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--> 1 Summary Millions of people suffer and many die from lack of minute traces of nutrients. Methods of prevention are cheap and simple. Their universal application could yield health and economic benefits comparable to those achieved by smallpox eradication. —Dr. V. Ramalingaswami, Chair, LTNDP Task Force on Health Research and Development, Ending Hidden Hunger Conference, Montreal, Canada, October, 1991 Micronutrient malnutrition affects approximately 2 billion people worldwide. The adverse sequelae of micronutrient deficiencies are profound and include premature death, poor health, blindness, growth stunting, mental retardation, learning disabilities, and low work capacity. Worldwide attention first focused on the massive problem of micronutrient malnutrition in the mid- to late 1980s. A pivotal event that fostered this attention was a U.S. Agency for International Development (USAID) -funded randomized trial of vitamin A supplementation in Aceh Province, Indonesia, conducted by Dr. Alfred Sommer and colleagues. In this study, vitamin A-supplemented preschoolers were observed to have a 34 percent reduction in mortality. Thus, while vitamin A deficiency had long been associated with blindness, the Aceh research clearly demonstrated a link between vitamin A deficiency and mortality.1 These findings prompted the United Nations Subcommittee on Nutrition to issue a statement in 1992 indicating that control of vitamin A deficiency might be an important way to reduce mortality in young children.2 Project Charge The Aceh project was one of a series of interventions implemented in the 1980s that was aimed at alleviating the ''hidden hunger" of micronutrient 1 Sommer, A., et al. 1986. Impact of Vitamin A Supplementation on Childhood Mortality. The Aceh Study Group. Lancet 1 (8491):1169-1173. 2 United Nations. 1992. Administrative Coordinating Committee, Subcommittee on Nutrition. Second Report on the World Nutrition Situation. Vol. 1, October 1992, p. 40. Geneva: United Nations.
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--> malnutrition. Although some of these interventions have been successful, a majority have not. Nevertheless, there had been no systematic examination of the reasons for these successes or constraints in program outcome. Recognizing this, the Office of Health and Nutrition of USAID decided that there was a need to bring together research scientists and project implementers to examine past approaches that had—or had not—been successful and to identify the elements of success or constraint. USAID requested that the Institute of Medicine's Board on International Health oversee this activity and draft a report directed to those funding U.S. and international programs to alleviate micronutrient malnutrition. Given this audience, the report does not offer recommendations on how to alleviate specific micronutrient deficiencies—such recommendations are already available through the publications of diverse organizations, including USAID, the Micronutrient Initiative, the World Bank, the United Nations Childrens' Fund (UNICEF), and the World Health Organization (WHO). Rather, this report provides a conceptual framework based on past experience that will allow funders to tailor programs to existing regional/country capabilities and to incorporate within these programs the capacity to address multiple strategies (i.e., supplementation/fortification/food-based appro-aches/public health measures) and multiple micronutrient deficiencies. To respond to USAID's request, the Board on International Health—in consultation with the Food and Nutrition Board—constituted an expert committee of eleven members with broad expertise related to micronutrient nutrition, diet, and health, especially as these relate to iron, vitamin A, and iodine, and to the conduct and evaluation of global micronutrient deficiency prevention programs. The committee focused on iron, vitamin A, and iodine because they believed there was sufficient literature and program experience on each to warrant review. Although the project concentrates on these three micronutrients, it is hoped that similar reviews of other key micronutrients—for example, zinc, folate, and vitamin B12—will be conducted as literature and experience accumulate. In addition, while the background papers focus on interventions conducted in developing countries, the committee broadened its conceptual framework and recommendations to encompass at-risk populations in industrialized countries as well. The eight-month project was conducted in two phases. Phase 1 featured a two-day workshop to evaluate successful approaches to the prevention of micronutrient malnutrition and to identify the elements that had led to this success. Workshop participants included committee members and additional experts with research and program expertise related to the committee's task. In planning the workshop, the committee recognized that while there is an array of potential alternative strategies to deal with micronutrient malnutrition, it is unlikely that any one intervention, by itself, will solve all the micronutrient deficiencies in a given region or country. Thus, the mix of scientists and project implementers invited to the workshop was designed to help ensure identification of the optimal combinations
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--> of interventions most likely to be successful in a selected context. The range of participants also allowed for complementarities in treating micronutrient deficiencies to be identified. Three background papers—evaluating iron, vitamin A, and iodine deficiency interventions, respectively—were commissioned in advance of the meeting. These provided a basis for much of the workshop discussion. The papers were updated following the workshop on the basis of recommendations from participants. This report of the committee provides the basis for Phase 2 of the project, which will involve convening representatives of key U.S. and international organizations with a programmatic interest in combating micronutrient deficiencies. Participants will discuss the implications of the report's findings and recommendations for future policy and action. The meeting will be held in early 1998. Organization Of The Report The report contains five chapters and one appendix. Chapter 1 summarizes the findings and recommendations of the workshop. Chapter 2 provides a synthesis of the discussions of the two working groups and the subsequent plenary discussion. Chapters 3 through 5 present the three background papers on iron, vitamin A, and iodine. The Appendix contains the workshop agenda. Chapters 1 and 2 focus on overarching themes that emerged from the workshop proceedings. In these chapters, the committee has attempted to provide a framework for planning intervention programs that integrates three micronutrients and provides matrices for assigning priorities to interventions in different contexts. The committee offers these matrices as guidelines only, recognizing that there may be circumstances in which unique personalities, opportunities, or barriers exist that may lead countries to deviate from the priorities in the matrix. The committee believes, however, that the matrices offer a useful starting point for planners and donor agencies. Readers interested in information on the specific micronutrients—iron, vitamin A, and iodine—should refer to the background papers presented in Chapters 3 to 5. Findings And Recommendations Findings Deficiencies of iron, vitamin A, and iodine are still highly prevalent in the world. Approximately 2 billion people—or one-third of the human race—are affected and at increased risk of death, disease, or disability as a result.
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--> These deficiencies disproportionately affect the groups most vulnerable to nutrient deficiency: women of childbearing age, pregnant women, lactating mothers, and children under 5 years of age. The consequences of iron, vitamin A, and iodine deficiencies are severe, both with respect to health and to the damaged human capital and national economic development they impose, particularly in developing countries. Iron deficiency (ID) affects over one billion people, particularly children and women. If uncorrected, iron deficiency leads to anemia, reduced work capacity, diminished learning ability, increased susceptibility to infection, and greater risk of maternal and childhood mortality. Vitamin A deficiency, defined by characteristic eye signs, has been identified as a public health problem in over 40 developing countries. The consequences of vitamin A deficiency (VAD) include increased risk of severe morbidity, mortality in children, and blindness. Iodine deficiency disorder (IDD) exists in most parts of the world, primarily because of low intake of iodine in the diet. The consequences of IDD include goiter, reduced mental function, increased rates of stillbirths and abortions, and infant deaths. The nutrition status of all populations is in flux. Groups are in continuous movement along a continuum of nutritional risk, extending from a situation of severe micronutrient malnutrition, through a wide spectrum of presumed nutrient adequacy, to one of nutrient overload and toxicity at the upper end. The goal of micronutrient interventions should be to move at-risk groups within populations along a continuum from a state of public health risk or crisis, which occurs when deficiencies and their health consequences are widespread, to states of nutrient sufficiency and health. There exists a "toolchest" of effective interventions against micronutrient malnutrition. These interventions include supplementation, food fortification, dietary diversification, and public health measures such as parasite and diarrheal disease control. Availability of the toolchest alone, however, does not ensure programmatic success. Review of past efforts indicates that many programs may have been designed or implemented without adequate attention to country circumstances or the context in which the intervention would be conducted. The "one size fits all" approach to identifying effective micronutrient interventions has not worked in the past, and it is unlikely to succeed in the future. Rather, successful programs meet the nutritional needs over time of at-risk groups within both resource constraints and the local cultural context. Review of successful past programs suggests that they were more likely than less effective interventions to have been tailored to local circumstances, matching the level of effort to the severity and prevalence of
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--> deficiency, addressing the constellation of preventable causes of deficiency, and tailoring their operations to a country's capacity to implement and sustain the intervention. Past interventions have focused on single micronutrients, thus missing opportunities to coordinate and leverage scarce human and financial resources across funding agencies and the programs they conduct. In addition, relatively few interventions have incorporated complementary public health control measures—for example, integrating dietary with supplementary measures or parasite control or the teaching of personal hygiene and sanitation practices—in their approaches to the alleviation of micronutrient malnutrition. Review of past programs reveals an almost total lack of attention in program design and implementation to the systematic collection of data on costs linked to program components and effectiveness of different interventions. Such program monitoring is essential to providing information on appropriate ways to improve the efficiency of implementation and coverage of given strategies in different country settings. The following recommendations were developed by the committee, based on the workshop deliberations and on the background papers presented in Chapters 3 to 5. Recommendations Successful interventions to date have incorporated knowledge of key factors—including the location (or clustering), severity, prevalence, and multiple causes of the deficiency(ies); level of country development; and the country's capacity to implement and sustain the intervention. Advance in-country analysis, coupled with timely, ongoing feedback and the flexibility to change programs as indicated, are essential to initially determine program targets, modify elements, and to remain efficient and effective in the long run. Program support from external donor agencies has been essential to the success of intervention programs to date, but such support—in order to be maximally effective in the future—must be better tailored to target country needs and capabilities than it has been in the past. Support should also be maintained for a sufficient and biologically plausible period of time to show success in achieving nutritional goals within the framework of the host country's development
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--> plan. Availability of short-term, goal-oriented, program-specific external funding should not be the primary factor driving the country program. Because deficiency of a single micronutrient seldom occurs in isolation, often existing in the context of deprivation and multiple micronutrient deficiencies, plans for sustained intervention should consider interventions to target multiple deficiencies to the degree appropriate and feasible. Interventions should incorporate all four strategies—supplementation, fortification, food-based approaches leading to dietary diversification, and complementary public health control measures—again, to the degree appropriate and feasible. Only the relative emphasis and time sequence for the four approaches should differ, by level of population risk, phase of intervention, and the micronutrients under consideration. Supplementation is the method of choice when therapeutic treatment is necessary—that is, to address severe micronutrient deficiency. Supplementation is also an appropriate tool for preventive programs as long as the distribution system can be maintained and those receiving the supplements continue to consume them. Supplementation has been shown to be highly cost-effective in achieving its nutritional goals and health impact. There is concern, however, that it may be more costly to maintain than either fortification or dietary diversification in the long term, although data to substantiate this concern are lacking. To date, most of the efforts to control vitamin A and iron deficiencies have focused on supplementation; comparatively few programs have also included fortification and dietary diversification components. Evidence on vitamin A replenishment from the Indonesia experience of the 1970s and the Tanzania experience of the 1980s suggests that a more comprehensive approach, designed to provide therapeutic treatment for those with frank deficiency along with the preventive strategies for the general population, may yield better results in the longer term. Food fortification, with the exception of iodized salt, and dietary diversification are not appropriate as therapeutic measures, but can be successful as sustainable preventive strategies to control micronutrient malnutrition. Food fortification requires the active participation of the food industry. Dietary diversification and changes in meal composition require individuals, families, and communities to change eating behavior in their unique cultural context. Both strategies require more time than supplementation to achieve the same change in micronutrient status. For this reason, supplementation has been the preferred preventive and therapeutic strategy. Food fortification, however, has the potential to reach a larger number of consumers than supplementation, and therefore to have broader impact, as evidenced by experiences with iodized salt and sugar fortification with vitamin A in Latin America. Except for iodine, food-based approaches are the most logical for integrating micronutrient control programs. Interactions are avoided between
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--> potential concentrated-dose incompatibilities among supplements, such as solubility differences, susceptibility to oxidation, and competition for absorption. The situation with IDD control is different, because the deficit is not correctable simply by growing more or different food in the same iodine-depleted area. Furthermore, there is a proven, cost-effective IDD control intervention—universal iodization of salt—that should receive continued support, using oral iodine supplements to control the problem in limited, unyielding situations. Combining of nutritional interventions with other complementary public health measures is frequently necessary to eliminate deficiency of a specific micronutrient. Successful examples include coupling deworming with iron supplementation to control anemia or enhancement of vitamin A status through diarrheal disease control. In addition, experience suggests that incorporating temporal combinations into an intervention—that is, combining short-term with longer-term approaches—increases the likelihood of sustained public health benefit. One such example was the effective emergency use of iodinated oil in Bolivia in the late 1980s while USI was being institutionalized. The long-term goal of intervention should be to shift emphasis away from supplementation toward a combination of food fortification—universal salt iodization (USI) or iron-fortified flour, for example—and dietary diversification, where appropriate and feasible. In other words, as populations move along the continuum of risk from a position of higher to one of lower risk, the relative mix of interventions should favor food, modeled after that presented in Table 1-1. There are a number of widely held beliefs among designers and implementers of micronutrient interventions that have not been empirically tested and that require such testing. Two examples of such "conventional wisdom" include: The belief that social marketing and education of recipients are essential to empower them to make informed decisions and to willingly participate. These elements are viewed by many as a necessary component of all successful, long-term intervention activities. With the exception of the Thailand ivy gourd initiative (see Chapter 4), however, there are few examples to support this contention. Research should, therefore, be directed toward confirming the Thailand ivy gourd experience in other regions of the world, particularly given the additional costs and complexities associated with incorporating social marketing and nutrition education in prevention or control programs.
