What Approaches are Most Effective at Addressing Micronutrient Deficiency in Children 0–5 Years? A Review of Systematic Reviews

Introduction Even though micronutrient deficiency is still a major public health problem, it is still unclear which interventions are most effective in improving micronutrient status. This review therefore aims to summarize the evidence published in systematic reviews on intervention strategies that aim at improving micronutrient status in children under the age of five. Methods We searched the literature and included systematic reviews that reported on micronutrient status as a primary outcome for children of 0–5 years old, had a focus on low or middle income countries. Subsequently, papers were reviewed and selected by two authors. Results We included 4235 reviews in this systematic review. We found that (single or multiple) micronutrient deficiencies in pre-school children improved after providing (single or multiple) micronutrients. However home fortification did not always lead to significant increase in serum vitamin A, serum ferritin, hemoglobin or zinc. Commercial fortification did improve iron status. Cord clamping reduced the risk of anemia in infants up to 6 months and, in helminth endemic areas, anthelminthic treatment increased serum ferritin levels, hemoglobin and improved height for age z-scores. Anti-malaria treatment improved ferritin levels. Discussion Based on our results the clearest recommendations are: delayed cord clamping is an effective intervention for reducing anemia in early life. In helminth endemic areas iron status can be improved by anthelminthic treatment. Anti-malaria treatment can improve ferritin. In deficient populations, single iron, vitamin A and multimicronutrient supplementation can improve iron, vitamin A and multimicronutrient status respectively. While the impact of home-fortification on multimicronutrient status remains questionable, commercial iron fortification may improve iron status.

     

Micronutrient status of populations and preventive nutrition interventions in South East Asia

Objectives Since the 1990s, programs for the control of micronutrient deficiencies became a public health priority for many governments, including the countries partnering the project “Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia” (SMILING): Cambodia, Indonesia, Laos-PDR, Thailand and Vietnam. The aim of this study was to map which micronutrient deficiencies have been addressed and which interventions were in place in the SMILING countries. Methods The mapping covered the period up to 2012. Updated information from relevant surveys after 2012 is included in this paper after the completion of the SMILING project. The mapping of micronutrient status was limited to either national or at least large-scale surveys. Information on nutrition interventions obtained through a systematic mapping of national programs combined with a snowball collection from various sources. Results Among the five SMILING countries, Thailand differed historically by an early implementation of a nationwide community-based nutrition program, contributing to reductions in undernutrition and micronutrient deficiencies. For Cambodia, Indonesia, Laos PDR, and Vietnam, some national programs addressing micronutrients have been implemented following adjusted international recommendations. National surveys on micronutrient status were scattered and inconsistent across the countries in design and frequency. Conclusion for practice In conclusion, some micronutrient deficiencies were addressed in national interventions but the evidence of effects was generally lacking because of limited nationally representative data collected. Improvement of intervention programs to efficiently reduce or eliminate micronutrient deficiencies requires more systematic monitoring and evaluation of effects of interventions in order to identify best practices.

     

Food Composition Tables in Southeast Asia: The Contribution of the SMILING Project

Objectives Food composition data are key for many nutrition related activities in research, planning and policy. Combatting micronutrient malnutrition among women and young children using sustainable food based approaches, as aimed at in the SMILING project, requires high quality food composition data. Methods In order to develop capacity and to align procedures for establishing, updating and assessing the quality of key nutrient data in the food composition tables in Southeast Asia, a detailed roadmap was developed to identify and propose steps for this. This included a training workshop to build capacity in the field of food composition data, and alignment of procedures for selecting foods and nutrients to be included for quality assessment, and update of country specific food composition tables. The SEA partners in the SMILING project finalised a country specific food composition table (FCT) with updated compositional data on selected foods and nutrients considered key for designing nutrient dense and optimal diets for the target groups. Results Between 140 and 175 foods were selected for inclusion in the country specific FCTs. Key-nutrients were: energy, protein, total fat, carbohydrates, iron, zinc, (pro-)-vitamin A, folate, calcium, vitamin D, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B12 and vitamin C. A detailed quality assessment on 13 key-foods per nutrient was performed using international guidelines. Nutrient data for specific local food items were often unavailable and data on folate, vitamin B12 and vitamin B6 contents were mostly missing. For many foods, documentation was not available, thereby complicating an in-depth quality assessment. Despite these limitations, the SMILING project offered a unique opportunity to increase awareness of the importance of high quality well documented food composition data. Conclusion for Practise The self-reported data quality demonstrated that there is considerable room for improvement of the nutrient data quality in some countries. In addition, investment in sustainable capacity development and an urgent need to produce and document high quality data on the micronutrient composition of especially local foods is required.

     

Interventions to Improve Micronutrient Status of Women of Reproductive Age in Southeast Asia: A Narrative Review on What Works,What Might Work,and What Doesn’t Work

Objectives To provide an overview of nutrition-specific and nutrition-sensitive interventions that could improve micronutrient status of women of reproductive age. Methods This narrative review has a special focus on Southeast Asia, as the work was undertaken within the framework of the SMILING (Sustainable Micronutrient Interventions to controL deficiencies and Improve Nutrition status and General health in Southeast Asia) project. Results In order for new interventions to become accepted, comprehension and interpretation of potential impact of different strategies by policymakers and non-nutritionists is needed. By presenting a wide overview of strategies, and discussing the context and current consensus on these strategies, the review aims to help with the formulation of new recommendations for national programs in Southeast Asia. Conclusions Current policies in Southeast Asia to improve micronutrient status of women of reproductive age are focused too much on single micronutrient supplementation for pregnant women (iron and folic acid supplements). A more holistic approach, including both nutrition-specific and nutrition-sensitive interventions, is needed.

     

An Assessment of the Impact of Fortification of Staples and Condiments on Micronutrient Intake in Young Vietnamese Children

Targeted fortification programs for infants and young children are an effective strategy to prevent micronutrient deficiencies in developing countries, but the role of large-scale fortification of staple foods and condiments is less clear. Dietary modeling in children aged 6–60 months was undertaken, based on food consumption patterns described in the 2009 national food consumption survey, using a 24-h recall method. Consumption data showed that the median intake of a child for iron, vitamin A and zinc, as a proportion of the Vietnamese Recommended Dietary Allowance (VRDA), is respectively 16%–48%, 14%–49% and 36%–46%, (depending on the age group). Potential fortification vehicles, such as rice, fish/soy sauces and vegetable oil are consumed daily in significant amounts (median: 170 g/capita/day, 4 g/capita/day and 6 g/capita/day, respectively) by over 40% of the children. Vegetable oil fortification could contribute to an additional vitamin A intake of 21%–24% of VRDA recommended nutrient intake, while fortified rice could support the intakes of all the other micronutrients (14%–61% for iron, 4%–11% for zinc and 33%–49% of folate requirements). Other food vehicles, such as wheat flour, which is consumed by 16% of children, could also contribute to efforts to increase micronutrient intakes, although little impact on the prevalence of micronutrient deficiencies can be expected if used alone. The modeling suggests that fortification of vegetable oil, rice and sauces would be an effective strategy to address micronutrient gaps and deficiencies in young children.     

Multi-criteria Mapping of Stakeholders’ Viewpoints in Five Southeast Asian Countries on Strategies to Reduce Micronutrient Deficiencies Among Children and Women of Reproductive Age: Findings from the SMILING Project

Background

Despite scientific evidence on the potential impact or importance of specific interventions to improve micronutrient status of vulnerable groups, political commitment and extensive support from national stakeholders is paramount to support introduction and implementation of these interventions at national level. In order to develop efficient nutritional strategies to improve the micronutrient status of children < 5 years of age and women of reproductive age that will be supported by a wide range of stakeholders, a better understanding of viewpoints on the nutrition politics and strategies is necessary. Multi-criteria mapping (MCM) was successfully used to assess the stakeholder’s viewpoint in a wide variety of contexts since the late 1990s.

Objective

The objective of the present study was to assess the viewpoints of stakeholders on a wide range of potential nutritional interventions in the five Southeast Asian countries participating in the SMILING project.

Method

MCM methodology was used to appraise the stakeholder’s viewpoints in five countries.

Results

The results show that the overall stakeholders’ preference was for actions already implemented in their country rather than for new, innovative options, even for supplementation. Indirect interventions such like food fortification (except in Indonesia), delayed cord clamping or food-based approaches were generally less favored by the stakeholders. However, the majority of stakeholders agreed that new approaches should be considered and put in place in the future provided that evidence of their impact was demonstrated, that they received adequate technical support for their implementation and their monitoring, and that they will be accompanied by strong advocacy among decision-makers, civil society and beneficiaries.

Conclusions for practice

To conclude, for the introduction of new, innovative strategies to reduce micronutrient deficiencies in South-East Asia, convincing stakeholders appears to be the first hurdle to be taken.

     

A micronutrient-fortified food enhances iron and selenium status of Zambian infants but has limited efficacy on zinc

Micronutrient-fortified, cereal-based infant foods are recommended for reducing multiple micronutrient deficiencies in low-income countries, but their nutritional quality is not always optimal. In a double-blind randomized trial, we compared the efficacy of a locally produced porridge based on maize, beans, bambaranuts, and groundnuts fortified with 19 (rich) or 9 (basal) micronutrients. Infants aged 6 mo from Lusaka, Zambia were randomized to receive the richly fortified (n = 373) or basal (n = 370) porridge daily for 12 mo along with routine vitamin A supplements. Baseline and final micronutrient status and inflammation (based on α-1-glycoprotein) were assessed using nonfasting blood samples. Baseline prevalence of anemia (39%) and zinc deficiency (51%) were a public health concern. There were overall treatment effects on hemoglobin (Hb) (P = 0.001), serum transferrin receptor (P < 0.001), serum ferritin (P < 0.001), and serum selenium (P = 0.009); biomarker responses for iron and zinc were modified by baseline concentrations, and for Hb and iron by socioeconomic status. At 18 mo, the adjusted odds of anemia, iron deficiency anemia (Hb <105 g/L and transferrin receptor > 11.0 mg/L), and iron deficiency were 0.37 (95% CI = 0.25, 0.55), 0.18 (0.09, 0.35), and 0.30 (0.18, 0.50) times those in the basal group, respectively. The rich level of fortification had no overall treatment effect on serum zinc (1.09; 0.66, 1.80) but improved serum zinc in children with lower Hb concentrations at baseline (P = 0.024). A locally produced cereal- and legume-based infant food richly fortified with micronutrients reduced anemia and improved iron and selenium status but may require reformulation to improve the biochemical zinc status of urban Zambian infants.     

The role of enriched foods in infant and child nutrition

Since the last century, fortified and enriched foods are products whose original composition has been modified-through addition of essential nutrients-to satisfy specific population needs. For the fortification of foods to have a positive impact on nutritional status, the micronutrients added must be well absorbed and utilized by the organism (bioavailability). Diverse factors affect bioavailability, such as the nutritional status of individuals, the presence in the diet of substances which facilitate or inhibit its absorption, interactions among micronutrients, illnesses, and chemical characteristics of the compound used for fortification. In countries such as Chile, Venezuela and Mexico, important effects have been demonstrated in reducing iron deficiency anaemia in children under 5 years of age. In less than a decade, the salt iodization programme has also proven its effectiveness. Other programmes have fortified foods with Zn, vitamin A and folic acid, which are deficient in infants and children of many populations. In summary, food fortification is a low-cost, relatively simple strategy that may reach a wide range of people, and contribute to reducing the high prevalence of micronutrient deficiencies affecting children, especially in poor countries. The costs due to losses of human capital and their repercussions on health and future development are very high. Building links among academic researchers, politicians, food manufacturers and consumers is essential in order for food fortification to be efficacious and effective, and therefore should be considered as part of an integral strategy to combat micronutrient deficiencies.     

To what extent can food-based approaches improve micronutrient status?

The main dietary sources of micronutrients are animal source foods, fruits, vegetables and legumes. Animal source foods are the only source of some micronutrients and the main dietary source of others. Micronutrient status and child development are improved by animal source food interventions in populations that habitually consume low amounts. Of particular concern is the high global prevalence of vitamin B12 depletion, which is associated with low animal source food intake. Some fruits and vegetables can supply vitamin A requirements even with the lower amounts of fat typically consumed in many countries. However, plant source foods are unlikely to supply enough iron, zinc and vitamin B12, even if strategies such as consuming ascorbic-acid rich foods to increase iron absorption are adopted. Identification of mineral-rich varieties of cereals and legumes may improve the future situation. Complementary foods for infants and young children are unlikely to meet micronutrient requirements, especially for iron and zinc, unless they are fortified. Other strategies to improve micronutrient status, such as fortification and supplementation, have limitations and should not replace food-based strategies. Moreover, food-based strategies will improve dietary quality in general and are consistent with the global need to lower the risk of chronic disease and overweight.     

Concurrent micronutrient deficiencies in lactating mothers and their infants in Indonesia

BACKGROUND: Deficiencies of vitamin A, iron, and zinc are prevalent worldwide, affecting vulnerable groups such as lactating women and infants. However, the existence of concurrent deficiencies has received little attention. OBJECTIVE: The aim was to investigate the extent to which deficiencies of vitamin A, iron, and zinc coexist and the nutritional relation between lactating mothers and their infants. DESIGN: In a cross-sectional survey in rural West Java, Indonesia, 155 lactating mothers and their healthy infants were assessed anthropometrically and blood, urine, and breast-milk samples were obtained. RESULTS: Marginal vitamin A deficiency was found in 54% of the infants and 18% of the mothers. More than 50% of the mothers and infants were anemic and 17% of the infants and 25% of the mothers were zinc deficient. There was a strong interrelation between the micronutrient status of the mothers and infants and the concentrations of retinol and beta-carotene in breast milk. Vitamin A deficiency in infants led to an increased risk of anemia and zinc deficiency (odds ratios: 2.5 and 2.9, respectively), whereas in mothers the risk of anemia and iron deficiency (odds ratios: 3.8 and 4.8, respectively) increased. In infants, concentrations of insulin-like growth factor I were related to concentrations of plasma retinol and beta-carotene but not to zinc. CONCLUSIONS: Micronutrient deficiencies were prevalent in West Java. The micronutrient status of lactating mothers and that of their infants were closely related; breast milk was a key connecting factor for vitamin A status. Furthermore, concurrent micronutrient deficiencies appeared to be the norm.     

Iron Nutrition in Schoolchildren of Western Mexico: The Effect of Iron Fortification

In Mexico, food fortification is used as a strategy to combat micronutrient deficiencies. However, little is known about the effects of food fortification in vulnerable populations. This study was carried out in a population of school children believed to be at risk of various micronutrient deficiencies, including iron. The study aimed at determining iron status of children, and identifying and quantifying the sources of iron intake and the presence of relevant enhancers and inhibitors of iron absorption in the diet. The iron status and dietary iron intake was assessed of schoolchildren aged 3–14 years in western Mexico. Hemoglobin, serum ferritin, and transferrin saturation percentages were used to evaluate the iron status in a school-based sample of 762 children. Dietary data were collected from 607 children using semi-quantitative food frequency questionnaires. The overall prevalence of anemia and iron deficiency was 3.7% and 4%, respectively. Iron intake ranged from 1.9 to 3.3 times the recommended daily allowance, with fortified iron accounting for 72% of the total iron intake. Although iron fortification of staples such as maize flour in Mexico for more than a decade most likely contributed to reducing the prevalence of anemia and iron deficiency, the relatively large amounts of iron consumed could eventually lead to problems related to excessive iron intake in some children. Nutritional guidelines for iron fortification in Mexico should be defined and put into practice.     

Iron Nutrition in Schoolchildren of Western Mexico: The Effect of Iron Fortification

In Mexico, food fortification is used as a strategy to combat micronutrient deficiencies. However, little is known about the effects of food fortification in vulnerable populations. This study was carried out in a population of school children believed to be at risk of various micronutrient deficiencies, including iron. The study aimed at determining iron status of children, and identifying and quantifying the sources of iron intake and the presence of relevant enhancers and inhibitors of iron absorption in the diet. The iron status and dietary iron intake was assessed of schoolchildren aged 3-14 years in western Mexico. Hemoglobin, serum ferritin, and transferrin saturation percentages were used to evaluate the iron status in a school-based sample of 762 children. Dietary data were collected from 607 children using semi-quantitative food frequency questionnaires. The overall prevalence of anemia and iron deficiency was 3.7% and 4%, respectively. Iron intake ranged from 1.9 to 3.3 times the recommended daily allowance, with fortified iron accounting for 72% of the total iron intake. Although iron fortification of staples such as maize flour in Mexico for more than a decade most likely contributed to reducing the prevalence of anemia and iron deficiency, the relatively large amounts of iron consumed could eventually lead to problems related to excessive iron intake in some children. Nutritional guidelines for iron fortification in Mexico should be defined and put into practice.     

Micronutrient deficiencies in early pregnancy are common, concurrent, and vary by season among rural Nepali pregnant women

Pregnant women in developing countries are vulnerable to multiple micronutrient deficiencies. We investigated their prevalence and seasonal variation as part of a baseline assessment in a population-based, maternal micronutrient supplementation trial conducted in the rural Southeastern plains of Nepal. Serum concentrations of 11 micronutrients were assessed in 1165 pregnant women in the 1st trimester before supplementation. Using defined cutoff values, the prevalence of deficiencies of vitamins A, E, and D were 7, 25, and 14%, respectively. Nearly 33% of the women were deficient in riboflavin, and 40 and 28% had serum vitamin B-6 and B-12 deficiencies, respectively. Only 12% of the women were folate deficient, but 61% were zinc deficient. The prevalence of low serum iron concentration was 40%, and 33% were anemic (hemoglobin < 110 g/L). Multiple micronutrient deficiencies were common among pregnant women. Over 10% of the pregnant women were both anemic and deficient in B-complex vitamins, whereas 22% of women were both anemic and zinc deficient. Only 4% of women had no deficiency, whereas approximately 20% of the women had 2, 3, or 4 deficiencies. Almost 18% of women had >/=5 deficiencies. Micronutrient status varied by season; it was generally best during the winter months, except for serum vitamin D concentration, which peaked during the hot summer and monsoon months. Women in rural South Asia are likely to begin a pregnancy with multiple micronutrient deficiencies that may vary with seasonality in micronutrient-rich food availability.     

Redistribution of vitamin A after iron supplementation in Indonesian infants

BACKGROUND: Deficiencies of iron and vitamin A are prevalent worldwide. Single-micronutrient supplementation is widely used to combat these deficiencies. However, micronutrient deficiencies often occur concurrently, and there are many interactions between micronutrients. OBJECTIVE: This study investigated interactions among 3 important micronutrients--iron, vitamin A, and zinc--when they are given as supplements. DESIGN: In a randomized, double-blind, placebo-controlled supplementation trial, 387 Indonesian infants aged 4 mo were supplemented 5 d/wk for 6 mo with 10 mg Fe, 10 mg Zn, 2.4 mg beta-carotene, 10 mg each of Fe and Zn, 10 mg Zn + 2.4 mg beta-carotene, or placebo. Complete data on micronutrient status, including hemoglobin, ferritin, retinol, zinc, and the modified relative dose response (a measure of liver retinol stores), were available from 256 infants at the end of the study. RESULTS: Iron-supplemented infants had significantly lower plasma retinol concentrations and a significantly higher prevalence of vitamin A deficiency, as defined by a plasma retinol concentration <0.70 micromol/L, than did the non-supplemented infants. In contrast, the modified relative dose response of the iron-supplemented infants indicated greater liver stores of vitamin A. Iron supplementation improved iron status, and zinc supplementation improved zinc status, but beta-carotene supplementation did not significantly improve vitamin A status. CONCLUSIONS: In this study, iron supplementation in infants with marginal vitamin A status led to lower plasma vitamin A concentrations and simultaneously to greater vitamin A liver stores. This implies a redistribution of retinol after iron supplementation, which might induce vitamin A deficiency. Therefore, iron supplementation in infants should be accompanied by measures to improve vitamin A status.     

