IMPLICATIONS OF
RESEARCH FINDINGS FOR
PROGRAMS TO REDUCE
MICRONUTRIENT
DEFICIENCIES
December 10, 2003
The USAID Micronutrient Program
PLEASE TAKE NOTE
n
n
The “FINDINGS” cited in the following
slides summarize results reported in
the literature
The “IMPLICATIONS” cited reflect the
views of MOST, not the views of the
authors responsible for the findings
The USAID Micronutrient Program
VITAMIN A
© Royalty Free Clip Art
The USAID Micronutrient Program
MODELS FOR VITAMIN A
SUPPLEMENTATION
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FINDING: Sustained high coverage with
vitamin A supplements in children 6 to 59
months of age is best achieved through
“Child Health Weeks”
n
IMPLICATION: In countries with high
prevalence of vitamin A deficiency,
consideration should be given to models
based on periodic, “active” distribution of
vitamin A supplements
Source: Presentation by Ruth Harvey at IVACG, February 2003. (Complete paper will appear on
MOST web site shortly.)
The USAID Micronutrient Program
VITAMIN A FROM DARK GREEN
LEAFY VEGETABLES
n
n
FINDING: The rate of conversion of βcarotene to retinol in fruits and vegetables
is lower than once thought (1:12 from fruits
and -carotene; and 1:24 from other
carotenoids and leaves)
IMPLICATION: Young children cannot eat
enough fruits and vegetables to meet their
vitamin A requirements limiting the
effectiveness of dietary diversification as a
means of delivering vitamin A
Source: Clive E. West and Ans Eilander, Bioefficacy of carotenoids in the Sight and Life
Newsletter, Feb 2000.
The USAID Micronutrient Program
WHEAT FLOUR FORTIFIED WITH
VITAMIN A
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FINDING: Fortification of wheat flour with
vitamin A (35% of RDA) is efficacious.
n
IMPLICATION: Countries considering wheat
flour fortification should not limited the
components of the pre-mix to iron, folic
acid and b-vitamins
Source: Rahman AS, et. al. Randomized, Double-blind Controlled Trial of Wheat Flour (Chapatti)
Fortified with Vitamin A and Iron in Improving Vitamin A and Iron status in Healthy, School Aged
Children in Rural Bangladesh. Report submitted to MOST, May 2003
The USAID Micronutrient Program
VITAMIN A IN PREGNANCY
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FINDING: Maternal deaths in malnourished
pregnant women in Nepal were reduced by
49% from weekly low-dose vitamin A
supplements (7000 µg of retinol equivalents)
n
IMPLICATION: Weekly supplementation could
have a major effect on mortality in pregnant
women in developing nations. Low-dose
supplementation of pregnant women with
night blindness is worthy of consideration.
Source: West, KP et al. Double blind, cluster randomised trial of low dose supplementation with
vitamin A or beta carotene on mortality related to pregnancy in Nepal. BMJ. 1999 Feb
27;318(7183):570-5.
The USAID Micronutrient Program
VITAMIN A IN NEONATES
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FINDING: In India, vitamin A supplements
(24,000 IU) to newborns within 48 hours of
birth reduced early infant mortality by 22%
and in Indonesia neonates given vitamin A
(50,000 IU) were 64% less likely to die in
infancy
n
IMPLICATION: Neonatal supplementation
may improve health and survival in the first
months of life, but evidence from other
trials varies. Further study is needed
Sources: 1Rahmathullah L, et al. Impact of supplementing newborn infants with vitamin A on
early infant mortality: community based randomised trial in southern India. BMJ. 2003 Aug
2;327(7409):254. 2Humphrey JH, et al. Impact of neonatal vitamin A supplementation on infant
morbidity and mortality. J Pediatr. 1996 Apr;128(4):489-96.
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IRON AND FOLATE
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IRON AND CHILD DEVELOPMENT
n
FINDING: Increasing evidence that iron
deficiency in children impedes
development and that supplementation can
reverse delays
n
IMPLICATION: Safe and effective public
health interventions are needed to address
iron deficiency in children
Sources: 1Lozoff B, et al. Behavioral and developmental effects of preventing iron-deficiency
anemia in healthy full-term infants. Pediatr. 2003 Oct;112(4):846-54. 2Algarin C, et al. Iron
deficiency anemia in infancy: long-lasting effects on auditory and visual system functioning.
Pediatr Res. 2003 Feb;53(2):217-23. 3Stoltzfus RJ, et al. Effects of iron supplementation and
anthelmintic treatment on motor and language development of preschool children in Zanzibar:
double blind, placebo controlled study. BMJ. 2001 Dec 15;323(7326):1389-93. 4Idjradinata P,
Pollitt E. Reversal of developmental delays in iron-deficient anaemic infants treated with iron.
Lancet. 1993 Jan 2;341(8836):1-4.
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IRON AND GROWTH
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FINDING: In India, iron supplementation
supported growth in iron-deficient children,
but delayed growth in iron-replete children
(Growth delay is believed to result from
excess iron competing with zinc
absorption)
n
IMPLICATION: Iron supplementation for
children is not necessarily a magic bullet
Source: Majumdar I, et al. The effect of iron therapy on the growth of iron-replete and iron-deplete
children. J Trop Pediatr. 2003 Apr;49(2):84-8.
The USAID Micronutrient Program
IRON SUPPLEMENTATION
PROTOCOLS
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FINDING: Among lactating women in
Ethiopia, weekly and daily supplementation
had comparable effects on iron status and,
in India, weekly supplementation was
effective for anemia prevention
n
IMPLICATION: Intermittent (non-daily)
supplementation is an option to be
considered
Sources: 1Haidar J, et al. Daily versus weekly iron supplementation and prevention of iron
deficiency anaemia in lactating women. East Afr Med J. 2003 Jan;80(1):11-6. 2Agarwal KN, et al.
Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.
Indian Pediatr. 2003 Apr;40(4):296-301.
The USAID Micronutrient Program
REDUCED IRON AND FORTIFICATION
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FINDING: Iron bio-availability in foods
fortified with reduced iron compounds is
low
n
IMPLICATION: Although reduced iron is
inexpensive and its organoleptic properties
are good, it is not a viable option in
fortification. More expensive compounds
should be considered
Sources: 1Hernandez M, et al. Iron bioavailability and utilization in rats are lower from limetreated corn flour than from wheat flour when they are fortified with different sources of iron. J
Nutr. 2003 Jan;133(1):154-9. 2Swain JH, et al. Bioavailability of elemental iron powders to rats is
less than bakery-grade ferrous sulfate and predicted by iron solubility and particle surface area.
J Nutr. 2003 Nov;133(11):3546-52. 3Alvarado M, De Leon LF, Dary O. Technical and economical
evaluation of wheat flour fortification with different iron compounds. Nutrition Institute of Central
America and Panama (INCAP), unpublished report.
The USAID Micronutrient Program
FORTIFICATION VEHICLES-1
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FINDING: Cereal fortification may improve
iron intake but evidence of general
effectiveness is still lacking
n
IMPLICATION: Cereal fortification is not a
“magic bullet” for addressing iron
deficiency in children
Sources: SUSTAIN Guidelines for Iron Fortification of Cereal Food Staples.
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FORTIFICATION VEHICLES-2
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FINDING: A study in Chile found that just
3% of infants fed iron-fortified milk (ferrous
sulfate + ascorbic acid) were anemic versus
26% of those fed non-fortified milk
n
IMPLICATION: In some cultures, milk
fortification may be a viable vehicle for
fortification to reduce iron deficiency
Sources: Source: Olivares M, et al. Prevention of iron deficiency by milk fortification. The Chilean
experience. Acta Paediatr Scand Suppl. 1989;361:109-13.
The USAID Micronutrient Program
FORTIFICATION VEHICLES-3
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FINDING: Fortified fish/soy sauce
(NaFeEDTA) found acceptable, efficacious
in Vietnam and Thailand
n
IMPLICATION: In some cultures, foods such
as fish/soy sauce may be viable vehicles for
fortification to reduce iron deficiency
Sources: Chavasit V, et al. Combating iodine and iron deficiencies through the double
fortification of fish sauce, mixed fish sauce, and salt brine. Food Nutr Bull. 2003 Jun;24(2):200-7.
Thuy PV, et al. Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and
reduces the prevalence of anemia in anemic Vietnamese women. Am J Clin Nutr. 2003
Aug;78(2):284-90.
The USAID Micronutrient Program
FORTIFICATION VEHICLES
GENERAL COMMENTS
n
Despite all of the attention given to food
fortification as a result of the creation of the
Global Alliance for Improved Nutrition and
the Flour Fortification Initiative, it is not an
immediate cure all for iron deficiency.
n
The selection of appropriate vehicles for
fortification should be determined by a
careful review of local conditions and
consumption patterns.
The USAID Micronutrient Program
IRON SPRINKLES
n
FINDINGS: In Ghana, sprinkles were shown
to be as effective as the standard therapy in
treating anemia and, in Zambia, iron+zinc
sprinkles did reduce anemia but did not
improve zinc status or catch-up growth in
infants
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IMPLICATION: Sprinkles is a promising
intervention with high acceptance rates and
proven efficacy but cost may be a major
constraint
Sources: 1Zlotkin S, et al. Treatment of anemia with micrencapsulated ferrous fumarate plus
ascorbic acid supplied as sprinkles to complementary (weaning) foods. Am J Clin Nutr 2001;
74: 791-5. 2Zlotkin S, et al. Home-fortification with iron and zinc sprinkles or iron sprinkles
alone successfully treats anemia in infants and young children. J Nutr. 2003 Apr;133(4):107580.
The USAID Micronutrient Program
FOLIC ACID AND NEURAL TUBE
DEFECTS
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FINDING: Incidence of neural tube defects in the
U.S. has declined by almost 20% since folic acid
fortification began in 1998 and preliminary data
from Chile show a decline in NTDs of 31% in
2000-01 following wheat flour fortification
n
IMPLICATION: Fortification with folic acid is
effective in preventing NTDs and should be given
due consideration in flour fortification programs
Sources: 1Green NS. Folic acid supplementation and prevention of birth defects. J Nutr.
2002 Aug;132(8 Suppl):2356S-2360S. 2Castilla EE, et al. Preliminary data on changes in
neural tube defect prevalence rates after folic acid fortification in South America. Am J Med
Genet. 2003 Dec 1;123A(2):123-8.
The USAID Micronutrient Program
ZINC
© US Agricultural Research Service
The USAID Micronutrient Program
ZINC AND VITAMIN A
INTERACTIONS
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FINDINGS: Zinc deficiency impairs vitamin A
transport and bioconversion and zinc
supplementation alone improved vitamin A
status in some studies
n
IMPLICATION: Adding zinc is likely to
increase the effectiveness of VA
supplementation
Source: 1Noh SK and Koo SI. Low zinc intake decreases the lymphatic output of retinol in rats
infused intraduodenally with beta-carotene. J Nutr Biochem. 2003 Mar;14(3):147-53. 2Munoz
EC et al. Iron and zinc supplementation improves indicators of vitamin A status of Mexican
preschoolers. Am J Clin Nutr. 2000 Mar;71(3):789-94.
The USAID Micronutrient Program
ZINC AND DIARRHEAL DISEASE
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FINDING: WHO declared zinc to be safe and
efficacious for treating acute watery
diarrhea in children and recommends 20 mg
doses given over 7 to 10 days to reduce the
severity and duration of a diarrhea episode
n
IMPLICATION: Diarrheal disease control
efforts should incorporate zinc
supplementation
The USAID Micronutrient Program
ZINC AND PNEUMONIA
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FINDINGS: In a pooled analysis of trials, zinc
supplementation reduced the incidence of
pneumonia infection by 41% and daily zinc
supplementation reduced the incidence of
pneumonia in Delhi children ages 6 to 30 months
given vitamin A
n
IMPLICATION: Zinc reduces the incidence of
pneumonia but zinc in combination with vitamin A
may be more effective than the administration of
either micronutrient alone.
Sources: 1Bhutta ZA, et al. Prevention of diarrhea and pneumonia by zinc supplementation in
children in developing countries: pooled analysis of randomized controlled trials. J Pediatr.
1999 Dec;135(6):689-97. 2Bhandari N, et al. Effect of routine zinc supplementation on
pneumonia in children aged 6 months to 3 years: randomised controlled trial in an urban slum.
BMJ. 2002 Jun 8;324(7350):1358.
The USAID Micronutrient Program
ZINC AND GROWTH
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FINDINGS: Although the evidence is
inconsistent, a meta-analysis concluded
that zinc supplementation produced
significant, positive responses in child
growth
n
IMPLICATION: Interventions to improve
children's zinc status should be considered
in some populations with high rates of
protein-energy malnutrition
Source: Brown KH, et al. Effect of supplemental zinc on the growth and serum zinc concentrations
of prepubertal children: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2002
Jun;75(6):1062-71.
The USAID Micronutrient Program
For more information
Contact MOST at most@istiinc.com
or visit www.mostproject.org.
The USAID Micronutrient Program