Hidden hunger

CARLOS H. LIFSCHITZ, M.D. Associate Physician,

Pediatric Gastroenterology, Italian Hospital, Buenos Aires, Argentina

Former Associate Professor, Baylor College of Medicine, Houston, Texas

FIRST 1000 DAYS FIRST 100 YEARS

Environmental factors can trigger different mechanisms affecting health & disease

The DOHaD

organisation is

built on this

concept.

McMullen, 2009

What percentage of lifelong health can

be explained by inherited genes?

The environment has much more impact onhealth in later life than your genes

• Estimation: ~ 20% of lifelong

health can be explained by

inherited genes.

• At least 80% of disease risk in

later life is due to the

environment, including nutrition

and life style.

Gluckman, 2013

What is hidden hunger?

Chronic lack of micronutrients -vitamins and minerals- whose effect may not be

apparent immediately and whose consequences can be long-term and

profound.

Hidden hunger

• Vitamin A

• Vitamin D, probably the most frequently deficient micronutrient in developed countries

• Iodine

• Iron

• Zinc

• Folic acid

• Vitamin E

Burden of hidden hunger

Cost to health expressed as the number of years of healthy life lost in a population due to disability or

premature death attributable to hidden hunger.

Surprisingly, micronutrient malnutrition is not only present in low-income countries,

But also in those of

middle income and

high.

Magnitude of the problem

• Worldwide, about 800 million people suffer from chronic hunger, that is, they are calorie deficient (FAO et al., 2017).

• More than 2 billion people are affected by hidden hunger, that is, they suffer from micronutrient deficiencies (WHO, 2006).

Hidden Hunger Map

Percentage of the population with specific micronutrient deficiencies.

Vitamin A

• preformed vitamin A, is found in meat, poultry, fish, and dairy products.

• Provitamin A, is found in fruits, vegetables, and other plant-based products.

Manifestations of vitamin A deficiency

• Dry Skin. • Dry Eyes (Xerophtalmia)• Night Blindness• Infertility and Trouble Conceiving• Delayed Growth• Throat and Chest Infections• Poor Wound Healing• Acne and Breakouts

ZINC

Signs of Zn deficiency

• Altered/loss of taste and smell.• Anorexia (lack or loss of appetite)• Apathy.• Ataxic gait (uncoordinated movements)• Decreased immunity.• Depression.• Diarrhea.• Excessive hair loss.

Vitamin D

• Association between low levels of vitamin D in the

mother and severe pre eclampsia.

• Pregnant women with gestational diabetes,

gestational intrahepatic cholestasis and periodontal

disease in the middle of pregnancy, have lower

vitamin D levels than controls.

• Maternal vitamin D levels in the 1st trimester of

pregnancy are related to the risk of low birth weight

and small babies for gestational age.

• Polymorphisms in the vitamin D receptor gene may

contribute to disparities related to vitamin D in fetal

growth.

• There is evidence that the status of vitamin D in the

mother has an influence on the early development of

the fetal skeleton with long-term effects.

• Vitamin D levels in the umbilical cord associated with

tolerogenic immune regulation and fewer respiratory

infections in the baby.

• Probability of preeclampsia in women with total vitamin D intake of 15-20 µg / d vs. <5 µg / d: 0.76 (95% CI = 0.6-0.95).

• Taking into account only vitamin D intake as a supplement: 27% reduction in the risk of preeclampsia for women taking 10-15 µg / d compared to no supplement.

Summary of the risk relationship of the association between vitamin D supplementation and fetal or

neonatal mortality

Summary of the risk relationship of the association between vitamin D supplementation and fetal or neonatal mortality

• 775 children followed from birth to age 18 at the Boston Medical

Center. Most lived in a low-income, urban area and 68% were African

American.

• Low vitamin D levels defined as < 11 ng/ml in cord blood at birth and

less than 25 ng/ml in a child's blood during early childhood.

• Compared to children born with adequate vitamin D levels:

• Children born with low vitamin D levels had a 60% higher risk of

elevated systolic blood pressure between ages 6 and 18;

• Children who had persistently low levels of vitamin D through early

childhood had double the risk of elevated systolic blood pressure

between ages 3 and 18.

IODINE

• Essential iodine for thyroid hormone production and normal intrauterine development

• During pregnancy Iodine intake should increase by 50% because there are:– Physiological increases in maternal thyroid

hormone production – Increase in maternal renal losses of Iodine

and – Fetal requirements of iodine for thyroid

hormone production.

Iodine sources

Means (95% CI) of cognitive outcomes in children according to level of maternal iodine in 1st trimester

8 years

9 years

Results of education in children whose mothers had inadequate urinary iodine concentration (UIC) (<150 μg / L) during pregnancy compared to mothers with adequate UIC.

Iron (Fe)

Fe Facts

• Only about 10% of dietary Fe is absorbed (1–2 mg/d)

• Humans unable to rid the body of excess Fe

• Absorptive process must be tightly regulated to avoid Fe deficiency and overload

Duodenal

cytochrome b +

vit. C

Divalent

Metal

Transporter

Absorption

almost exclusively in

duodenum

FERROPORTIN• Major cell exporter of Fe

• Located in basolateral membrane of

enterocyte &

• Hepatocyte

Hephaestin

Converts (Fe2+) to (Fe3+)

Regulation of Intestinal Fe Absorption

• by body Fe stores, which prevent Fe overload oncethat Fe needs are reached

• Important component of this regulation system is hepcidin, a 25 AA peptide secreted by the liver in response to:• inflammatory stimuli (often linked to oxidative stress)

and

• Fe overload

Ferroportin

Fe

enterocite

Blood stream

Hepcidin

Ferroportin FeHepcidin

Changes in body Fe during Infancy

Fe deficiency (ID)

• ID in utero or early in postnatal life effects brain development

• It alters the development of oligodendrocytes, not only resulting in hypomyelination of white matter, but also may be linked to changes in auditory evoked potentials, motor function and startle response,

Fe deficiency (ID)• ID in utero or early in postnatal life effects brain

development

• It alters the development of oligodendrocytes, not only resulting in hypomyelination of white matter, but also may be linked to changes in startle response, auditory evoked potentials, and motor function

• Early ID also neurochemically alters function of neurotransmitters &

• metabolism of cytochrome oxidase, which negatively effects the ability of the brain to generate and use metabolic energy, perhaps especially in the hippocampus.

Representative auditory brainstem responses at 6 mo.

• Higher proportion of chronic Fe-deficient group did not complete secondary school (58.1% vs.19.8% p = . 003)

• were not pursuing further education/training (76.1% vs. 31.5% p = .08)

• were single (83.9% vs. 23.7%, p = .03) • Reported poorer emotional health and more negative

emotions and feelings of dissociation/detachment.

Results

• Swedish infants: gains in length & head circumference significantly lower in those who received Fe vs. placebo from 4 to 9 mo.

• The same effect on length was seen in Honduras, but only at 4–6 moamong those with initial hemoglobin (Hb) ≥110 g/L.

• No significant main effect of Fe supplementation on morbidity, nor any significant interaction between Fe supplementation and site, but for diarrhea (with both sites combined), there was an interaction between iron supplementation and initial Hb.

• Among infants with Hb < 110 g/L at 4 mo., diarrhea was less common among those given Fe than in those given placebo from 4–9 mo., whereas the opposite was true among those with Hb ≥ 110 g/L (P < 0.05)

Translating the demand effects into changes in Fe deficiency anemia

(prevalence 6–23-month-old children from Faisalabad and Hyderabad districts).