 38 nutrition http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf DIETARY FAT INTAKE FOR PREGNANT AND LACTATING WOMEN Source: International Society for the Study of Fatty Acids and Lipids. http://www.issfal.org/dietary_fat_intak es_for_pregnant_and_lactating_wom en_bjn_2007.pdf 39 TAKE HOME MESSAGES Adequate nutrition is key during first 1,000 days of life – a requirement to meet global nutrition targets Diversified nutritious diet is key to provide required micronutrients – when difficult to obtain, food fortification should be used In early childhood the need for essential nutrients (i.e. iron, zinc) and essential amino acids is very high due to growth – foods need to be nutrient dense (fortified complementary foods) International recommendations on adequate nutrition, including micronutrients, exist for pregnancy, lactation and adequate complementary feeding – but difficulties to implement 40 Thank you Information & correspondence: Regina Moench-Pfanner, PhD Chief Executive Officer, Ibn 360 Pte Ltd 3 Pickering Street, #02-36 Nankin Row, China Square Central, Singapore 048660 m +65 8387 2535 • t +65 6327 8824 • f +65 6223 7314 [email protected] • www.ibn-360.com • @Moenchpfanner 42