Micronutrient Deficiencies

Shuchi Kapoor, Cabul Mehta

Revised October 16, 2009

Vignette

Jean-Wesley Nelson, aged 18 months, arrived at the clinic in Haiti with his mother after a three and a half hour walk.  He was quickly diagnosed with severe "kwashiorkor," and the skin on the back of his leg was beginning to peel off due to lack of nutrients.  Upon further evaluation, the attending physician learned that Jean-Wesley had been “mix fed” at the age of two months. His “Road to Health” chart showed one dose of DPT administered and a BCG, but he had not yet received a capsule of Vitamin A.  Jean-Wesley's family drinks from the only spring in the area, from which all the animals in the area drink as well.  Thankfully, one week of treatment with vitamins, powdered milk, and black bean sauce completely resolved Jean-Wesley's swelling; however, at just 11 pounds, he still has a lot of growing to do. 

 

Introduction

 

What exactly is a micronutrient? According to the World Health Organization (WHO), micronutrients are named as such because they are needed only in very small amounts, and these substances are the ‘magic wands’ that enable the body to produce enzymes, hormones, and other substances essential for proper growth and development.  In global public health terms, iodine, vitamin A, and iron are among the most important micronutrients (WHO, Micronutrients).

 

Interest in micronutrients has increased substantially over the past few years, mainly due to the realization that micronutrient malnutrition contributes to a large proportion of the global burden of disease (Allen et al., 2006).  Micronutrient deficiencies are among the most prevalent health problems in the world today.  The World Health Organization estimates that at least 2 billion people worldwide are deficient in vitamins and minerals necessary for health, including Vitamin A, iron, iodine, and zinc.  The problem is particularly severe among children and lactating or pregnant women in developing countries.  It is estimated that 250 million preschool children are vitamin A deficient (WHO, Micronutrient Deficiencies, Vitamin A Deficiency). Deficiency in key micronutrients increases the risk of infection and death.  Individuals become more susceptible to diseases like measles, malaria, diarrhea and pneumonia, the primary causes of death among children under 5 in the developing world.

 

Each year, micronutrient deficiencies lead to millions of hours of lost productivity and to severe morbidity and mortality, encompassing disorders as diverse as blindness, mental retardation, severe exhaustion, and decreased immunity.  The World Bank estimates that the total annual cost of micronutrient deficiencies amounts to 5% of the gross national product (GNP) of developing countries. WHO estimates that 250 000 to 500 000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight (WHO, Micronutrient Deficiencies, Vitamin A Deficiency). Interventions, on the other hand, might cost only 0.3% of these nations’ total GNP (McGuire & Galloway, 1994).

 

The most prevalent micronutrient deficiencies in the developing countries today are from a lack of Vitamin A, iron, iodine and zinc and affect approximately one third of the world's population. Accordingly, this chapter will focus on these four micronutrients, discussing the epidemiology, causes, symptoms, consequences and interventions for these micronutrient deficiencies in detail.

A number of other deficiencies, including Vitamins B, C, D and folate, can also cause significant morbidity and mortality. The prevalence of such deficiencies is, however, not as common today as it was a few decades ago. The epidemiology of these deficiencies will be outlined briefly in this chapter.  Program management and new development techniques for improved nutrition will also be discussed. 

 

 

Epidemiology

As mentioned above, children and pregnant or lactating women are particularly susceptible to severe morbidity and mortality as a result of under nutrition.  In addition to increasing children's risk of death from infectious disease, micronutrient deficiencies also lead to complications of children's mental and physical development.  For this reason, UNICEF, WHO, and other organizations specifically target children aged 6-59 months (under 5 years), as well as pregnant and lactating mothers, for micronutrient supplementation in situations where available food resources cannot sufficiently supply the micronutrients necessary for basic health.

 

Micronutrient deficiencies are caused by a host of factors.  Chief among these factors is poverty.  Poverty is a clear contributor to malnutrition, as it inhibits access to food. In particular, poverty blocks its victims from foods rich in micronutrients, such as vegetables, fruits, or micronutrient-fortified foods.  Additionally, factors such as the level of education, climate, cultural practices related to food, food production, breastfeeding, and lack of access to quality health services can lead to deficiencies.  (Figure 1)

 

 

 

Figure 1: Direct and Indirect Causes of Malnutrition/Micronutrient Deficiencies (Muller)

Just as micronutrient deficiencies can lead to increased susceptibility to infectious diseases, infectious disease can also contribute to micronutrient deficiencies since the body requires increased micronutrients when combating disease.

 

Vitamin A

Worldwide, between 140 and 250 million children suffer from Vitamin A deficiency (VAD).  The problem is particularly prevalent in Africa and Southeast Asia (www.who.int/nut/vad.htm). Primary VAD is usually caused by prolonged dietary deprivation, in particular lack of vegetables and animal products, and is particularly endemic in areas where rice is the staple food (Muller & Krawinkel, 2005).

 

Vitamin A is necessary for proper functioning of the immune system, as well as for eyesight.  Good sources of this vitamin include carrots, milk, spinach, mango and liver.  A lack of Vitamin A increases the risk of death from acute respiratory disease (ARI), diarrhea, and measles.  In addition, VAD is the leading cause of preventable blindness in children worldwide, and can cause growth retardation.  It also frequently leads to night blindness, particularly among pregnant women, and increases maternal mortality risk.   VAD may also be associated with increased risk of mother-to-child HIV transmission (www.who.int/nut/vad.htm, WHO International).

 

Unfortunately, VAD is often not recognized until a child is already experiencing severe effects such as blindness (xeropthalmia).  Once a child has progressed to this stage, his risk of death is high due to other conditions associated with VAD (http://www.iefusa.org/ sightreach_prevention.shtml).  Vitamin A deficiency can also be manifested through thickening of the skin, and hardening of the tissues of the lungs, gastrointestinal tract, and urinary tract (http://www.merck.com/mrkshared/mmanual/section1/chapter3/3b.jsp). 

 

Prior to the manifestation of symptoms, the best available way to measure Vitamin A deficiency is to measure food intake on a population level.  Helen Keller International has developed a food frequency method to analyze weekly consumption of Vitamin A-containing foods in various geographic areas (Sloan).  This method is both simple and inexpensive.  However, individual intake of Vitamin A can only be measured at present through laboratory assessments of plasma retinol levels.  Financial, logistical and technical restraints prevent most organizations from carrying out this type of diagnostic activity (www.merck.com/mrkshared/mmanual/ section1/chapter3/3b.jsp).

 

In developing countries, micronutrient deficiencies result not only in major negative biomedical outcomes, but also in negative social and economic consequences that add to the overwhelming challenges faced by these countries. Vitamin A deficiency is part of this cycle of poverty for developing countries.  However, with good vaccine programs, Vitamin A supplements can be distributed within an existing framework. An example of this important capsule support comes from the Micronutrient Initiative, who has helped to fully protect 210 million children against Vitamin A deficiency since 1997 through the provision of capsules to resource-poor settings (http://www.micronutrient.org/work2/childsurvival/supplement.asp).

 

According to the WHO, approaches to combating VAD should include short-term interventions and proper infant feeding which are backed up by long-term sustainable solutions.  Strategies could include a combination of breastfeeding and vitamin A supplementation, coupled with long-lasting solutions, such as promotion of vitamin A-rich diets and food fortification.  Since breastmilk is a rich natural source of vitamin A, the promotion of breastfeeding is the best way to protect babies from VAD.  However, since breastfeeding is time limited and the effects of supplementation capsules only last about 4-6 months, these are only initial steps.  This is where fortification comes in, which can help to maintain vitamin A status especially for groups at high-risk and needy families.  For vulnerable rural families, for example in Africa and SE Asia, cultivating and growing fruits and vegetables in home gardens is a complement to dietary diversification and fortification and contributes to improved lifelong health (WHO, Micronutrient Deficiencies, Vitamin A deficiency).

 

Several partnerships have developed to combat the problem of VAD.  In 1998, the Vitamin A Global Initiative was formed and its partners include the WHO, the Canadian International Development Agency, USAID, Micronutrient Initiative, the UK’s DfID, and UNICEF.  Activities under this initiative include supplementation in conjunction with other health interventions such as National Immunizations Days (NID); fortification of food staples, such as sugar; and nationwide supplementation for children, and post-partum or breastfeeding women.  Since 1998, these supplements have prevented an estimated 1.25 million deaths since 1998 in 40 countries (http://www.unicef.org/nutrition/index_iodine.html).

