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Presentation on theme: "The USAID Micronutrient Program IMPLICATIONS OF RESEARCH FINDINGS FOR PROGRAMS TO REDUCE MICRONUTRIENT DEFICIENCIES December 10, 2003."— Presentation transcript:


2 The USAID Micronutrient Program PLEASE TAKE NOTE n The “FINDINGS” cited in the following slides summarize results reported in the literature n The “IMPLICATIONS” cited reflect the views of MOST, not the views of the authors responsible for the findings

3 The USAID Micronutrient Program © Royalty Free Clip Art VITAMIN A

4 The USAID Micronutrient Program MODELS FOR VITAMIN A SUPPLEMENTATION n 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.)

5 The USAID Micronutrient Program VITAMIN A FROM DARK GREEN LEAFY VEGETABLES n FINDING: The rate of conversion of β- carotene 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) n 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.

6 The USAID Micronutrient Program WHEAT FLOUR FORTIFIED WITH VITAMIN A n 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

7 The USAID Micronutrient Program VITAMIN A IN PREGNANCY n 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.

8 The USAID Micronutrient Program VITAMIN A IN NEONATES n 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: 1 Rahmathullah 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. 2 Humphrey JH, et al. Impact of neonatal vitamin A supplementation on infant morbidity and mortality. J Pediatr. 1996 Apr;128(4):489-96.

9 The USAID Micronutrient Program IRON AND FOLATE

10 The USAID Micronutrient Program 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: 1 Lozoff B, et al. Behavioral and developmental effects of preventing iron-deficiency anemia in healthy full-term infants. Pediatr. 2003 Oct;112(4):846-54. 2 Algarin 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. 3 Stoltzfus 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. 4 Idjradinata P, Pollitt E. Reversal of developmental delays in iron-deficient anaemic infants treated with iron. Lancet. 1993 Jan 2;341(8836):1-4.

11 The USAID Micronutrient Program IRON AND GROWTH n 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.

12 The USAID Micronutrient Program IRON SUPPLEMENTATION PROTOCOLS n 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: 1 Haidar 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. 2 Agarwal KN, et al. Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation. Indian Pediatr. 2003 Apr;40(4):296-301.

13 The USAID Micronutrient Program REDUCED IRON AND FORTIFICATION n 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: 1 Hernandez M, et al. Iron bioavailability and utilization in rats are lower from lime- treated corn flour than from wheat flour when they are fortified with different sources of iron. J Nutr. 2003 Jan;133(1):154-9. 2 Swain 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. 3 Alvarado 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.

14 The USAID Micronutrient Program FORTIFICATION VEHICLES-1 n 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.

15 The USAID Micronutrient Program FORTIFICATION VEHICLES-2 n 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.

16 The USAID Micronutrient Program FORTIFICATION VEHICLES-3 n 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.

17 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.

18 The USAID Micronutrient Program IRON SPRINKLES Sources: 1 Zlotkin 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. 2 Zlotkin 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):1075- 80. 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 n IMPLICATION: Sprinkles is a promising intervention with high acceptance rates and proven efficacy but cost may be a major constraint

19 The USAID Micronutrient Program FOLIC ACID AND NEURAL TUBE DEFECTS Sources: 1 Green NS. Folic acid supplementation and prevention of birth defects. J Nutr. 2002 Aug;132(8 Suppl):2356S-2360S. 2 Castilla 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. n 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

20 The USAID Micronutrient Program ZINC © US Agricultural Research Service

21 The USAID Micronutrient Program ZINC AND VITAMIN A INTERACTIONS n 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: 1 Noh 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. 2 Munoz 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.

22 The USAID Micronutrient Program ZINC AND DIARRHEAL DISEASE n 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

23 The USAID Micronutrient Program ZINC AND PNEUMONIA n 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: 1 Bhutta 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. 2 Bhandari 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.

24 The USAID Micronutrient Program ZINC AND GROWTH n 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.

25 The USAID Micronutrient Program For more information Contact MOST at or visit


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