Micronutrient vitamin and mineralDr. Joko wahyu Wibowo,MKes

Micronutrientsand MacronutrientsMicronutrients are substances required in very small amounts (mg or g) and that mainly function as co-factors of enzymes ( < 0.005% body weight). Examples include:Vitamins Trace minerals (Fe, Cu, F, Zn, I, Se, Mn, Mo, Cr, Co and B).Macronutrients are chemical substances that are required in relatively large amounts (> 0.005% body weight). Examples include proteins, fats, carbohydrates and minerals (Na, Mg, K, Ca, P, S, and Cl).*

Minerals*

Minerals*

MineralFunctionFood sourcesZincEnzymes production of genetic material/proteins, vitamin A transport, wound healing, sperm production and the normal development of the fetusGreen vegetables, tomato juice ,lentils, oysters, shrimp, crab, meats yoghurt, cheeseSeleniumAntioxidant, works with vitamin E to protect body from oxidationseafood, meats and grainsIodineThyroid hormones regulate growth, development and metabolic ratesalt, seafood, bread, milk, cheeseCopperAbsorption/utilization of iron, formation of hemoglobin , enzymesmeats, waterManganeseFacilitates many cell processeswidespread in foodsFluorideformation of bones and teeth, helps to make teeth resistant to decayfluoridated drinking water, tea, seafoodChromiumAssociated with insulin and is required for the release of energy from glucosevegetable oils, liver, whole grains, cheese, nutsMolybdenumFacilitates many cell processeslegumes, organ meats

Vitamin CharacteristicsEach vitamin has one or more specific purposes.Vitamins are essential to life processes. Vitamins are generally used by the body with very minimal changesVitamins are usually required in only small amounts Most vitamins cannot be synthesized by the body directly *

Important Vitamins*

Classification of VitaminsVitamins can be classified as either Water soluble Fat soluble. Water soluble vitamins are generally involved in the cellular metabolism of energy supplying nutrients. Fat soluble vitamins often have very specialized functions*

Water Soluble VitaminsWater soluble vitamins usually contain hydrogen attached to electronegative atoms such as oxygen or nitrogen. They easily form hydrogen bonds with water molecules. Water soluble vitamins do not accumulate in the body, so regular supplies are necessary*

Fat Soluble VitaminsFat soluble vitamins have long nonpolar hydrocarbon chains or rings. Common fat soluble vitamins includeA, D, E, F K. *

Fat Soluble Vitamins

Fat soluble vitamins usually accumulate in tissues and are not leached out quickly. Unlike water soluble vitamins, an excess of a fat soluble vitamin can be just as harmful as a deficiency

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Vitamin C- SourcesVitamin C is found in many fresh fruits and vegetables. It contains several polar groups, making it very water soluble. Cooking vegetables in water tends to leach the vitamin from the food. Cooked foods also contain less vitamin C, since it is also easily oxidized and hence destroyed in the cooking process.

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Vitamin FunctionsInvolved in the biosynthesis of the protein, collagen, found in connective tissues such as cartilage, ligaments, and tendonsAid in healing wounds and helping to prevent bacterial infections. Massive doses of vitamin C have often been thought to help in the prevention of the common cold, There is NO reliable evidence to show that this is true

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Vitamin C DeficienciesScurvy or Scorbutus. Symptoms include swollen legs, rotting gums, and bloody lesions. Common among sailors in the 18th and 19th centuries who spent a long time at sea without fresh fruits and vegetables

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Vitamin AVitamin A is also known as retinol *The long chain hydrocarbon structure of vitamin A means that the vitamin is essentially non-polar. Hence it is fat soluble rather than water soluble.

Vitamin A SourcesCommonly found in cod liver oil, green vegetables, and fruit. Carrots indirectly serve as a source of vitamin A since they contain b carotene which the body readily converts to vitamin A*

Vitamin A Functions Vitamin A is fat soluble. It is not readily broken down by cooking.Role in aiding in night vision. Retinol is oxidized to retinal, which combines with the protein opsin to form rhodopsin. Rhodopsin is the active agent which converts light signals to electrical impulses that the optic nerve transmits to the brain

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Prevalence of Vitamin A Around the world 250 million children vitamin A deficient (serum retinol

Vitamin A DeficienciesA deficiency in vitamin A results in night blindness. The most serious deficiency results in a condition known as Xeropthalmia, a severe form of conjunctivitius or blindness.

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Vitamin A deficiency: consequences Night blindness - ancient Egypt, Greek and Assyrian medical literature Early deaths High rates of respiratory and diarrheal diseases Affects immunocompetence Cured with animal and fish liver or plants with green and yellow pigments

Risk factors for VAD Age Diet Disease Seasonality Culture Clustering

Illness related indicators for 6-71 month old children

Indicator

Immunization

1%

Diarrhea disease (1)

> 20%

Fever rates (2)

> 20%

Worm infections (3)

> 50%

Dietary modification for VAD Ex. Where food sources of vitamin A are underutilized:Thailand: VAD in preschool children, pre-clinical levels, Animal foods expensiveFruits are seasonalIvy gourd-underutilized, low esteem

Fortification of VAD EX. Guatemala; sugar fortificationLow serum retinol levelsLow dietary intake of vitamin ASugar usually refinedSugar consumed within a narrow range of daily intake across age groups In 1970, sugar was fortified with vitamin A, program very successful (Arroyave, 1979 PAHO publication)

Vitamin A deficiency - summaryVitamin A deficiency is highly prevalent It has severe consequences especially in the young Supplementation, fortification and dietary changes have all been used successfully to reduce its prevalence The cost of the programs is not high if integrated into existing child care services

Vitamin D - Sources Vitamin D is commonly found in fish liver oil as well as egg yokes. Unlike other vitamins, the body synthesizes vitamin D in the skin through the action of ultraviolet light on 7-dehydrochlosterol*Like vitamin A, the long chain Hydrocarbon structure makes vitamin D fat soluble

Vitamin D Functions Vitamin D is an important regulator of calcium metabolism. It is involved in the uptake of calcium and phosphate ions from food into the body. It is necessary for the proper formation of bone structures and teeth.*

Vitamin D A serious deficiency in vitamin D results in a condition known as Ricketts. Ricketts is characterized by bone softening an malformation. *Child with Ricketts and two years after treatment

Micronutrient DeficienciesVitamin Deficiency DiseasesRetinol (Vitamin A) xerophthalmia / night blindnessAscorbic acid (Vitamin C) scurvy or scorbutusCalciferol (Vitamin D) rickets.Niacin (Vitamin B3) pellagraThiamin (Vitamin B1) beriberi*Mineral Deficiency DiseasesIron anemiaIodine goiterPellegraBeriberiGoiter

Macro-nutrient DeficienciesMacronutrient deficiencies diseases in chlidren often result from a lack of protein*MarasmusKwashiorkorKwashiorkor is a specific wasting away often occurring in infants at weaning. It results from a lack of protein in the dietMarasmus is a wasting away of the body tissues from the lack of calories as well as protein in the diet. The child is fretful rather than apathetic and is skinny rather than swollen with edema.

Iodine deficiency (ID)Iodine must be obtained from the environmentThyroid hormones, thyroxin and triiodothyronine (T4 &T3) contain 4 and 3 iodine atoms, respectively.Adults need 100-150 g/dailyChildren require less in total, but more per Kg body weight

Iodine deficiency: consequencesThe following are affected by iodine deficiency: Thyroid size; enlargement (goiter) Mental and neuromotor abilities Reproductive results Physical growth

Consequences of IDNeuromotor and cognitive impairment are the most important effects of ID Where ID is severe and mothers have severe ID, endemic cretinism is found results include: cognitive impairment learning, speech deficits psychomotor problems Reproductive effects Rates of reproduction may be lower Fetal and postnatal survival lower Motor performance in childhood impaired

ID prevalenceassessment methodsGoiter rates (*)Classification of goiters into grades 0, 1 and 2 ID suspected when >5% of school age children have grade 1 or 2 goitersUrinary iodine (**) Can define individual status Used to define population status Used to monitor interventions

Prevention of ID - fortification Salt fortification Unique in micronutrient supplementation as no dietary changes required Fortified product more expensive Social marketing to create demand Mass media campaigns Universal salt iodization is the goal Level of fortification 25-50 mg iodine/Kg

ID prevention-supplementation Drops and tablets Original study showing that iodine prevents goiter used sodium iodide tablets given to school children twice per year Lugols solution also used in classroomsIodinated oil Iodinated poppy seed oil - New Guinea Intra-muscular or oral routes Well accepted Costly due to delivery teams required

ID National Programs Europe and North America Iodized salt universally available Mass media campaign Medical education Nutrition education Cooperation of industry Iodine deficiency nearly non existent

Iodine deficiency - summaryIodine deficiency occurs in geographic clusters It results in severe mental and physical disability It can be virtually eliminated by national supplementation programs Correction of ID should be performed with close monitoring to prevent adverse reactions

Nutritional DeficienciesProposed approaches to combating nutritional deficiencies world-wide include: Providing food rations that are composed of fresh and vitamin- and mineral-rich foods. Adding nutrients missing in commonly consumed foods. Genetic modification of food. Providing nutritional supplements. Providing selenium supplements to people eating foods grown in selenium-poor soil.*

GAKI

GAKI dan IQ

POTENSI PENURUNAN IQ KARENA GAKY: Kretin: 50 IQ Point Gondok:10 IQ Point Tinggal di daerah GAKY: 5 IQ Point

Efek defisiensi folat di tingkat molekuler

Spina BifidaNeural tube fails to close on lower end

Spinal cord and back do not develop properly

Iodine deficiencyKELOMPOK RENTAN DAMPAK Ibu Hamil Keguguran Janin Lahir mati, meningkatkan kematian janin, kematian bayi, kretin (keterbelakangan mental, tuli, mata juling, lumpuh spatis), cebol, kelainan fungsi psikomotor Neonatus Gondok dan hipotiroid Anak dan Remaja Gondok, Gangguan pertumbuhan fisik dan mental, hipotiroid juvenile Dewasa Gondok, hipotiroid, gangguan reproduksi

Healthful dietA healthful diet can be attained through the intake of multiple combinations of a variety of foods. Given this, it is difficult to define the ranges of intake for a specific food, which should be included in a given combination with other foods to comply with nutritional adequacy. In practice, the set of food combinations which provide nutritional adequacy are limited by the level of food production sustainable in a given ecological setting.

Phytochemical and antioxidantThe recent interest in the role of phytochemicals and antioxidants on health, and their presence in plant foods, lends further support to the recommendation for increasing the consumption of vegetables and fruit in the diet.The need for dietary diversification is supported by the knowledge of the interrelationships of food components, which may enhance the nutritional value of foods and prevent undesirable imbalances which may limit the utilization of some nutrients. For example, fruits rich in ascorbic acid will enhance the absorption of non-haem iron.

How to accomplish dietary diversity in practiceCommunity or home vegetable and fruit gardensRaising of fish, poultry, and small animals (rabbits, goats, and guinea pigs).Implementation of large-scale commercial vegetable and fruit productionReduction of post-harvest losses of the nutritional value of micronutrientrich foods, such as fruits and vegetablesImprovement of micronutrient levels in soils and plants, which will improve the composition of plant foods and enhance yields

Practices which will enhance the success of foodbasedapproachesTo achieve dietary adequacy of vitamin A, vitamin C, folate, iron, and zinc by using food-based approaches, food preparation and dietary practices mustbe considered. For example, it is important to recommend that vegetables richin vitamin C, folate, and other water-soluble or heat-labile vitamins are minimally cooked in small amounts of water

Vitamin A deficiency (VAD)Vitamin A required to support fast growthVitamin A activity is found in green and yellow pigmented fruits and vegetables in the form of provitaminPreformed vitamin A is found in liver and breast milk

Vitamin A deficiency results in:Slowing regeneration of visual pigments after exposure to bright sun lightDisrupting epithelium integrityReduces immunocompetenceThe combined effects on cellular integrity and on immune capabilities believed to contribute to the deaths of 1.1 to 3 million children under 5 years of age, that could be saved by normalizing Vitamin A levels. Age: highest prevalence in children 6M to 5Y Diet: carotenoids are highly available but require fat for absorption Disease: infectious disease contribute to depletion. Diarrhea decreases absorption, fever increases urinary losses and metabolic utilization rates Measles specifically affect vitamin A balance - absorption and utilization Seasonality: seasonality affects both the availability of foods and the incidence of infectious disease Cultural: in certain cultures use of green leafy vegetables or mangoes is taboo. There are also cultural influences regarding feeding of infants and pregnant women Clustering: clusters exist on national, neighborhood or household levelsAdditional indirect indicators of vitamin A deficiency in pediatric populations are: Less than half the infants are not fully immunized. Measles case fatality rate is 1% or more 2 week point prevalence rate of diarrhea diseases of 20% or higher (1) 2 week point prevalence rate of fever of 20% or higher (2) Worms infections rates especially ascaris in 50% or more of the population (3)Method: Intensive social marketing (advertising) Promotion within the community Recipe menus for school and family meals Ivy Gourd Man promotion and exposure All levels of the community involvedResult: Increased use & consumption of vitamin A rich foods,use of fats/oils in the preparation of ivy gourd Decreased prevalence of night blindness No change in serum retinol levels (may be due to technical problems) Drawback: program could not be sustainedReadings: Smitasiri et al. Participatory action for nutrition education: social marketing vitamin A-rich foods in Thailand. Ecol Food Nutr 1992:28;199-210.1970 program stopped due to increase in needs for importation of sugarVitamin A deficiency reappearedIn 1990, due to increased awareness following the cancellation of a successful program, global agitation and global commitments, the program was started again.Results: 1996, VA levels increased from 1990 levelsGuatemala now defined as a country with moderate rather than severe VAD problem Other Latin American countries followed: Honduras, El-Salvador Ecuador, BoliviaReading: Arroyave 1996, OMNI, USAID, INCAP publication Daily intake of iodine fluctuate greatly and Iodine absorption is very efficientThe thyroid system is intrinsically stable.Iodine is sparsely distributed in the earths surface. Iodine deficiency (ID) is very common, and occurs in geographically defined clusters. Over 1.5 billion people live in iodine deficient areas, about half have thyroid disturbances, and 1/5 have health problems.

Thyroid effects:Response to ID is enlargement of the thyroid gland. Goiter may appear in preadolescence, and rates may reach 100% when ID is severe. Thyroid nodules occur when ID is severe. While the goiter in itself is harmless, the nodules can cause obstruction of the trachea or impair function of laryngeal nerves. Some increase in cancer rates is suspected to be associated with goiter cases.Damage to the embryo starts in the second trimester of pregnancy and is reversible if iodine is given. Damage occurring after the second trimester can not be corrected.In less than severe ID, neurological effects range from detectable neurological changes to impaired learning capacity and performance in school, or reduced ability to handle formal tests of psychomotor functions. Readings: Stanbury ed., The damaged Brain of iodine deficiency. 1994, NY, Cognizant communicationsMeta-analysis of 18 studies covering 2214 persons suggests that ID persons have a mean IQ score 13.5 points lower than iodine sufficient persons.

Goiter classification:Grade 0: no palpable or visible goiterGrade 1: Not visible with neck in normal position. Mass moves upwards when subject swallows. Nodular changes can occur when goiter is not visibleGrade 2: A swelling in the neck that is visible when the neck is in the normal position and is consistent with enlarged thyroid by palpitation.Urinary iodine: