The USAID Micronutrient Program IMPLICATIONS OF RESEARCH FINDINGS FOR PROGRAMS TO REDUCE...

The USAID Micronutrient Program

IMPLICATIONS OF RESEARCH FINDINGS FOR PROGRAMS TO

REDUCE MICRONUTRIENT DEFICIENCIES

December 10, 2003


PLEASE TAKE NOTE

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


© Royalty Free Clip Art

VITAMIN A


MODELS FOR VITAMIN A SUPPLEMENTATION

FINDING: Sustained high coverage with vitamin A supplements in children 6 to 59 months of age is best achieved through “Child Health Weeks”

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.)


VITAMIN A FROM DARK GREEN LEAFY VEGETABLES

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)

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.


WHEAT FLOUR FORTIFIED WITH VITAMIN A

FINDING: Fortification of wheat flour with vitamin A (35% of RDA) is efficacious.

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


VITAMIN A IN PREGNANCY

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)

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.


VITAMIN A IN NEONATES

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

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.


IRON AND FOLATE

Gravity Feed Method of Premix Delivery

flour in

flour out

mixing conveyor

premixdosifier


IRON AND CHILD DEVELOPMENT FINDING: Increasing evidence that iron

deficiency in children impedes development and that supplementation can reverse delays

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.


IRON AND GROWTH

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)

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.


IRON SUPPLEMENTATION PROTOCOLS

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

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.


REDUCED IRON AND FORTIFICATION

FINDING: Iron bio-availability in foods fortified with reduced iron compounds is low

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 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. 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.


FORTIFICATION VEHICLES-1

FINDING: Cereal fortification may improve iron intake but evidence of general effectiveness is still lacking

IMPLICATION: Cereal fortification is not a “magic bullet” for addressing iron deficiency in children

Sources: SUSTAIN Guidelines for Iron Fortification of Cereal Food Staples.



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

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.



FINDING: Fortified fish/soy sauce (NaFeEDTA) found acceptable, efficacious in Vietnam and Thailand

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.


FORTIFICATION VEHICLES GENERAL COMMENTS

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.

The selection of appropriate vehicles for fortification should be determined by a careful review of local conditions and consumption patterns.


IRON SPRINKLES

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):1075-80.

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

IMPLICATION: Sprinkles is a promising intervention with high acceptance rates and proven efficacy but cost may be a major constraint


FOLIC ACID AND NEURAL TUBE DEFECTS

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.

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

IMPLICATION: Fortification with folic acid is effective in preventing NTDs and should be given due consideration in flour fortification programs


ZINC AND VITAMIN A INTERACTIONS

FINDINGS: Zinc deficiency impairs vitamin A transport and bioconversion and zinc supplementation alone improved vitamin A status in some studies

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.


ZINC AND DIARRHEAL DISEASE 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

IMPLICATION: Diarrheal disease control efforts should incorporate zinc supplementation


ZINC AND PNEUMONIA 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

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.


ZINC AND GROWTH

FINDINGS: Although the evidence is inconsistent, a meta-analysis concluded that zinc supplementation produced significant, positive responses in child growth

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.


For more information

Contact MOST at [email protected] or visit www.mostproject.org.

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