ࡱ> ` 0sbjbjss 8v7JJJJJJJ^9999<B9^n999999&9 :6888888$h\uJpB99pBpB\JJ99ѷrFrFrFpBJ9J96rFpB6rFrFFJJƶ99 _9pBN0h^ɼ~DɼƶɼJƶT :<rF>:@6 : : :\\PF" : : :pBpBpBpB^^^ ^^^ ^^^JJJJJJ  Jordans Nutritional Health Setting Ibrahim M.D. Khatib (MSc, PhD) Research in Jordan: Time Course Current Combat Today's challenges fall in two broad lines: Diet related degenerative diseases (among adults) Type 2-Diabetes : prevalence among adults exceeds 20 % Cardio-Vascular Disease, CVD : prevalence is on the rise Obesity : has been observed to follow a rapidly ascending curve Nutritional Deficiencies : considerable among risk groups, especially young children. Roles of Partners Participating in the Combat Leading Role : MOH Nutrition Division Research Role : University Academics Supportive Role : International organizations (WHO and Unicef ) Scientific Reports : The Beginning Early 1960s : The historic early discovery of VAD in Jordan First survey 1 : WHO-sponsored, 1963, a clinic based interventional study of young children admitted to hospitals with ocular signs of xerophthalmia. 1st Report* on Xerophthalmia 300 xerophthalmic children / year Mean serum retinol (SRC) = 55 g/l Second survey 2 : The Jordan Paediatric Study, 1964 ; joint ICNND and ICNJ -community based non-interventional study on children 2nd Report* on Xerophthalmia Proportion of U5y- children with mean SRC below 200 g/l H" 37%. After 1965 : VAD in Jordan became a forgotten risk. Following the 1960s reports, concern in VAD risk faded ! 35 years elapsed before non-ocular VAD could be re-discovered Scientific Research After the 1960s 1970s & 1980s : Research focused on growth deficit, anaemia and breast feeding Anthropometric reports on child growth deficits continued Special focus paid to anaemia in infancy and its association with breast feeding Early 1990s : focus on links between micronutrients and growth deficits Started with study of stunting & zinc deficiency (The JUST Project, 1991-1994) Area: North Jordan; 18 rural locations randomly selected Subjects : 6-24 months - children Prevalence of stunting =16 %, and anaemia = 40 % During the first six months, infant growth is nearly similar to the standards. Growth curve declination starts at mid-infancy and continues afterward. Supplementation : baby rusks used as preventive intervention ; rusks- options given to recipients were: fortified with zinc, zinc & iron, or plain rusks Zinc/iron-intervention prevented only some infant growth declination. Conclusion : other micronutrients, such as iodine and vitamin A were suggested to be deficient.This agreed with the Nutrition Related Recommendations of the 1990 report: The World Summit For Children : Goals for the year 2000 1995 : IDD Baseline Survey. The results reported mild to moderate IDD problem Prevalence : 37 % (in the age group 8-12 years) Action taken : enforcing a universal salt iodination program Re-Discovery of Vitamin A Deficiency (VAD) 1995- 97 : 'Is VAD a hidden culprit in Jordan and thus involved in the growth curve declination that starts at mid-infancy?'. This question on VAD remained un-tackled during this period while efforts were focused on literature reviews about the disorder. Collecting the relevant information about VAD epidemiology was required to prepare for capacity building that includes establishing a lab-capability for measuring retinol concentration in serum, using the HPLC technique, at JUST-community medicine metabolic laboratory. Of the hallmarks in VAD epidemiology, the following four basic domains are emphasized : VAD Clustering VAD hits specific regions within the high-risk country VAD concentrates within high-risk families & communities IVACG Statement: Impact of non-ocular VAD may include immediate impairment of: Growth and development Immunity Vulnerability to ill health Predisposition to IDA Vision acuity Skin and epithelia VAD - Grading System Cut-off points used in diagnosis / screening At Clinical Setups [Serum Retinol Concentration (SRC_ g / L )] = > 300 : normal 299 -200 : borderline <200 : deficient =< 100 : severely deficient (Clinical Emergency) At Community (VAD Prevalence ) < 5 % : acceptable 5 - < 10 % : mild 10 - < 15 % : moderate = > 15 % : severe (Public Health Problem) 1997: MOH - Pilot Trial (design : convenient (well-located) sample of U5y - children) Results : 35 % at risk of VAD (SRC < 250 g/L). 1999 : Onset of the MOE/ MOP - School Snack Service (SSS) - Program Idea : initiated on tentative basis ( 1 year program) Snack : iron fortified biscuit (70 gram) + fresh milk (100ml) + one season fruit Sponsor : Ministry of Planning / the Social Security Package Sites : hamlets of 7 underprivileged governorates Recipients : young pupils aged 5.5-10 years ; elementary governmental schools Duration : continued through the scholastic years starting from September 1999 and still going on upon recommendations from the reported JUST-research surveys. 1999 : Launching the first MOE School Surveys (baseline / impact assessments) of SSS program. MOE- 1st School Survey 1999-2000 (Study of the 7 Underprivileged Districts) Baseline Prevalences : VAD 21.8 % stunting 19.9 % anaemia 18.8 % Supplement : daily mid-morning snack + one time vitamin A capsule Results showed that except on stunting, intervention made a difference Conclusion : VAD in poor school children may be a public health issue. 2001-2002 MOE- 2nd School Survey- Part 1( involved 8 Underprivileged Districts) Approach : interventional study . Target Areas : poorest - remote villages of 8 disadvantaged districts. Supplement : daily snack meal + one vitamin A capsule; Intervention included a Nutrition Education Campaign VAD prevalence : 32.9 % Conclusion : VAD among poor school children is a public health problem MOE- 2nd School Survey 2001-2002 - Part 2 (Al-Saafi Study) Approach : controlled interventional study (3 study groups) VAD prevalence : 35.3 % Effective supplementation : daily snack + one VA capsule (200000 i.u.) Conclusion : A National Vitamin A Program in Jordan should phase in. December 2002 : The Royal Philanthropic Gratuity-1 The Royal Philanthropic Gratuity developed after a royal visit of HM King Abdullah II to the MOE and being informed of the VAD story. HM expressed his wish to see vitamins / minerals tablet supplements reaching all school children. Multivitamin/mineral tablet supplementation started early 200 2002 : North Badia Survey ( Population : U5y Beduin children) Prevalence rates of : stunting H" 20% anaemia H" 19 % non-ocular VAD H" 22% 2002 : The Wheat Flour Fortification Program The Nicosia - EMRO  Workshop in February, 2002 National- wheat flour- fortification program started in May, 2002 Fortificants: iron and folate Early 2003 : Jordan Population and Family Health Survey (DoS-DHS) Anaemia prevalence in children (age group U5y) : 34 % Anaemia prevalence in infants (age group 10-11 months) : 65% Early 2003 : NNS (MOH National Nutrition Study of U5y Children) Anaemia = 20.1 %.(Hb <11 g/dl) Iron deficiency (ID) = 26.1 % Iron deficiency anaemia (IDA) = 10.1 % VAD prevalence = 15.2 % Late 2003 - West Bank & Gaza Nutrition Survey : A Meaningful Finding VAD Prevalence H" 22% in U5y children The Royal Philanthropic Gratuity-2 HM King Abdulla II expressed his wish to see the SSP extending so that it reaches to all young school children. Vitamin/mineral fortified biscuits shall be replacing the Multi-VM tablet supplements starting from January 2006. VAD and IDA have triggering social components. VA status and anaemia have been found to be always correlated with: i) Maternal nutrition education ; ii) Consumption of animal based food, and ; iii) Family socio-economic status. Frontline - MCH - service providers should stress . exclusive breast-feeding, complementary feeding, good diet during pregnancy, vitamin A and IFA supplements, training of community- (in-field) - volunteers. In JordanMNDs are No Longer a Hidden Hunger Secondary PEM (s-PEM) is common ; MNDs are the major causes Stunting: remains the devious face of s-PEM Vitamin A, Iron, and Zinc deficiencies : endemic Anaemia due to IDA and / or VAD : prevalent Ongoing Combat Programs: i) Iodination of Table Salt (started 1996) ii) Wheat Flour Fortification : (Iron and Folic acid started 2002) 2005 : Recommendation of the National High Commission on Nutrition in Jordan: Jordan needs switching from tablet supplement distribution to a new program of food (flour) fortification to secure higher coverage for other risk groups. The shortcoming in the governmental planning for the program is the disregard of the importance of impact assessment studies. Minor consideration is generally given to the need for before / after assessments. The planner has a focused attitude on the importance of budgeting for launching the program without realizing that any interventional act has to be evaluated by the cost-benefit analysis. The urgent ambitions include.. Checking whether VAD affects women in the reproductive age Elimination of VAD as a health risk factor (i.e., to reach a point where only < 5% of the age group 6-71 months to have low serum retinol (< = 0.70 mol/L) . Exploration of unrecognized MNDs : There is an immediate need for studying the B12 status of the Jordanian population. Childhood Nutrition : Concerns and Policies Policies and Child Nutritional Problems A nutritional disorder is more than an individuals health issue. It should be recognized as leading to dysfunction in social, demographic, and cultural sectors: economy : decreased manpower productivity burden on health care system Nutrition Surveillance System (NSS) is a need Strategic Resources: Qualified Health-Manpower Efficient MCH-Care Centers Sustainable Flow of supplements Immediate - Public Health Needs in Jordan There is no need for building fancy hospitals to tackle public health challenges Building a delivery system that reaches the community is a strategic need The first tool is capacity building and training On the part of practicing physicians and health- planners, there is an urgent need for better understanding of the significance of the micronutrient-deficiencies (MNDs) hitting in childhood. There is a particular importance in becoming aware of: The main MNDs prevalent in the Kingdom Iodine Deficiency Disorders (IDD) Goiter, and Cretinism (which is associated mental deficiency) Iron Deficiency Anaemia, IDA, and the associated - impaired learning Non-ocular VAD, and its association with the depressed immunity: infections / diarrhea & ARI physical growth deficiency predisposition to IDA sad ending with visual impairment followed by nutritional blindness The common outcomes of MNDs on health Frequent diarrheas and infections / suppressed immunity Stunting / Subnormal child growth pattern Low IQ / compromised cognitive development Poor performance / school achievement Weak muscles / decreased work potential Anaemia / reduced physical and mental potential Increased risk of death Conclusive Remarks Undernutrition in the Middle East is still ignored by those who should care more. Recognition of undernutrition in the East Mediterranean countries as a community-threatening risk is still inadequate. Planners have little recognition that no single developing community may claim to be off the hook of malnutrition. It is not fully clear to all those concerned that undernutrition particularly strikes at the high risk groups' level. International scientific bodies and expertise can play a key role to help bridging the awareness-gap between the concerned parties: the who know and who do not know. References McLaren DS, Shirajian E, Tchalian M, and Khoury G. Xerophthalmia in Jordan. Am J Clin Nutr 1965; 17: 117-130. The Interdepartmental Committee on Nutrition for National Defense, and the Inter-departmental Committee on Nutrition for Jordan. The ICNND-ICNJ nutrition survey on infants and preschool children in Jordan (1962-63). US Government Printing Office,1964. Khatib I, and Hijazi S. JUST-Percentiles: a cross-sectional study of the declination observed in the Jordanian child growth curve and its association with the infant weaning patterns. Jordan University of Science & Technology (JUST)-Publications,1992, Irbid-Jordan . Khatib I, Hijazi S, and Aggett P. A longitudinal -interventional-study of the impact of zinc fortified weaning food on linear growth of infants in northern Jordan. The Higher Council for Science and Technology Publications,1995, Amman-Jordan. The IDD National Committee: Iodine Deficiency in Jordan,1995 . A national baseline study. Report of UNICEF office-Amman, 1995. The IDD National Committee: Iodine Deficiency in Jordan, 2000. A national baseline study. Report of UNICEF office-Amman, 2000. Khatib I. High prevalence of subclinical vitamin A deficiency in Jordan: a forgotten risk Food Nutr Bull., September 2002, 3; 23 (Supp. 228-236). %&:;CDEGHPZ\gį{pV?V*)h)hB*CJOJQJ^JaJph,h;N69B*CJOJQJ]^JaJph2h)h69B*CJOJQJ]^JaJphh)h4uCJaJhCJaJh4uCJaJ#hNyh4u6B*CJ]aJph#h;Nh4u6B* CJ]aJph)h;Nh4u56B* CJ\]aJphh)hCJaJ2h)h59B*CJOJQJ\^JaJph,h4u59B*CJOJQJ\^JaJph%&EFGHhi|x$ & F 7A$gd$ & FA$^`gd$ & F hA$gd$ & F A$^gd $A$a$gd4u$A$gd$qA$^qa$gd4u$qA$^qa$gd2 sghi| 5 N  & 3 * F R 4 8 p ޲޲ކxllކxllކ޲h)hCJH*aJh)h5CJ\aJ h)h56CJ\]aJ5h)h59>*B*CJOJQJ\^JaJphh)h6CJ]aJ;h)h569>*B*CJOJQJ\]^JaJphh)hCJaJ,h)h9B*CJOJQJ^JaJph! 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Poverty Linked vitamin A deficiency (VAD) in Jordan is endemic and coupled with compromised vitamin E Status. ( A report submitted to the MOE in 2002; currently under-modification for publication ). Khatib I . Supplementation with vitamin A capsules along with iron fortified school meals can have positive impact on the growth of young school children: a controlled trial. (An abstract orally presented in the X Auxology Congress , Florence-Italy , July 4-7, 2004) Khatib I and Hijazi S. Nutritional status of the U5- years beduin children. A study report submitted to the Jordanian sponsor, the Badia Development Program, HCST, December 31,2003 . Department of Statistics. The 2002 Jordan Population and Family Health Survey. The ORC Macro Publications,2003. The National Committee on Micronutrients. The year 2003 National Nutrition Study of Anaemia and VAD. MOH Publications, 2003.  ssh)hAICJaJ6&P 1h:pS?. 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