Effect of Fortification with Multiple Micronutrient Powder on the Prevention and Treatment of Iron Deficiency and Anaemia in Brazilian Children: A Randomized Clinical Trial

Fortification with multiple micronutrient powder has been proposed as a public health intervention able to reduce micronutrient deficiencies in children. Our objective was to compare the effectiveness of fortification with multiple micronutrient powder with drug supplementation in the prevention and treatment of iron deficiency and anaemia. This was a cluster trial with anemic and non-anaemic children between six and 42 months old, in randomization data. Non anaemic children received fortification with multiple micronutrient powder or standard drug supplementation of ferrous sulfate associated with folic acid in a prevention dose. Anaemic children who were randomized to receive multiple micronutrient powder also received the recommended iron complementation for anaemia treatment. A total of 162 children were evaluated. The prevalence of anaemia decreased from 13.58 to 1.85%. Iron deficiency decreased from 21.74% to 7.89% (by serum ferritin) and iron deficiency decreased from 66.81 to 38.27% (by soluble transferrin receptor). No difference was identified between interventions for hemoglobin (p = 0.142), serum ferritin (p = 0.288), and soluble transferrin receptor (p = 0.156). Fortification with multiple micronutrient powder was effective in preventing iron deficiency and anaemia in children aged six to 48 months. In anaemic children; it was necessary to supplement the dose of multiple micronutrient powder with ferrous sulfate.     

Micronutrient Status in Female University Students: Iron,Zinc, Copper,Selenium, Vitamin B12 and Folate

Young women are at an increased risk of micronutrient deficiencies, particularly due to higher micronutrient requirements during childbearing years and multiple food group avoidances. The objective of this study was to investigate biomarkers of particular micronutrients in apparently healthy young women. Female students (n = 308; age range 18–35 year; Body Mass Index 21.5 ± 2.8 kg/m²; mean ± SD) were recruited to participate in a cross-sectional study. Blood samples were obtained from participants in the fasted state and analysed for biomarkers of iron status, vitamin B₁₂, folate, homocysteine, selenium, zinc, and copper. The results show iron deficiency anaemia, unspecified anaemia, and hypoferritinemia in 3%, 7% and 33.9% of participants, respectively. Low vitamin B₁₂ concentrations (<120 pmol/L) were found in 11.3% of participants, while 4.7% showed sub-clinical deficiency based on serum methylmalonic acid concentrations >0.34 μmol/L. Folate concentrations below the reference range were observed in 1.7% (serum) or 1% (erythrocytes) of participants, and 99.7% of the participant had erythrocyte-folate concentrations >300 nmol/L. Serum zinc concentrations <10.7 μmol/L were observed in 2% of participants. Serum copper and selenium concentrations were below the reference range in 23% and 11% of participants, respectively. Micronutrient deficiencies including iron and vitamin B₁₂, and apparent excess of folate are present in educated Australian female students of childbearing age, including those studying nutrition. The effects of dietary behaviours and food choices on markers of micronutrient status require further investigation.     

The Key Role of Government in Addressing the Pandemic of Micronutrient Deficiency Conditions in Southeast Asia

Micronutrient deficiency conditions are a major global public health problem. While the private sector has an important role in addressing this problem, the main responsibility lies with national governments, in cooperation with international agencies and donors. Mandatory fortification of basic foods provides a basic necessary intake for the majority and needs to be supported by provision of essential vitamin and mineral supplements for mothers and children and other high risk groups. Fortification by government mandate and regulation is essential with cooperation by private sector food manufacturers, and in the context of broader policies for poverty reduction, education and agricultural reform. Iron, iodine, vitamin A, vitamin B complex, folic acid, zinc, vitamin D and vitamin B12 are prime examples of international fortification experience achieved by proactive governmental nutrition policies. These are vital to achieve the Millennium Development Goals and their follow-up sustainable global health targets. National governmental policies for nutritional security and initiatives are essential to implement both food fortification and targeted supplementation policies to reduce the huge burden of micronutrient deficiency conditions in Southeast Asia and other parts of the world.     

The Effects of an Oil and Wheat Flour Fortification Program on Pre-School Children and Women of Reproductive Age Living in C?te d’Ivoire,a Malaria-Endemic Area

Anemia and micronutrient deficiencies are widespread in sub-Saharan Africa, but the impact of food fortification is still debated. The objective of this study was to estimate the iron and vitamin A status of preschool children (PSC) and women of reproductive age (WRA) in households consuming fortified oil and wheat flour. The survey was cross-sectional in a rural and an urban area. Data on demographics, socioeconomic status, and fortified foods were collected at households. Hemoglobin (Hb), retinol binding protein (RBP), ferritin, soluble transferrin receptors (sTfR), subclinical inflammation, and Plasmodium spp. infection data were collected. In PSC, vitamin A deficiency (VAD) was prevalent, but for each 1 mg retinol equivalents (RE)/kg of oil consumed, RBP increased by 0.37 μmol/L (p = 0.03). In WRA, there was no significant VAD in the population (0.7%). Anemia was found in 92.2% of rural and 56.3% of urban PSC (p < 0.001). PSC with access to adequately fortified flour had Hb concentrations 15.7 g/L higher than those who did not (p < 0.001). Hb levels increased by +0.238 g/L per mg/kg increase in iron fortification levels (p < 0.001). The national program fortifying vegetable oil with vitamin A and wheat flour with iron and folic acid may have contributed to improved micronutrient status of PSC from two areas in Côte d’Ivoire.     

Linking the bioavailability of iron compounds to the efficacy of iron-fortified foods

The bioavailability (relative bioavailability value; RBV) of iron compounds relative to ferrous sulfate has proven useful in ranking the potential of iron compounds for food fortification. The efficacy of iron-fortified foods however depends on the absolute iron absorption from the fortified food and not on the RBV of the iron compound. Compounds of lower RBV can be used to design efficacious fortified foods by adding them at an appropriately higher level. Efficacy thus depends on the amount of iron added to the food vehicle as well as the daily consumption of the fortified food by the target population, the amount of iron lacking in the diet of the target population in relation to their needs, and the prevalence of widespread infections and other micronutrient deficiencies. The World Health Organization has recently published guidelines for food fortification, which include recommendations for iron fortification compounds and a method of how to define the iron fortification level. The same organization has also published guidelines on the iron status methods to be used to monitor interventions. Recent efficacy studies, which have to a large extent followed these guidelines, have shown good efficacy of iron-fortified salt, fish sauce, wheat flour, and rice in improving the iron status of target populations. However, although we now know how to design an efficacious iron-fortified food, efficacy cannot be ensured in populations with widespread infections and other micronutrient deficiencies. In such situations, other public health measures may be necessary before we can ensure an improvement in iron status.     

Multiple micronutrient deficiencies persist during early childhood in Mongolia

Data on the prevalence of micronutrient deficiencies in children in Mongolia is limited. We therefore determined the prevalence of anaemia, iron deficiency anaemia (IDA), and deficiencies of iron, folate, vitamin A, zinc, selenium, and vitamin D among young Mongolian children. Anthropometry and non-fasting morning blood samples were collected from 243 children aged 6-36 months from 4 districts in Ulaanbaatar and 4 rural capitols for haemoglobin (Hb), serum ferritin, folate, retinol, zinc, selenium, and 25-hydroxyvitamin D (25-OHD) assays. Children with alpha-1-glycoprotein >1.2mg/L (n=27) indicative of chronic infection were excluded, except for folate, selenium, and 25-hydroxyvitamin D assays. Of the children 14.5% were stunted and none were wasted. Zn deficiency (serum Zn <9.9 micromol/L) had the highest prevalence (74%), followed by vitamin D deficiency 61% (serum 25-OHD<25 nmol/L). The prevalence of anaemia (24%) and iron deficiency anaemia (IDA) (16%) was lower, with the oldest children (24-36 mos) at lowest risk. Twenty one percent of the children had low iron stores, and 33% had vitamin A deficiencies (serum retinol < 0.70 micromol/L), even though two thirds had received vitamin A supplements. Serum selenium values were low, perhaps associated with low soil selenium concentrations. In contrast, no children in Ulaanbaatar and only 4% in the provincial capitols had low serum folate values (<6.8 nmol/L). Regional differences (p<0.05) existed for anaemia, deficiencies of vitamin A, folate, and selenium, but not for zinc or IDA. Of the children, 78% were at risk of > or = two coexisting micronutrient deficiencies emphasizing the need for multimicronutrient interventions in Mongolia.