 

 

Iron

Iron deficiency is the world's most widespread nutritional disorder, affecting more people than any other condition.  It is especially prevalent in developing countries and among poor populations.  According to UNICEF, approximately 4-5 billion people worldwide are iron deficient, and about 2 billion people are iron deficient anemic (www.unicef.org/nutrition/index_iodine.html).  As iron deficiency progresses, it eventually becomes anemia, which can range from mild to very severe. With severe anemia, there can be multiple organ failures, as well as auditory and visual impairments. Almost all young children and pregnant women in developing countries have low body iron stores (WHO, 1999).

 

The primary cause of iron deficiency is a poor diet.  Many typical diets lack variety, making iron deficiency common.  Good sources of iron include meat, fish, eggs, whole grains, and green leafy vegetables.  Iron stores can also be depleted as a result of chronic parasitic infections.  Iron is necessary for the production of hemoglobin, myoglobin, and various enzymes; its lack can lead to anemia, fatigue, impaired development, reduced growth, physical strength, and physical activity, and even death.  Anemia also leads to increased risk of maternal hemorrhage and sepsis, and to premature and low birth weight babies.  Maternal anemia leads to anemia in the infant, which can then cause further complications (Muller, www.unicef.org/nutrition/index_iodine.html).

 

Because of the association of anemia with fatigue and decreased productivity, the WHO estimates that treatment for anemia in countries where rates are high could raise national productivity levels by an average of 20% (www.who.int/nut/ida.htm).  UNICEF also cites the influence of iron deficiency as a significant factor in economic productivity and general "quality of life" in developing countries (www.unicef.org/nutrition/index_iodine.html).  (Figure 2)

 

 

 

Figure 2: Percentage of estimated loss in gross national product (GNP) due to iron deficiency [Ross & Horton 1998 (24), Horton 1999 (56)]

 

The Micronutrients Initiative (MI) (a Canadian based NGO whose goal is to “eliminate vitamin and mineral deficiencies worldwide) develops innovative programs to improve populations' iron intake and reached 48 million people last year. MI has developed a number of innovative approaches, which include double-fortifying salt with both iodine and iron, and creating lozenges and home fortification mixes containing iron and other essential nutrients. MI also provides iron-rich vitamin and mineral mixes that can be added to foods that are distributed as part of emergency aid or through institutional feeding programs. MI supports and expands proven interventions, such as the fortification of wheat and corn flour with iron. They also advocate for and support flour fortification in developing countries.

 

 

Iodine

Despite the fact that humans require only small amounts of iodine, only 100-150 micrograms per day or 1 teaspoon throughout a lifetime, iodine deficiency is the leading worldwide cause of preventable mental retardation and brain damage (www.unicef.org/sowc98/fs03.htm; Levine, 2004).  Approximately 740 million people (13% of the world's population) suffer from the broad range of morbidities caused by iodine deficiency, which include goiter, stillbirths, stunted growths, thyroid deficiencies, and mental defects.  Of these 740 million people, it is estimated that 43-50 million people have experienced brain damage or physical impairment as a result of their deficiency.  Approximately 20 million people worldwide suffer brain damage resulting specifically from maternal iodine deficiency during pregnancy  (Muller).

 

Lack of iodine reduces production of thyroid hormone but stimulates production of the thyroid-stimulating hormone, leading to goiter (enlargement of the thyroid gland) and to growth retardation and cretinism (Muller).  Clinical signs of iodine deficiency, such as goiter and retardation, are easy to spot, but unfortunately are usually noticed only after irreversible effects have already occurred.  However, 'sub-clinical' iodine deficiency, in which children have lost up to 15 IQ points but have not experienced irreversible mental retardation, deafness or cretinism, can still be treated through increased iodine consumption (www.unicef.org/nutrition/index_iodine.html).

 

Studies have shown a general loss of IQ points throughout the population in areas where iodine deficiency is prevalent. This adversely affects school performance, decreases productivity, and places an enormous economic burden on nations.

 

Salt iodization continues to be one of the most cost-effective ways to protect against iodine deficiency. Adding iodine to salt costs between two and seven cents per kilogram, which is less than five percent of the retail price of salt in most countries (Levine, 2004). Via a new partnership with the World Food Programme, MI has focused its efforts on the six countries of the world most affected by iodine deficiency: India, Pakistan, Sudan, Ghana, Senegal, and Haiti (Micronutrient Initiative, Annual Report 2006-7).

