Ahmed_Program Considerations for Calcium Supplementation
Transcript of Ahmed_Program Considerations for Calcium Supplementation
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Program Considerations for Calcium
Supplementation
Dr Tahmeed AhmedDirector, Centre for Nutrition &Food Security, ICDDR,B
Professor, Public Health NutritionJames P. Grant School of PublicHealth, BRAC University
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PE affects 7-10% pregnancies, rates higher in
India
Malnutrition, inadequate dietary intakes?
Villar J, et al. Int J Gynae Obstet, 2004
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Bioavailability of Calcium from Different Foods
is a Key Factor
Food Serving size(g)
Calciumcontent
(mg)
Fractionalabsorption
%
Estimatedabsorbable
calcium/
serving(mg)
Servingsneeded to
equal to 1
cup of milk
Milk or 1
cup yogurtor 1.5 oz
cheese
260 300 32 96 1
Beans, dried 177 50 16 8 12
Kale 65 47 59 28 4
Spinach 90 122 5 6 16
Tofu,
Calcium set126 258 31 80 1
Adapted from Weaver, CM, et al., AJCN 70:543S-8S.,1999
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254
159
88.1
68.7 61.8
40.928.7
16
0
50
100
150
200
250
300
Consumptionof
MilkProducts
(Kg/Capita/year)
Consumption of Milk Products
Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008
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962
879
400
211200
0
200
400
600
800
1000
1200
United States Egypt China India Bangladesh
CalciumIn
take
(meanintakein
mg/day)
Calcium intake in Countries
Bhatia 2008, He Y 2007, Darwish 2009, Islam MZ 2003, Wang Y 2008
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Pirgacha
Trishal
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Daily Calcium Intake of Women in
Pirgacha and Trishal, Bangladesh
Age (years) Daily calciumintake (mg)
Pirgacha(n=240)
26.26.7 157 (103, 227)
Trishal(n=236) 29.6
8.8 144 (97, 226)
Islam M, Ahmed T, et al. Unpublished
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The Lancet Series on Maternaland Child Undernutrition
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Interventions with Sufficient Evidence to
Implement in All Countries
Maternal and BirthOutcomes
Iron folate
supplementation Maternal supplementsof multiple micronutrients
Maternal iodine throughiodization of salt Maternal calciumsupplementation Interventions to reducetobacco consumption orindoor air pollution
Newborn Babies
Promotion ofbreastfeeding(individual and groupcounseling)
Infants and Children
Promotion ofbreastfeeding (individual
and group counseling) Behavior changecommunication forimprovedcomplementary feeding Zinc supplementation Zinc in management ofdiarrhea Vitamin A fortification orsupplementation Universal salt iodization Hand washing orhygiene interventions
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13 trials involving 15,730 women
Randomized trials comparing at least 1 g daily
of calcium with placebo
Hofmyer GJ, et al. Cochrane Collab 2011
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Hofmyer GJ, et al. Cochrane Collab 2011
Risk of hypertension reduced with Ca, RR 0.65
(0.53-0.81)
Risk of PE reduced, RR 0.45 (0.31-0.65)
Among low Ca consumers, RR 0.36 (0.2-0.65)
Pre-term birth reduced, RR 0.76 (0.6-0.97)
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Belizan JM, Villar J. Am J Obs Gynecol 1988
Reduced serum Ca
Parathormone & renin
Vascular Intracellular Cain smooth muscle
Vascular resistance &vasoconstriction
Poor Calcium intake
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What is the way forward for introduction and
implementation of calcium supplementation?
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Calcium Supplementation: Early Introduction
Policy &Financing
SBCCstrategy
Pre-
service/in-servicetraining
Clinicalcoverage
Local evidence
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Guidance on Calcium from Exercise:
Early Introduction
Advocate with policy makers using global evidence
Separate national policy or streamline into clinicalguidelines
Develop advocacy plan/ strategy to reduce PE/E Cost deliver calcium in a cheap way; work with
manufacturers to reduce cost
Training of volunteers and health workers Logistics part of essential and national drug list,
supported by USAID, UNICEF, WHO
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Raise awareness of community health workers
Develop IEC materials (benefits to child, lower riskof PE/E)
Carry out social marketing for calcium
Address misperceptions of health workers aboutcalcium
Product compliance, feasibility
Guidance on Calcium from Exercise:
Early Introduction
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Inform prior to pregnancy the benefits of Casupplementation (adolescents, newly weds)
Generate country-specific information on Cadeficiency and intake
Track through monitoring and evaluation
Develop public/private partnerships
Guidance on Calcium from Exercise:
Early Introduction
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Conduct formative research on practices andunderstanding of PE/E; BCC strategy
Develop different formulations of calciumthrough research
Research interactions between calcium and iron,currently testing pill with both calcium and iron
Research on optimal dose of calcium (500 mg?)
Guidance on Calcium from Exercise:
Research
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Next Steps
Fill out country-level maps in your country
MCHIP to follow-up in 3 months on calcium
introduction maps