By Gemiliano DL. Aligui, MD, MPH, PhD
Historically, night blindness has been the earliest description of vitamin A deficiency in the 18th and 19th centuries. Today, micronutrient deficiencies still exist as a major health problem not only among children but also in adults. In the Philippines, anemia (iron/B12 deficiencies), in the last 26 years (1990-2016), has declined very little from about 45.7 percent to 30.3 percent, among women of reproductive age. Currently, about half a million pregnant and lactating Filipino women have vitamin A deficiency. Among preschool children VAD has increased from 15.2 percent in 2008 to 20.4 percent in 2013 (FNRI-NNS), representing about 2.1 million Filipino children, from six months to five years old having the burden of deficiency. Worldwide, the condition is estimated to be 190 to 250 million preschool children, based on the World Health Organization reports in 2009 and 2012. The Global Hidden Hunger Index, which roughly measures micronutrient deficiency, places the Philippines in the moderate category (30.7).
Among the most vulnerable segments of the population, women and children are at greatest risk of decline in immune defenses against diseases, while children would also suffer from blindness. VAD is due to the lack of vitamin A in the diet; a vicious cycle of VAD and decreased appetite, which brings about inability of the body to absorb vitamin A, will further aggravate the deficiency. If left untreated, VAD will result into permanent blindness, partial or total. The problem of VAD is not only biological (physical body) but also economic, affecting the community and society. It impacts on human development and productivity. According to the United Nations Children’s Fund Study on the Economic Burden of Malnutrition in the Philippines (2016), there are 1,840 childhood deaths per year associated with VAD. This translates to projected cost or economic burden due to malnutrition of more than $4.65 billion annually and contributing to the overall burden of about $33 million. As a factor of the total GDP, childhood undernutrition is impactful to combined cost of education and productivity losses, amounting to 2.84 percent and, in 2013, this is about P328 billion.
More than a decade ago, there were two breakthroughs in the control and prevention of VAD, these are direct oral supplementation of vitamin A (Patak Vitamin A, Garantisadong Pambata) to counteract dietary deficiency, and the fortification of commonly consumed food (Sangkap Pinoy). However, these have less long-term effects due to the need of providing a steady supply of vitamin A in a diversified diet. This is problematic since current data show that our diet is below the standard diversity to provide the micronutrient needs. Due mainly to poverty, most families are not able to purchase the right food rich in nutritional value. Operationally, implementing public health interventions in an archipelagic geography, with wide community dispersal, limits the reach of programs nationwide. Given the increasing population, the solution should seriously consider the sustainability and availability of micronutrients in the main staple diet, while improving the supply and increasing the consumption of affordable fruits, vegetables and food from animal sources. We made progress in vitamin A supplementation, which has reduced by 24 percent to 30 percent all-mortality causes in children less than five years old. With the current projection, vitamin A should be available enough to prevent 1.3-2.5 million deaths, among nearly 8 million late-infancy and preschool-age population. Not to mention the importance of prenatal nutrition, which can prevent neonatal and maternal morbidity and mortality associated with undernutrition, this appears to be the scope of the problem. Note that vitamin A is needed for fetal lung maturation, so if given adequately during pregnancy, can potentially reduce lung diseases in infants at birth and onwards.
What is needed is a sustainable food-based intervention to deliver beta-carotene and/or vitamin A. The novel approach is to create a way to provide a steady supply of nutrients, particularly to those at risk; food that can improve the poor dietary diversity score of vulnerable population groups. Beta-carotene and vitamin A delivery within the Filipino diet should be steadily available. There are two ways to look at the diet as a function of vitamin A supplementation: increase vitamin A content of animal products, improved maternal nutrition—particularly breast feeding, and increase the content of pro-vitamin A (beta-carotene) in vegetables and grains. Will these cause any untoward effects? Technically or biologically not; our experience in population intervention from fortified food, such as “Sangkap Pinoy,” as vitamin A was made available in most consumed food, showed that it has approximated natural food. One possibility is biofortification using carotenoid (beta-carotene) for population with low consumption of animal products, and for this example, the simulated model, given the proper selection on food consumption pattern, the projection showed that about 55 percent to 60 percent reduction in the prevalence of VAD can be achieved in women and about 30 percent reduction of VAD in children for the Philippines. Thus, we need to be proactive in nutritional interventions; we can even reduce stunting in the long term, which is a problem we have been trying to solve for more than 10 years. We can make a difference in our intergenerational health through our “epigenes” by making our nutrition right.
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The author is the vice president for Academic Affairs at the University of the East Ramon Magsaysay Memorial Medical Center Inc.
E-mail: gdlaligui@gmail.com.