 

Zinc

Zinc is essential for proper growth and immune system response, the production of many enzymes, and for the synthesis of RNA and DNA.  Precise prevalence estimates for zinc deficiency are unclear, but it is recognized as endemic in those areas where malnutrition is rampant.  Diets low in animal protein and high in refined grains like white rice and pasta often lead to a deficiency in zinc (Muller, 2005).

 

Studies show that zinc deficiency is an important cause of morbidity in children (Tontisirin et al). Zinc deficiency leads to growth retardation, immune suppression, and poor wound healing. It can also cause pregnancy complications and illness and death in childhood (Muller).  Zinc, as we have seen in an earlier chapter, is important for fighting diseases, particularly diarrhea.  It also must be present in sufficient quantities in order for the body to maximize the beneficial effects of Vitamin A (www.umm.edu/altmed/ConsModalities/Nutritioncm.html).

 

Daily supplementation with zinc at home has been shown to reduce infant mortality by 70% and it is now recommended treatment for diarrhea, along with oral rehydration therapy. There is little reported experience on delivery mechanisms suitable for large-scale interventions, except perhaps with multiple fortification (WHO/UNICEF, 2004).

 

Other Micronutrients

Other micronutrients that produce important health benefits include the B vitamins, Thiamine (B1) and Niacin (B3), Vitamin C, Vitamin D, and folate.  Though deficiencies in these micronutrients are not presently the cause of major public health problems, they can cause severe morbidity and mortality in individuals with deficiencies.  Table 1, below, outlines the basic epidemiology of these micronutrients.

 

Table 1.  Other Micronutrients: Basic Epidemiology

Nutrient	Function	Causes of deficiency	Clinical Presentation	Prevention and Management
Thiamine - Vitamin B1	- Carbohydrate metabolism	- 'Polished' rice & diets poor in whole grains, legumes, red meat - Exacerbated by hyperthyroidism, pregnancy, lactation, fever, diarrhea	- Wet beriberi: loss of appetite, vomiting, pallor, turning blue, weak pulse, coma - Dry beriberi: weakness, weight loss, paralysis of digits and limbs	- Light milling of rice - Drinking water in which rice was boiled - Consumption of whole grains, legumes, red meat
Niacin - Vitamin B3	- Hormone manufacture - Flushes harmful chemicals from body	- Poor diet - Diets with corn (very low in niacin) as staple food	Pellagra: - Skin reddening - Skin becomes thick & scaly, cracks & bleeds - Diarrhea - GI problems - Dementia	- Consumption of protein-rich foods - Vitamin B3 supplementation
Vitamin B12	- Bone marrow function - Neurological processes	- Poor diet - Alcoholism - Association with HIV/AIDS	- Loss of appetite, fatigue, numbness/ tingling of hands and feet	- Consumption of animal products
Vitamin C	- Protects skin & gums - Protects against disease - Promotes healing - Increases iron absorption	- Poor diet - Diarrhea - Exacerbated by pregnancy and lactation	- Scurvy: Irritability & weakness, rough skin, shortness of breath, swollen joints & gums, anemia, slow wound healing	- Improved cooking methods - Kitchen gardening - Consumption of fruits and vegetables - Breastfeeding - Vitamin C supplementation
Vitamin D	- Calcium absorption, bone health - May decrease risk of cancer	- Lack of exposure to sunlight - Poor diet - Cystic fibrosis and other malabsorptive diseases	- In children, rickets: bowing of the legs - In adults, osteomalacia: presents as chronic muscle pains	- Food fortification - Vitamin D supplementation - Consumption of some types of fish
Folate	- Prevents neural tube defects in the developing fetus	- Poor diet, lacking fresh fruits and vegetables - Exacerbated by pregnancy	- Anemia - Cardiovascular disease	- Food fortification

 

Sources:          www.emedicine.com/med/topic221.htm; WHO 1999, WHO 2000; www.umm.edu/altmed/ConsSupplements/VitaminB3Niacincs.html;http://dermnetz.org/systemic/pellagra.html;      www.ennonline.net/fex/05/sf26.html;www.vitaminsdiary.com/vitamin-c-benefits.htm;www.whfoods.com/genpage.php?tname=nutrient&dbid=109#function;www.merck.com/mrkshared/mmanual/section1/chapter3/3q.jsp;http://www.emedicine.com/med/topic3729.htm;http://www.emedicine.com/neuro/topic439.htm; http://www.emedicine.com/med/topic802.htm.

