First Global Conference on BiofortificationNovember 10th, 2010

Keith P. West, Jr., Dr.P.H., R.D.Center for Human Nutrition

Johns Hopkins Bloomberg School of Public HealthBaltimore, Maryland, USA

kwest@jhsph.edu

How Biofortification Fits into (Malnutrition) Interventions to Reduce Micronutrient

Deficiencies

My Biofortification Vote

Day dream believer

Daily believer

Weekend (Fri, Sat or Sun) believer

Healthy skeptic

Agnostic

Bio-atheist

My Biofortification Vote

Day dream believer

Daily believer

Weekend (Fri, Sat or Sun) believer

x Healthy skeptic

Agnostic

Bio-atheist

Treat night blindnesswith roasted oxen liver

Old Kingdom pyramindat Sakura: Depicts night blindness

Night blind pregnant Woman in Nepal, 2000

Severe Iodine Deficiency 16th Century and Today

Zhou Chen, 1516

Beggars and Street Characters

Tibet, 2000

World History of Micronutrient Deficiency

World up to early 20th C

DeficientDeficient

(biofortify)

Sufficient(fortified)

World from mid-20th Cto new Millennium

Global Micronutrient Deficiencies

Worldwide prevalence of anaemia 1993–2005: WHO 2008 Iodine Deficiency Worldwide; WHO 2004

Zinc Vitamin A

AnemiaIodine

Worldwide Distribution of Child Deaths(Black, Morris & Bryce Lancet 2003;361:2226

Maternal-mortality Adjusted World Map

http://www.worldmapper.org/

Life in Rural South Asia Undernourished, Pre-transition

•Protein-energy•Micronutrient s:

Vitamin A, zinc,iron, iodine, folate, others

•Behavioral Causes:Related to poorbreast feeding,complementaryfeeding, home diet, poverty and poor education

Nutritional Deficiencies

•Infant or Child•Infection•Poor growth•Poor cognition & motor development •Death

Child and Maternal Health Problems

•Mother•Obstetric morbidity•Infection/sepsis•Anemia •Death

Nutritional Deficiencies & Health Consequence

Increased chronic disease risk?

Demra, Dhaka, 1977

Altered tissue nutrient levels & metabolism

Chronic dietary deficit of micronutrients

Micronutrient Deficiencies as Public Health ProblemsArise from Chronic Dietary Deficits in Relation to Need

Systemic & non-specific

defects

Adapted from K West, J Nutr 2002

Clinical signs

Poor dietary intakes

Low blood/tissue nutrient /biomarker levels

Abnormal functional tests

Clinical disease

DietFortification

Supplements

DeficientPopulation

Strategies for Preventing Micronutrient Deficiencies

Biofortfication

Micronutrient Supplementation that Works

• The vulnerable: • Pregnant women • Young children

• Proven practices –• Six-monthly vitamin A < 5 years• Daily iron & folic acid in pregnancy • Zinc + ORS to treat diarrhea• Salt iodization to control “IDD”

Vitamin A Supplementation Reduces Preschool Child Mortality in Undernourished Societies

Sommer A & West KP, 1996

Presently ~600 million vitamin A supplements distributed by UNICEF preventing ~1 million child deaths each year

Zinc Effective in Treating Diarrhea

• Zinc deficiency increases risk of severe diarrhea; Zn limits it…

• 10 mg oral zinc daily for 10–14 days • WHO/UNICEF policy• Rolling out• Very low cost• No mass zinc

supplementation programs

Iron Prevents Iron Deficiency and Consequent Anemia

Ane

mia Iron

deficiency

IDA

Hookworm

Malaria

HIV/AIDS

Anemia of Inflammatory Conditions

Other vitamin deficiencies

IDA= iron deficiency anemia

Modern Salt Iodization in China

1995

Per cent

< 6060 - 8080 - 90>= 90

Missing Data

19971999

Multiple Micronutrient SupplementsEfficacies Unclear at Present

Micronutrient Fortification of Food

Passive Delivery

“Centrally” Processed

Widely Consumed

Technically Fortifiable

Innovative Financing

Arroyave et al, PAHO 1979

Baseline

1 year later

6 mo later

Effects of Sugar Fortification with VA in Guatemala

Impact of MSG + A in Indonesia

0

5

10

15

20

25

0 5 10 15 20 25 30 35 40 45 50Serum Retinol (ug/dL)

Perc

ent o

f Chi

ldre

n

Baseline5 Months11 Months

Muhilal et al, Am J Clin Nutr 1988;48:1265

Flour

Noodles

Sugar

Biofortified staple crops

Salt

Goal of BiofortificationEffectiveness & Safety

Increasing Intake

UL

Ris

k of

inad

equa

cy Risk of excess

EAR1

RDA1

217-03

Goal of BiofortificationEffectiveness & Safety

Increasing Intake

UL

Ris

k of

inad

equa

cy Risk of excess

EAR1

RDA1

217-03

Prevents corneal blindness and milder xerophthalmia

Normalized epithelia, immunity,less severe morbidity, reduced

anemia

Tissue and plasmarepletion

Dietary adequacy

VA Deficiency Expect to Respond to Biofortification

Return/ protect function

Expect to Respond

Expect to respond use to assess effect

Partially addressesunderlyingdietary risk

Data Collection Activity PurposeBaseline survey (panels) to assess individual:

More than 1 survey likely needed to assess seasonal intakes, trends and individual estimates

• Micronutrient status and prevalence of deficiency

Quantify nutrient status; calculate % marginal or deficient to establish prevalence and severity of deficiency

• Dietary micronutrient intake

Quantify intake for all groups; evaluate against RDA, EAR and UL to estimatedietary gaps and risks for each nutrient

• Candidate staple food products intake

Quantify staple food items portion size distributions among groups to estimate intakes of biofortified food & nutrients

Representative assessments for biofortified food potency

Monitor over time/ambient conditionsbiofortified nutrient delivery in foods

Repeated periodic survey Monitor population responses to interventions : changes in status, prevalence of deficiency, nutrient and biofortified food intakes

Assessment, Monitoring and Evaluation

Prepared by Nina Series for the ACC-SCN of the UN -appointed Commission on the Nutrition Challenges of the 21st Century, 1998

Prevalence of Low Serum Concentrations of Micronutrients among Women in 1st Trimester

NNIPS-3, Nepal

61

20.6

0.7

11.6

27.7

46.3

31.8 32.8

13.9

0

20

40

60

80

Zinc <8.6

umol/L

Iron <

8.95 umol/L

Copper <

11.8 um

ol/L

Folate <6.8 nmol/

L

B12 <147.7 pmol/L

B6 <20 nmol/L

Riboflav

in <11.3

nmol/L

Vit E <10 um

ol/L

Vit D <25

nmol/L

%

Jiang et al, J Nutr 2005

Antenatal Vitamin A Supplementation in Nepalese Mothers Increased Lung Volume by ~46 ml in Offspring by 9-13 Years of Age

Forced Vital Capacity

Checkley W, West KP, Wise R et al NEJM 2010;362:1784Massaro D NEJM 2010

Antenatal Iron+Folic Acid Supplementation and Child Mortality to 7 Years of Age, Nepal

Christian P et al Am J Epidemiol 2009

Antenatal Folic Acid Supplementation and Kidney Function in Children ~7 Years of Age, Nepal

Stewart CP et al J Nutr 2009

HPLC system

Micronutrient Deficiency Assessment in need of major advances for population assessment

Summary Thoughts• Micronutrient deficiencies reflect a diet

quality problem of poor populations that remains to be been solved: Biofortificationaddresses this problem head on

• Questions remain: bioavailability, efficacy/ effectiveness/safety, specific population group needs, additional nutrient needs, etc

• Nutritionists need to be ready to apply, adapt, test, help integrate, monitor, guide, advocate from evidence, and advance biofortified products as they “arrive”

Summary Thoughts• Improved methods of dietary and status

assessment, and food composition databases are needed to quantify, monitor, and know when closing dietary gaps

• Continued research is needed to better understand and explain health implications of what we do, define new horizons…

• Agriculture-nutrition: an intersection of science, program, political, economic and commercial communities that can advance the human condition. Biofortification sits at this intersection.

THANK YOU

Hidden Hunger = low nutrient density imbalanced nutrient densitieschronic micronutrient inadequacy

MDG #1: Eradicate Severe Hunger

MDG 4 & 5: Reduce Child & Improve Maternal Health

----

----H

ealth

Con

sequ

ence

------

- LessKnown

WellKnown

Micronutrient deficiencies:Depleted nutritureAltered metabolism Impaired function

Deficiency disorders:Blindness, severe infection,mental retardation, death,complications of pregnancy,fetal loss, etc

Supplement

Improve diet

Different Micronutrient Deficiency Control Approaches to Achieve Different MDGs?

Long

-act

ing

Hea

lth C

onse

quen

ces