Iron deficiency disorder in Nepal

Iron deficiency is the most prevalent nutritional deficiency in the world. It is also major public health problem of Nepal associated with nutritional deficiency.

Globally, it is estimated to 1.25 billion people are affected by iron deficiency. Iron requirement s is highest during infancy, early adolescence, and pregnancy.

In infancy and early childhood, iron is required for rapid growth. In early adolescence, iron requirements are high because of the growth spurt and even higher for girls who experience both a growth spurt and onset of menses. In pregnancy, iron requirement s are driven by tissue synthesis in the mother , the placenta , and the fetus and by blood loss at delivery.

Status in Nepal

The recent NDHS (2006) revealed that anemia levels in children and women are high in Nepal. Nearly one in two (48%) Nepalese children 6-59 months old were reported to be anemic, with 26 % mildly anemic, 22 % moderately anemic, and less than 1 % severely anemic .

Source; NDHS 2006

Causes

• Inadequate intake of iron from daily diets

• Inadequate absorption of dietary iron

• Infestations such as hookworms and malaria

• High requirements of iron particularly during growth and pregnancy

• Blood loss (menstruation, and injury)

• Vitamin A deficiency

Consequences

• Impaired human function at all stages of life

• Impaired work performances, endurance and productivity

• Increased risk of maternal morbidity and mortality

• Increased risk of sickness and death for the baby

•Reduced physical capacity

•Reduced learning capacity etc.

Nepal‘s protocol for iron deficiency disorder

Prevention

• Dose; 60mg iron +400µg folic acid, daily

• Duration; from the beginning of the second trimester in pregnancy (6month)till 45 days postpartum (total 225 days)

Note; if 6 months duration cannot be achieved in pregnancy , continue during the postpartum for 6 months or increase the dose to 120 mg iron in pregnancy.

Treatment

•<2 years; 25mg iron +100-400 µg folic acid daily 3 months

• 2-12 years ; 60 mg iron +400 µg folic acid daily 3 months

• Adolescents and adults, including pregnant women ; 120 mg iron +400 µg folic acid daily 3 months.

Vitamin A deficiency disorder in Nepal

Vitamin a is a key factor for normal vision , growth of epithelial cells, production of  membranes and myelin , which coats the nerves, growth and formation of  bones and teeth , synthesis of  collagen and cartilage , wound healing, maintenance of  the adrenal glands , synthesis of hormones such as thyroid hormone; development of  body’s  natural defenses and the development of  embryos.

Vitamin A is present in colostrum’s and breast milk. Infants should being to take vitamin A supplementation and eat foods rich in vitamin A at the age of 6 months.

Prevalence of night blindness among women in Nepal

• The overall prevalence of night blindness in reproductive aged women and pregnant women was 4.7% and 6.0% respectively, while 16.7% of women reported having night blindness during their last pregnancy.

Causes

·        Low intake of Vitamin A from daily diets

·        Restricted Vitamin A (VA) absorption

·        Worm infestation

·        Increased VA requirement resulting from infectious diseases

Consequences

·        Xerophthalmia (Night blindness, Bi-tot's spot, corneal ulcer, Keratomalacia, xerosis)

·        Increased risk of morbidity and mortality

·        Increased risk of anemia

·        Miscarriage

·        Stillbirth

·        Low birth weight

National protocols of vita deficiency disorder

Severely malnourished children are at high risk of developing blindness due to vitamin A deficiency. For this reason a large dose of vita is given as follows for;

Prevention

100000 IU of vita 3 times /year    for children 6-12 month

200000 IU of vita 3 times /year     for children above 12 month

200000 IU of vita for mother within 6 weeks of deliver

Treatment

 Day 1;

< 6 months of age    50000 IU

6-12 month of age 100000 IU

>12 month of age 200000 IU

Day 2; same age – specific dose.

At least 2 weeks later; same age­­_ specific dose.

Protein energy malnutrition in Nepal

Protein energy mal nutrition is a global public health problem. In Nepal, this is a major nutritional disorder. Mainly it occurs in two forms such as kwashiorkor and marasmus mainly in children.

Sign/symptoms

Mild

Growth failure, repeated infection, anemia, lethargic

Moderate

Always crying, refuse to eat, diarrhea, thin limbs and loose folds of skin,

Severe

Muscle wasting, fat wasting, edema, mental change.

Status in Nepal

•   49 % of children below 5 years of age are affected by stunting (short for their age), which can be a sign of early chronic under-nutrition.

•   39 % of the children are underweight (low weight for age)

•   13 % of the children are wasted (thin for their age), which can be an indicator of acute under-nutrition.

 Stunting and underweight are more common in the rural areas than in the urban, but wasting are more common in the urban areas. Prevalence of stunting, underweight and wasting tended to increase after 6 months of age indicating that the practice of complementary feeding was not appropriate for their growth.

Nutritional status of children under five years of age in Nepal

imAGE

Source; NDHS 2006

Causes

•   Inadequate energy intake

•   Inadequate knowledge and practice of maternal feeding

•   Heavy physical workload

•   Lack of extra food intake during pregnancy and lactation

•   Inappropriate breastfeeding

•   Inadequate complementary feeding practices 

•   Insufficient health services (Growth monitoring and counseling)

•   Low birth weight.

•   Infectious diseases

•   Inadequate energy intake

Consequences

•   Low birth weight

•   Increased risk of maternal mortality and morbidity

•   Reduced productivity

•   Failing to grow (underweight, stunted, and wasted)

•   Reduced learning ability

•   Reduced resistance and immunity against infection

•   Reduced productivity in the future

Nutritional situation in Nepal

Malnutrition among children, adolescents and women is still a serious public health problem. About half of under-five children are affected by stunting. The proportion of underweight children is around 48%. Of them, 10% suffer from acute malnutrition and 13% by a combination of stunting, vitamin A deficiency and iron deficiency. It is believed that one of the main causes for malnutrition is the high prevalence of worm infestation, which is very high in rural areas (74% as per a survey conducted in three districts). Similarly, the prevalence of iron deficiency anemia is equally high (46% among adolescent girls, 78% among preschool children and 75% among pregnant women).

Continuation of exclusive breast feeding beyond six months, without any complementary feeding is another cause of malnutrition among infants and children. The situation of Vitamin A deficiency disorders has improved over the years but it is still a public health problem, as indicated by the prevalence of night blindness among pregnant women and women of reproductive age (6% and 4.7% respectively). The initiative by the Ministry of Health on the micronutrient intensification program, with the focus on iron supplementation during pregnancy and postpartum is continuing but the desired outcomes are awaited.