 

Folate has long been known to be important in the etiology of neural tube defects and anemia and is now understood to also be important for the prevention of cardiovascular disease.  It is an essential component of flour fortification in most countries with fortification. (Bishai et.al, 2001)

MI has supported projects to fortify cereal flours with folic acid as well as developing and scaling-up innovative interventions that help adolescent girls and women of child-bearing age. For example, iron and folic acid supplements were distributed to pregnant women through community health volunteers in Nepal and in Bangladesh.  They were socially marketed to adolescent girls through community workers. MI also led national folic acid advocacy efforts in India (MI Annual Report, 2004-5).

 

Program management

Supplement, Fortify, Diversify

Micronutrient Operational Strategies and Technologies (MOST, the USAID micronutrient program) and other organizations recommend a three-pronged approach towards addressing micronutrient deficiencies: supplementation, fortification, and dietary diversification (USAID).

 

It is increasingly accepted that to tackle many vitamin and mineral deficiencies, an integrated approach is required, including dietary diversification, fortification and supplementation. Integrating micronutrient delivery into programs to control intestinal parasites and malaria is a good option. Micronutrient programs should also coincide with environmental, sanitary, and political interventions. Using already existing programs as a catalyst for micronutrient supplementation is a good way to use existing knowledge and infrastructures for dissemination of better nutrition.

 

Food fortification has a two-fold advantage of being able to deliver needed nutrients to large portions of the population without requiring drastic changes in food preparation and consumption patterns (Allen et al., 2006).  Fortification with iron and folic acid is the best way to provide daily doses of these essential micronutrients to women before they get pregnant and in the early months of pregnancy when brain development and neural tube developments take place. It is the most effective approach in societies where women do not plan their pregnancies.

 

WHO has analyzed the cost effectiveness and benefit-to-cost ratios of micronutrient interventions, especially fortification and salt iodization programs; both of which were identified as having very high benefit-to-cost ratios. Seen in relation to the overall disease burden (all population groups, all causes, all developing countries), eliminating micronutrient malnutrition in children (plus anemia in reproductive age women) would save 8% of the global burden of disease, while reducing the number of underweight children by an additional 15%. In addition, high-dose vitamin A supplements are considered safe for infants younger than six months. Several studies suggest that giving vitamin A within 48 hours of birth reduces mortality in the first three months by 21 to 74 percent (Ross).

 

Ecology, Economy, Culture

More attention needs to be paid to the ecological, economic, and cultural factors that influence the local consumption and absorption of nutrients. To achieve sustainable improvement of the nutritional status of children, women’s status should be improved in all regions, but especially in South Asia and Sub-Saharan Africa. An example of this type of intervention is MI’s efforts to help local women produce and market nutrient-rich red palm oil to help reduce vitamin A deficiency (Micronutrient Initiative, Africa).

 

Women’s health must also be improved so that they are able to play productive, healthy, and vital roles in their societies, which would, in turn, reap economic and social benefits. Women in developing countries stand as the cornerstone of local economies. Investing in female nutrition through long-term, comprehensive life-course based programs will help break the intergenerational cycle of malnutrition, reduce the cost of micronutrient deficiencies, and have multiple other benefits for women, children, their households, and ultimately for nations. An example of a program that targets women’s health through attacking poverty as well as micronutrient deficiency was the Progresa trial conducted in Mexico. Researchers developed a poverty alleviation program that distributed complementary foods fortified with multiple micronutrients (including iron) to children and pregnant and lactating women. They found positive effects on anemia rates and also saw better growth in height among the poorest and youngest children. (Rivera et. al)

 

Too often nutrition program managers and donors overemphasize resolving the immediate causes of malnutrition and neglect many of the underlying causes.  Rarely do these programs touch malnutrition’s root sources (UNICEF, Poverty Reduction Begins with Children). The importance of information, communication, and education to diminishing malnutrition is often oversold. In fact, nutritionists end up teaching mothers to feed their families food that they are unable to afford, or, using social marketing techniques, they seek to impose behavior changes without seeking to enhance people's understanding of why these changes are needed and beneficial.  Because these strategies fail to help people to gain greater control of their own lives, they fail to fully address the multifaceted nature of malnutrition and micronutrient deficiencies. (Schuftan)

 

Combating protein-energy malnutrition (PEM) is about poverty alleviation. It is about equity, popular participation, wealth redistribution, access to health care and education, and the appropriate care women and children should, but do not, receive. In recent years, Brazil has served as a good model for incorporating food fortification into the larger socioeconomic and cultural arena, as it tries to involve consumers and promote community participation in its micronutrient programs (UNICEF, State of the World’s Children).

 

New Developments: Innovation for Improved Nutrition

 

Double Fortified Salt (DFS)

The Micronutrient Initiative has recently been working on developing DFS. Microenapsulation is the process used to make DFS and involves spraying iron particles on the salt.  The most recent study conducted in 2008 in Bangalore showed  DFS being effective in addressing iron deficiency in primary school children and raising hemoglobin levels. DFS has also been shown to be stable during storage and transportation, biologically available, and acceptable to consumers. Micronutrient Initiatve hopes to scale up this program in the near future.

 

Fortification of Wheat and Maize Flour

A 2008 meeting with WHO's Department of Nutrition for Health and Development in close collaboration with Food and Agriculture Organization of the United Nations (FAO, The United Nations Children's Fund (UNICEF), Global Alliance for Improved Nutrition (GAIN), and The Micronutrient Initiative (MI) discussed wheat and maize flour fortification. The wheat and maize flours can be fortified with micronutrients such as iron, vitamin B12, vitamin A, folic acid, and zinc. The micronutrients used to fortify the wheat/flour can be adjusted according to a country's needs.

 

 

 Use of GPS Technology

The Micronutrient Initiative recently completed a project to map all of the small-scale salt producers in Senegal and Bangladesh using GPS technology. This has enabled them to design and procure iodization equipment appropriate for small-scale production. Enabling and supporting small-scale iodization efforts will make progress towards the goal of universal salt iodization (MI Annual Report, 2006-7).

 

Multi-Nutrient Lozenges

Young children are particularly vulnerable to iron deficiency anemia and vitamin A deficiency. MI developed “Nutri-Candies” or lozenges fortified with vitamin A, vitamin C, folic acid, and iron, to help protect children where there are no readily processed and accessible foods to fortify. Also, because the lozenges were designed to be delectable, they encourage children and their families to attend the health centers and programs where they are distributed on a regular basis. First tested in India in West Bengal, the lozenges are now also distributed in the State of Bihar to some 3.5 million people daily. A year’s supply costs just US $1.20 per child. (Micronutrient Initiative)

 

Vitamins and Minerals in Emergency Situations

The importance of vitamins and minerals in emergency situations has been recognized for some time within the health and nutrition community, but it is often challenging to provide adequate levels through relief efforts. MI has developed a range of products to help field workers prevent hidden hunger during emergency relief efforts including multi-nutrient mixes that can be added to food at the household level. Individually packaged sachets called "Anuka" are ideal for children 6 to 24 months old. Another mix that is appropriate for the entire family, and costs only 45 cents per person, is distributed under the name "Vita Shakti" in India, or "Rahma" in the Darfur region of the Sudan.  Because these solutions are food-based, medical staff is not required to administer them, so the burden does not fall on health systems.  As such, they can be particularly beneficial in emergency situations where health services are unavailable or inaccessible. (Micronutrient Initiative)

 

Gravity-Powered Mills

The Micronutrient Initiative has recently completed a pilot project in rural Nepal around the use of a gravity-powered mill that automatically fortifies flour with the correct amounts of iron, folic acid, and vitamin A. No electricity is needed. With support from the World Bank, MI will expand this project to 100 mills in rural Nepal, bringing micronutrients to those most in need (MI Annual Report, 2006-7).

