1. First Global Conference on Biofortification
November 10th, 2010
Keith P. West, Jr., Dr.P.H., R.D.
Center for Human Nutrition
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland, USA
kwest@jhsph.edu
How Biofortification Fits into (Malnutrition)
Interventions to Reduce Micronutrient
Deficiencies
2. My Biofortification Vote
Day dream believer
Daily believer
Weekend (Fri, Sat or Sun) believer
Healthy skeptic
Agnostic
Bio-atheist
3. My Biofortification Vote
Day dream believer
Daily believer
Weekend (Fri, Sat or Sun) believer
x Healthy skeptic
Agnostic
Bio-atheist
4. Treat night blindness
with roasted oxen liver
Old Kingdom pyramind
at Sakura: Depicts
night blindness
Night blind pregnant
Woman in Nepal, 2000
6. World History of Micronutrient
Deficiency
World up to early 20th C
Deficient
Deficient
(biofortify)
Sufficient
(fortified)
World from mid-20th C
to new Millennium
14. 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”
15. 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
16. 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
17. Iron Prevents Iron Deficiency and
Consequent Anemia
Anemia
Iron
deficiency
IDA
Hookworm
Malaria
HIV/AIDS
Anemia of Inflammatory Conditions
Other vitamin deficiencies
IDA= iron deficiency
anemia
18. Modern Salt Iodization in China
1995
Per cent
< 60
60 - 80
80 - 90
>= 90
Missing Data
19971999
27. Prevents corneal blindness
and milder xerophthalmia
Normalized epithelia, immunity,
less severe morbidity, reduced
anemia
Tissue and plasma
repletion
Dietary adequacy
VA Deficiency Expect to Respond to Biofortification
Return/
protect
function
Expect to
Respond
Expect to respond
use to assess
effect
Partially
addresses
underlying
dietary risk
28.
29. Data Collection Activity Purpose
Baseline 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 estimate
dietary 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 conditions
biofortified 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
30. Prepared by Nina Series for the ACC-SCN of the UN -appointed
Commission on the Nutrition Challenges of the 21st Century, 1998
31. 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
um
ol/L
Iron
<8.95
um
ol/L
Copper <11.8
um
ol/L
Folate
<6.8
nm
ol/L
B12
<147.7
pm
ol/L
B6
<20
nm
ol/L
Riboflavin
<11.3
nm
ol/L
Vit E
<10
um
ol/L
Vit D
<25
nm
ol/L
%
Jiang et al, J Nutr 2005
32. 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;362:1784
Massaro D NEJM 2010
33. Antenatal Iron+Folic Acid Supplementation and
Child Mortality to 7 Years of Age, Nepal
Christian P et al Am J Epidemiol 2009
34. Antenatal Folic Acid Supplementation and Kidney
Function in Children ~7 Years of Age, Nepal
Stewart CP et al J Nutr 2009
36. Summary Thoughts
• Micronutrient deficiencies reflect a diet
quality problem of poor populations that
remains to be been solved: Biofortification
addresses 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”
37. 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.
39. Hidden Hunger = low nutrient density
imbalanced nutrient densities
chronic micronutrient inadequacy
MDG #1: Eradicate
Severe
Hunger
MDG 4 & 5:
Reduce Child &
Improve Maternal
Health
--------HealthConsequence-------
Less
Known
Well
Known
Micronutrient deficiencies:
Depleted nutriture
Altered 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-acting
HealthConsequences
