PREVENTION AGAINST
MICRONUTRIENT MALNUTRITION
IODINE
FOLIC ACID
VITAMIN D
3RD
SUMMER SCHOOL
MANI, GREECE
2014
Professor St...
Sydney, Australia
Nutrition Related Disorders
MicronutritionMicronutrition
Undernutrition PCMUndernutrition PCM
Minerals and VitaminsMineral...
PAMM
 Iodine
 Folic Acid
 Vitamin D
Iodine Deficiency Disorders
 Thyroid
 Thyroid autonomy
 Nodular thyroid
disease
 Goitre
 Thyroid Malignancy
 Brain
...
Iodine Deficiency Disorders
 Iodine Deficiency Disorders (IDD) refers to all of
the ill effects of iodine deficiency in a...
Endemic Goitre
Pathogenesis of goitre
Adaptation to iodine deficiency
Iodine Deficiency Disorders
Early recognition of goitre with impaired
mental ability
"Hence while travelling in a
certain region in the County
Tyrol, ...
Endemic Cretinism
 Occurs in areas of
severe iodine
deficiency and almost
universal endemic
goitre
 Geographic clusterin...
Endemic Cretinism: Clinical
Phenotypes
 Neurological
 Euthyroid
 Goitrous
 Severe mental
disability
 Deafness
 Neuro...
Timing of insult
Timing ofTiming of
insultinsult
PrenatalPrenatal PostnatalPostnatal
TargetTarget Fetal brainFetal brain
F...
Why are certain parts of brain predisposed?
Timing of the insult and preferential sites for
thyroid hormone action
Differential expression of TH
receptors
ARE IODINE LEVELS
FALLING?
Are we at risk?
Are iodine levels falling?
Figure 1. (A) Median U.S. urinary iodine concentrations in
males and females, 1971-2002 (B) Med...
Pregnancy increases risk of iodine
deficiency
Iodine Deficiency in Australia
Tasmania
Urine Iodine Distribution
Median UIE 84mcg/l
Thyroid Size: Boys and Girls
24.6% 20.7%
Other States
NINS study
 Overall, children in mainland Australia are borderline
iodine deficient, with a national median UIE of 104
mc...
Just eat sushi! Is that ok?
What is normal intake?
Too little and Too much can be a
problem
ENDEMIC GOITRE IN CENTRAL CHINA CAUSED BY
EXCESSIVE IODINE INTAKE
 Thyroid status was examined in children from two
villa...
TOPICAL IODINE-CONTAINING ANTISEPTICS AND NEONATAL
HYPOTHYROIDISM IN VERY-LOW-BIRTHWEIGHT INFANTS:
P. Smerdely, S. C. Boya...
Medications
Amiodarone related thyroid
disease
FOLIC ACID
Sources of folate intake
Folate
sources
Folate
Folic acid
(FA)
Dietary Folate Equivalents
(DFE)
Food (natural) + - 1 DFE =...
Association of folate with health outcomes
• NTD’s and other birth defects
• Cardiovascular disease
• Cognition
• Cancer
•...
Monitoring of the impact of folic acid fortification
Changes in
dietary intake
Changes in blood
levels
Changes in NTD
rate...
Changes in biomarker levels of folate status
How much did folate blood
levels change after the
introduction of fortificati...
Serum folate levels have nearly tripled
• Serum folate levels have
increased much more than
expected from FDA intake
model...
Prevalence of low RBC folate levels has decreased
Red blood cell folate levels have also stabilized after fortification
an...
Folate dietary intake data
Strengths Challenges
Non-invasive Self-reported data; flawed with
multiple errors
Relatively ea...
VITAMIN D
Health benefits of vitamin D
 Low 25(OH)D levels linked to
 Osteoporosis and osteopenia
 Cancer
 Diabetes
 Cardiovasc...
Adequate vitamin D status
Vitamin D (nmol/L*)
Conventional
guidelines
Newer
recommendations+
Severe Deficiency <12.5
Moder...
Australian Studies
46974697
31131 25(OH)D assays
1 July 2008 and 30 July 2010
31131 25(OH)D assays
1 July 2008 and 30 July 2010
Primary test,...
Mean 25(OH)D by gender
37%
reduction
by June
Mean 25(OH)D by patient
setting
Mean 25(OH)D by gender and
patient setting
Supporting Women with Breast
Cancer Today and Every Day
Mean 25(OH)D by age group
Mean 25(OH)D by
remoteness
Results
Bilinski & Boyages MJA 197 (2) · 16 July 2012
Requests per 100000 for FBC, bone
densitometry and vitamin D
Bilinski & Boyages BMJ Open 2013;3: e002955
Frequency of repeated
testing
Bilinski & Boyages BMJ Open 2013;3: e002955
Vitamin D intake
recommendations
*Recommendations based on maintaining serum vitamin D > 75 nmol/L
(30ng/ml)
Recognition t...
Health Implications
 Public health messages required to address
high prevalence of vitamin D deficiency
 Australians are...
Percentage of households with access
to iodised salt
Food Fortification
 Eradication of iodine deficiency has always the highest priority.
 Optimal prevention of thyroid dis...
Risks of iodisation programmes
 Sudden increase in the prevalence of
hyperthyroidism
 Jod Basedow phenomenon
 Developme...
CONCLUSION
 Thyroid hormone is essential for normal
somatic and neurological development.
 Iodine deficiency leads to th...
Acknowledgements
 Australia
 CJ Eastman
 JP Halpern
 John K Collins
 Li Mu
 China
 Indonesia
 The Netherlands
 He...
Prevention against micronutrient malnutrition
Prevention against micronutrient malnutrition
Prevention against micronutrient malnutrition
Prevention against micronutrient malnutrition
Prevention against micronutrient malnutrition
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Prevention against micronutrient malnutrition

Micronutrident disorders are common and a major cause of morbidity in all populations. In this presentation we discuss the importance of iodine, folic acid and vitamin D deficiency. Prevention is the solution
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Prevention against micronutrient malnutrition

  • 1. PREVENTION AGAINST MICRONUTRIENT MALNUTRITION IODINE FOLIC ACID VITAMIN D 3RD SUMMER SCHOOL MANI, GREECE 2014 Professor Steven C. Boyages Westmead Hospital Sydney, Australia
  • 2. Sydney, Australia
  • 3. Nutrition Related Disorders MicronutritionMicronutrition Undernutrition PCMUndernutrition PCM Minerals and VitaminsMinerals and Vitamins Folic AcidFolic Acid Vitamin D deficiencyVitamin D deficiency Vitamin A deficiencyVitamin A deficiency Fe deficiencyFe deficiency Selenium deficiencySelenium deficiency Iodine deficiencyIodine deficiency MicronutritionMicronutrition Undernutrition PCMUndernutrition PCM Minerals and VitaminsMinerals and Vitamins Folic AcidFolic Acid Vitamin D deficiencyVitamin D deficiency Vitamin A deficiencyVitamin A deficiency Fe deficiencyFe deficiency Selenium deficiencySelenium deficiency Iodine deficiencyIodine deficiency MacronutritionMacronutrition ObesityObesity HyperlipidemiaHyperlipidemia Insulin ResistanceInsulin Resistance DiabetesDiabetes AlcoholAlcohol MacronutritionMacronutrition ObesityObesity HyperlipidemiaHyperlipidemia Insulin ResistanceInsulin Resistance DiabetesDiabetes AlcoholAlcohol
  • 4. PAMM  Iodine  Folic Acid  Vitamin D
  • 5. Iodine Deficiency Disorders  Thyroid  Thyroid autonomy  Nodular thyroid disease  Goitre  Thyroid Malignancy  Brain  Endemic cretinism  Deafness  Subclinical deafness  intellectual disability  ?Attention deficits  ? Colour perception deficits Iodine Deficiency Disorders (IDD)Iodine Deficiency Disorders (IDD) 1000 million people at risk for the1000 million people at risk for the development of IDDdevelopment of IDD
  • 6. Iodine Deficiency Disorders  Iodine Deficiency Disorders (IDD) refers to all of the ill effects of iodine deficiency in a population that can be prevented by ensuring that the population has an adequate intake of iodine  Iodine deficiency at critical stages during pregnancy and early childhood results in impaired development of the brain and consequently in impaired mental function.
  • 7. Endemic Goitre
  • 8. Pathogenesis of goitre
  • 9. Adaptation to iodine deficiency
  • 10. Iodine Deficiency Disorders
  • 11. Early recognition of goitre with impaired mental ability "Hence while travelling in a certain region in the County Tyrol, under the jurisdiction of the Bishop of Gurk, I was astonished at the very large number of madmen, fools and dolts; but when I considered the frigidity and the humidity of the air, and also perceived the crudity of the waters from the very frequent occurrence of goitre... all astonishment ceased entirely."  EUSTACHIUS RUDIUS, A PHYSICIANFRO MUTRECHT  (1 551 -1 6 1 1 )
  • 12. Endemic Cretinism  Occurs in areas of severe iodine deficiency and almost universal endemic goitre  Geographic clustering  Two predominant clinical phenotypes
  • 13. Endemic Cretinism: Clinical Phenotypes  Neurological  Euthyroid  Goitrous  Severe mental disability  Deafness  Neurological abnormalities  More frequent  Myxedematous  Hypothyroid  Thyroid atrophy  Severe mental disability  Deafness  Neurological abnormalities  Less frequent
  • 14. Timing of insult Timing ofTiming of insultinsult PrenatalPrenatal PostnatalPostnatal TargetTarget Fetal brainFetal brain Fetal thyroidFetal thyroid MaternalMaternal thyroidthyroid Child andChild and AdultAdult ThyroidThyroid OutcomeOutcome EndemicEndemic cretinismcretinism Impaired IQImpaired IQ EndemicEndemic GoitreGoitre ShortShort
  • 15. Why are certain parts of brain predisposed? Timing of the insult and preferential sites for thyroid hormone action
  • 16. Differential expression of TH receptors
  • 17. ARE IODINE LEVELS FALLING? Are we at risk?
  • 18. Are iodine levels falling? Figure 1. (A) Median U.S. urinary iodine concentrations in males and females, 1971-2002 (B) Median U.S. urinary iodine concentrations in pregnant and non-pregnant women of child-bearing age (15- 44 years old), 1971-2002. [Adapted from Hollowell et al, JCEM 1998; 83:3401-8 & Caldwell et al, Thyroid 2005;15:692-9]
  • 19. Pregnancy increases risk of iodine deficiency
  • 20. Iodine Deficiency in Australia
  • 21. Tasmania Urine Iodine Distribution Median UIE 84mcg/l
  • 22. Thyroid Size: Boys and Girls 24.6% 20.7%
  • 23. Other States
  • 24. NINS study  Overall, children in mainland Australia are borderline iodine deficient, with a national median UIE of 104 mcg/L.  On a state basis, NSW and Victorian children are mildly iodine deficient, with median UIE levels of 89 mcg/L and 73.5 mcg/L, respectively. South Australian children are borderline iodine deficient, with a median UIE of 101 mcg/L.  Both Queensland and Western Australian children are iodine sufficient, with median UIE levels of 136.5 mcg/L and 142.5 mcg/L, respectively.  There was no significant association between UIE and thyroid volume.
  • 25. Just eat sushi! Is that ok?
  • 26. What is normal intake? Too little and Too much can be a problem
  • 27. ENDEMIC GOITRE IN CENTRAL CHINA CAUSED BY EXCESSIVE IODINE INTAKE  Thyroid status was examined in children from two villages in China where the iodine concentrations in drinking water were 462.5 and 54 μg/1  Goitres were present in 65% (n = 120) and 15.4% (n=51), respectively.  Children from the high-iodine village had a lower mean serum triiodothyronine and higher serum free thyroxine and serum thyroid-stimulating hormone concentrations than the children from the control village. 2 cases of overt hypothyroidism were detected in the high-iodine village.
  • 28. TOPICAL IODINE-CONTAINING ANTISEPTICS AND NEONATAL HYPOTHYROIDISM IN VERY-LOW-BIRTHWEIGHT INFANTS: P. Smerdely, S. C. Boyages, et al. Lancet 1989  The thyroid function of very-low-birthweight (VLBW; below 1500 g) infants admitted to neonatal intensive-care units was studied at two hospitals; one routinely used topical iodinated antiseptic agents and the other used chlorhexidine-containing antiseptics.  Serial Urinary iodine excretion rose dramatically in the 54 iodine-exposed infants and was up to fifty times greater than in the 29 non-exposed infants.  Within 14 days, 25% (9 of 36) of the infants exposed to iodine had serum thyrotropin levels above 20 mIU/l, compared with none of the control group.  The mean serum thyroxine level in these 9 infants (44·1 nmol/l) was significantly lower than that in exposed infants with normal thyrotropin levels (83·1 nmol/l) and in the non-exposed control group (83·0 nmol/l), thyroxine levels fell before serum thyrotropin rose.
  • 29. Medications
  • 30. Amiodarone related thyroid disease
  • 31. FOLIC ACID
  • 32. Sources of folate intake Folate sources Folate Folic acid (FA) Dietary Folate Equivalents (DFE) Food (natural) + - 1 DFE = 1 μg food folate Food (fortified): ECGP + RTE cereals + + 1 DFE = 1 μg food folate or 0.6 μg FA from fortified food Supplements - + 1 DFE = 0.6 μg FA taken with food or 0.5 μg FA on empty stomach
  • 33. Association of folate with health outcomes • NTD’s and other birth defects • Cardiovascular disease • Cognition • Cancer • Acceleration of cancerous growth • Masking of vitamin B12 deficiency • Twinning • Immunity • Epigenetic changes Cause and effect has not been proven Potential adverse effects; basis is observational data Proven effectiveness of folic acid intervention
  • 34. Monitoring of the impact of folic acid fortification Changes in dietary intake Changes in blood levels Changes in NTD rates Folic acid fortification policy Changes in other health outcomes Benefits Risks anes
  • 35. Changes in biomarker levels of folate status How much did folate blood levels change after the introduction of fortification? What are the challenges associated with assessing folate status through biochemical measurements?
  • 36. Serum folate levels have nearly tripled • Serum folate levels have increased much more than expected from FDA intake modeling and short-term FA supplementation trials – demonstrating the value of biomonitoring. • Post-fortification serum folate levels have stabilized after several years. http://www.cdc.gov/nchs/data/databriefs/db06.htm http://www.cdc.gov/nutritionreport
  • 37. Prevalence of low RBC folate levels has decreased Red blood cell folate levels have also stabilized after fortification and the prevalence of low levels in women of childbearing age was ~5% compared to ~40% at pre-fortification. http://www.cdc.gov/nchs/data/databriefs/db06.htm RBC folate <140 ng/mL
  • 38. Folate dietary intake data Strengths Challenges Non-invasive Self-reported data; flawed with multiple errors Relatively easy and inexpensive to conduct Various sources of intake need to be captured Easier to compare between countries Computation of data is complex (DFE) Requires two 24-h dietary recalls to calculate usual intakes
  • 39. VITAMIN D
  • 40. Health benefits of vitamin D  Low 25(OH)D levels linked to  Osteoporosis and osteopenia  Cancer  Diabetes  Cardiovascular disease  Autoimmune disease  Multiple sclerosis  Respiratory Illness  Mental Health
  • 41. Adequate vitamin D status Vitamin D (nmol/L*) Conventional guidelines Newer recommendations+ Severe Deficiency <12.5 Moderate deficiency 12.5-25 Mild deficiency 25-50 <50 Insufficiency 50-75 Sufficiency >50 >75 *2.5 nmol/L = 1 ng/ml + Bischoff Ferrari, AJCN 2006
  • 42. Australian Studies
  • 43. 46974697 31131 25(OH)D assays 1 July 2008 and 30 July 2010 31131 25(OH)D assays 1 July 2008 and 30 July 2010 Primary test, complete data available for gender, age, patient setting, date of test, postcode**, known breast cancer case, 25(OH)D ≤400 nmol/L Sample type 1083910839 1397913979 Diagnostic referral Outpatient Private outpatient Emergency Inpatient Private hospital patient Public hospital patient Private patient 2951629516 2481924819 Yes 680668061801218012 Female Male 6201620162516251 Summer Winter 6121612162456245 Autumn Spring 16151615 QC sample Research Miscellaneou s Unknown * *Matched to ARIA, SEIFA, Latitude, Longitude
  • 44. Mean 25(OH)D by gender 37% reduction by June
  • 45. Mean 25(OH)D by patient setting
  • 46. Mean 25(OH)D by gender and patient setting Supporting Women with Breast Cancer Today and Every Day
  • 47. Mean 25(OH)D by age group
  • 48. Mean 25(OH)D by remoteness
  • 49. Results Bilinski & Boyages MJA 197 (2) · 16 July 2012
  • 50. Requests per 100000 for FBC, bone densitometry and vitamin D Bilinski & Boyages BMJ Open 2013;3: e002955
  • 51. Frequency of repeated testing Bilinski & Boyages BMJ Open 2013;3: e002955
  • 52. Vitamin D intake recommendations *Recommendations based on maintaining serum vitamin D > 75 nmol/L (30ng/ml) Recognition that individuals who are obese or on certain medications be give 2-3 times more vitamin D 40 IU = 1 µg Age NHMRC IOM US Endo Society* 0-1 200 400 1000 1-18 200 600 1000 19-49 200 600 1500-2000 50-69 400 600 1500-2000 70 and over 600 800 1500-2000
  • 53. Health Implications  Public health messages required to address high prevalence of vitamin D deficiency  Australians are not adequately supplementing - suitable guidelines are required  Implications regarding frequency and timing of testing
  • 54. Percentage of households with access to iodised salt
  • 55. Food Fortification  Eradication of iodine deficiency has always the highest priority.  Optimal prevention of thyroid disease by modification of iodine intake in the population is achieved by keeping iodine intake in individuals within a relatively narrow interval around the recommended level.  To run an optimal iodization program it is necessary to have information on dietary habits in the population, and on iodine contents of different food items.  Iodine used for enrichment of food should be well distributed in different food items, e. g. by universal or nearly universal iodization of salt. Optimal methods may differ between European countries depending on dietary habits.
  • 56. Risks of iodisation programmes  Sudden increase in the prevalence of hyperthyroidism  Jod Basedow phenomenon  Development of hypothyroidism in those with pre-existing autoimmune thyroid disease  Positive anti-TPO antibodies  Change in the pattern of thyroid disease, rise in the prevalence of thyroid autoimmunity
  • 57. CONCLUSION  Thyroid hormone is essential for normal somatic and neurological development.  Iodine deficiency leads to thyroid hormone deficiency at critical periods of brain development that leads to irreversible neurological damage.  Prevention of iodine deficiency is essential
  • 58. Acknowledgements  Australia  CJ Eastman  JP Halpern  John K Collins  Li Mu  China  Indonesia  The Netherlands  Hemmo Drexhage  USA, Atlanta  GF Maberly  Italy, Pisa  Alessandro Antonelli

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