 

Harvest Plus

Harvest Plus is an effort to minimize the effects of micronutrient malnutrition through biofortification, the breeding of plant varieties that are higher in micronutrients. The program uses food crops that are staples to the poor and focuses its efforts on rice, wheat, maize, cassava, sweet potato and beans. Harvest Plus works with a global alliance of research institutions around the world and is coordinated by the International Center for Tropical Agriculture (ICAT) and the International Food Policy Research Institute (IFPRI) (Harvest Plus).

 

Iron and Zinc Sprinkles

Research continues to be done on  the feasibility of home fortification with iron and zinc sprinkles to reduce infant and child anemia. A study conducted in 2003 in rural Ghana shows promising results (Zlotkin, et. al). However, more recent work suggests that there may be some interactions between the two micronutrients; zinc may interfere with iron status (Wieringa, 2007).

 

Conclusion

It is tempting to look at the problem of micronutrient deficiencies as a fairly straightforward one, which can be solved through vertical programs that focus on, for example, food fortification with one or two micronutrients a time. While fortification and supplementation programs have been quite successful at reducing micronutrient deficiencies in many different contexts, the underlying causal factors of malnutrition, like poverty, political upheaval, and unequal distribution of resources, are less easily tackled. As long as these risk factors remain, the “hidden hunger” of micronutrient deficiencies will continue to afflict billions of the world's people. Future approaches to preventing micronutrient deficiencies should seek innovative new ways to address them as part of the broader social, economic and political context within which they continue to exist.

 

References

Allen L, de Benoist B, Dary O, Hurrell R, Eds.  Guidelines on food fortification with micronutrients. Switzerland: WHO and FAO.  2006.

Beaton, G. H., and G. McCabe. "Efficacy of Intermittent Iron Supplementation in the Control of Iron Deficiency Anaemia in Developing Countries: An Analysis of Experience Final Report to the Micronutrient Initiative." Montreal: Micronutrient Initiative. 1999.

Bishai D, Nalubola R. The history of food fortification in the United States: its relevance for current fortification efforts in developing countries.Econ Devel Cultural Change. 2002.51:37–53

Busschots G. Beriberi (Thiamine Deficiency). Emedicine. 2002. http://www.emedicine/com/med/topic221.htm. Accessed September 2005.

Darnton-Hill, Patrick Webb, Philip WJ Harvey, Joseph M Hunt, Nita Dalmiya, Mickey Chopra, Madeleine J Ball,Martin W Bloem, and Bruno de Benois. “Micronutrient deficiencies and gender: social and economic costs”.  2006.

Dermnetz.org. Pellagra. http://dermnetz.org/systemic/pellagra.html. Accessed September 2005.

Gentili A. Folic acid deficiency. Emedicine. 2006. Available at: http://www.emedicine.com/med/topic802.htm. Accessed October 2006.

Harvest Plus. “Breeding Crops for Better Nutrition.” 2006. http://www.harvestplus.org/about.html

International Eye Foundation. Prevention and Treatment. http://www.iefusa.org/prevention.shtml. 2006.

Joint Statement by the World Health Organization, the World Food Programme and the United Nations Children's Fund. Preventing and controlling micronutrient deficiencies in populations affected by an emergency.

Levine, R., and the What Works Working Group. Millions Saved: Proven Successes in Global Health. Washington, D.C. 2004.

McGuire J., & Galloway R. (1994) Enriching lives: overcoming vitamin and mineral malnutrition in developing countries. Development in Practice Series. Washington DC: World Bank.

The Merck Manual of Diagnosis and Therapy. Sec. 1 Ch. 3: Vitamin Deficiency, Dependency, and Toxicity. Available at: http://www.merck.com/mrkshared/mmanual/section1/chapter3/3b.jsp. Accessed October 2006.

The Micronutrient Initiative. “Africa: Integrating Vitamin A With Essential Health Services”. Available at: http://www.micronutrient.org/work2/childsurvival/diets.asp. Accessed 2006.

The Micronutrient Initiative. “Solution for Hidden Hunger”. Annual Report 2005-6.

Muller, O., & Krawinkel, M., (2005) Malnutrition and Health in Developing Countries. CMAJ, 279-286.

Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA. June 2,2004.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15173147.

Ross, D.A.. 2002. Recommendations for Vitamin A Supplementation. Journal of Nutrition 132: Suppl. 9 S2902-6.

Schuftan, Claudio. Chapter I: Malnutrition causes, consequences and solutions. pp. 7-90. 2004. aviva@netnam.org.vn

 

Singh NN. Vitamin B12 deficiency and associated neurological disorders. Emedicine. 2006. Available at: http://www.emedicine.com/neuro/topic439.htm. Accessed October 2006.

Sloan N et. al. 1997. Identifying Areas with Vitamin A Deficiency: The Validity of a Semiquantitative Food Frequency Method. American Journal of Public Health, 87(2):186-191.

Tangpricha V. Vitamin D deficiency and related disorders. Emedicine. 2006.

Available at: http://www.emedicine.com/med/topic3729.htm. Accessed October 2006.

Tontisirin K and Bhattacharjee L. “Global burden of malnutrition and infection in childhood. In Nutrition, Immunity and Infection”. Eds. R Suskind and Tontisirin K. Nestle Nutrition Workshop Series, Pediatric Program, Vol. 45. Vevey/Lippincott Williams & Wilkins, Philadelphia. 2001.

UNICEF. Nutrition: Micronutrients: Iodine, Iron and Vitamin A. Available at: www.unicef.org/nutrition/index_iodine.html. Accessed October 2006.

UNICEF. Poverty Reduction Begins with Children. 2000.

UNICEF. State of the world's children 1998. www.unicef.org/sowc98/fs03.htm. Accessed September 2003.

University of Maryland Medical Center. Nutrition. www.umm.edu/altmed/ConsModalities/Nutritioncm.html. Accessed September 2005.

USAID. Micronutrients Lead the Way. 2004 p. 4

Vitamins Diary. Learn the benefits of Vitamin C. Available at: www.vitaminsdiary.com/vitamin-c-benefits.htm. Accessed September 2005.

Watson F. Micronutrients: the basics. Available at: www.ennonline.net/fex/05/sf26.html. Accessed October 2006.

WHO, FAO, UNICEF, GAIN, MI, & FFI.Reccomendations on wheat and maize flour fortification. Meeting Report: Interim Consensus Statement. Geneva, World Health Organization 2009 (http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf, accessed [October 2009]).

World Health Organization. (n.d.). WHO | Micronutrients.  Retrieved 10 15, 2009, from WHO | World Health Organization: http://www.who.int/nutrition/topics/micronutrients/en/index.html

 

World Health Organization. (2008). WHO | Vitamin A Deficiency.  Retrieved 10 15, 2009, from WHO | World Health Organization: http://www.who.int/nutrition/topics/vad/en/

WHO et al. “Joint Statement on Preventing and Controlling Micronutrient Deficiencies in Populations Affected by an Emergency”. 2001.   http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf#search=%22Joint%20Statement%20on%20Preventing%20and%20controlling%20micronutrient%20deficiencies%20in%20populations%20affected%20by%20an%20emergency%2C%20%22

WHO/UNICEF Joint Statement. Clinical management of acute diarrhea. ( World Health Organization. WHO/FCH/CAH/04.7/United Nations Fund for Children UNICEF/PD/Diarrhoea/01. 2004. IZiNCG (International Zinc Consultative Group). Hotz C, Brown KH, eds. Assessment of the risk of zinc deficiency in populations and options for its control. IZiNCG Technical document #1. Food Nutr Bull 2004; 25(suppl):96S–203S)  I need a simpler version of this reference.

WHO International. Vitamin A. www.who.int/nut/vad.htm. Accessed October 2005.

WHO. 2000. Management of nutrition in major emergencies. Geneva: World Health Organization.

WHO. Nutrition. “Micronutrient Deficiencies: Battling Iron Defiency Anemia”. Available at: www.who.int/nut/ida.htm. Accessed October 2004.

WHO. 1999. Scurvy and its prevention and control in major emergencies. Geneva: World Health Organization.

The World's Healthiest Foods. Vitamin C. Available at: www.whfoods.com/genpage.php?tname=nutrient&dbid=109#function. Accessed September 2005.

Zlotkin, Stanley, Paul Arthur, Claudia Schauer, Kojo Yeboah Antwi, George Yeung^, and Ana Piekarz. Home-Fortification with Iron and Zinc Sprinkles or Iron Sprinkles Alone Successfully Treats Anemia in Infants and Young Children. The American Society for Nutritional Sciences. April 2003. http://jn.nutrition.org/cgi/content/abstract/133/4/1075.