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--> TABLE 1-1 Preferred Initial Approaches to Prevention and Control of Iron, Vitamin A, and Iodine Deficiencies in Populations at Different Levels of Micronutrient Malnutrition Deficiency Level IV Level III Level II Level I Iron Vit A Iodine Iron Vit A Iodine Iron Vit A Iodine Iron Vit A Iodine Supplementation Targeted to vulnerable groups — ++ ++++ +++ +++ ++ +++ ++ + ++ + + Universal ++++ ++++ — ++ + — — — — — — — Fortification Targeted foods + +++ — — — — — — — — — — Universal — — +++ + ++ ++++ +++ ++ ++++ +++ ++ ++++ Food-based approaches Nutrition education + ++ + ++ +++ + +++ ++++ + ++++ ++++ ++ Food production ++ +++ n.a. + ++ n.a. — + n.a. — — n.a. Food-to-food ++++ ++++ — +++ +++ — — — — — — — Public health control measures Immunization ++++ ++++ — ++++ ++++ — ++++ ++++ — ++++ ++++ — Parasite control +++ ++ — +++ ++ — — — — — — — HW/S +++ — — +++ ++ — — — — — — — DD/ARI +++ +++ — +++ ++ — — — — — — — Personal sanitation/hygiene ++++ ++++ — ++++ ++++ — ++++ ++++ — ++++ ++++ — NOTE: Level IV, populations with severe micronutrient malnutrition; Level III, populations with moderate to severe micronutrient malnutrition; Level II, populations with mild and widespread micronutrient malnutrition; Level I, populations with mild and clustered micronutrient malnutrition; ++++, very strong emphasis; +++, strong emphasis; ++, moderate emphasis; +, light emphasis;—, no emphasis; food-to-food fortification, mixing of staple foodstuffs—e.g., mango with gruel—at the household level to enrich nutrient content; n.a., not applicable; HW/S, healthy water and public sanitation; DD/ARI, control of diarrheal diseases and acute respiratory infections.
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--> The belief that community-level involvement is critical to high-coverage and sustainability of progress achieved by programs (where progress refers to continued program support that is political and public, as well as financial). Again, there is little past experience to support this contention; thus, confirmation is warranted. There is a critical need for information systems that will allow governments and international funders to plan, monitor, and evaluate processes and outcomes of micronutrient intervention programs. Such information systems are most effective when designed and included in interventions from the start. Key elements of program information systems include: An ability to monitor sentinel aspects of performance at low cost and refine process and output in a way that provides timely and relevant feedback at each decisionmaking level of the program. A capability to monitor dietary intakes and micronutrient status over time, as needed, to detect changes in these key outcomes and to determine the level and stability of a population's risk so that interventions can be responsive to changes in need. Application of standard methods of quality assurance and control that can facilitate comparison of performance within and across interventions and allow for more systematic evaluation of the elements and context of program successes and failures in the future. Standardization of methods can also make it easier to decide which trials are the more promising for expansion to fully operational levels. Guidance from experts in nutrition, population sciences, food science and technology, management, and economics to assure the inclusion of critical program elements to monitor and evaluate programs. Data on the costs and effectiveness of interventions for the control of micronutrient deficiencies should be collected routinely as part of all interventions. The collection of data on cost-effectiveness through operations research can provide information on appropriate ways to improve efficiency of implementation and enhance effectiveness of selected strategies in different country environments. Funders should increasingly engage governments and the private sector—for example, national food industries and food cooperatives—as partners
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--> in achieving sustainable improvements in the micronutrient content of diets. Because continued economic and social deprivation in target populations constrain implementation of interventions and the sustainability of progress, funders should also engage organizations that seek to improve the socioeconomic status in populations suffering micronutrient malnutrition as partners. As socioeconomic conditions gradually improve in many developing societies, it is likely that the private food industry will increasingly influence the nature and nutritional adequacy of the diets in these populations. Initiating constructive working relationships and instilling a sense of responsibility within the food industry are likely to yield stronger and more committed partnerships in preventing micronutrient deficiencies in the future.
Representative terms from entire chapter: