United Nations System
Standing Committee on Nutrition

Report of the Sub-Committee on Nutrition at its Twenty-Fifth Session

II.  Work in Progress:  Summary of Discussion and Conclusions

C. Reports of decisions taken in Working Groups

C.7  Iron Deficiency Control -- Summary Report of the Working Group

51.  This Group's report discusses technical issues, along with some encouraging reports from agencies. However, it was noted with dismay that attention paid to the problem is not commensurate with its magnitude. Control (encompassing both treatment and prevention) calls for an integrated, strategic approach.  Such an approach would  combine dietary interventions, fortification of appropriate foods and supplementation of the most vulnerable groups.  Promoting exclusive breastfeeding and appropriate complementary feeding, improving women's reproductive health and child spacing, and controlling infectious disease (with special concern for malaria and parasitic diseases that directly precipitate iron deficiency and anaemia), are an integral part of this approach.

52.  Prevention of iron deficiency throughout the lifecycle is needed, focussing on periods when iron deficiency can cause the most lasting damage, i.e., pregnancy and young childhood. This requires assuring that mothers enter pregnancy with adequate iron and folate status and also meet their added iron needs during pregnancy.  Success requires information, education and communications components (IEC), along with monitoring and evaluation. Micronutrient malnutrition often appears as a cluster of deficiencies.  A human rights approach was welcomed.

53.  The Group agreed that:

• UNICEF and UNU  develop a combined statement on the integration of approaches to the control of vitamin A and iron deficiencies;
• a technical workshop to resolve issues using a practical, field-oriented, science-based approach be held before the next meeting of the Working Group. The report of this workshop will be presented at next year's Working Group meeting.

Full Report of the Meeting of the Working Group on Iron Deficiency

Sunday 29 March 1998, Oslo, Norway

Chairman: Nevin Scrimshaw, UNU
Rapporteurs: Gary Gleason, INF, Rainer Gross, GTZ,Fernando Viteri, UNU, and Ray Yip, UNICEF

The magnitude and significance of iron deficiency were strongly emphasized in the December, 1997 SCN Third Report on the World Nutrition Situation and through an update provided by WHO during the session. The 1997 report of the Working Group summarized the multiple serious consequences of iron deficiency and iron deficiency anemia for cognition, resistance to infection, physical performance, metabolic impairments, morbidity and mortality. The goal of micronutrient interventions is to move at-risk groups to a level of nutritional sufficiency compatible with good health. To achieve this multiple concurrent approaches that lead to sustained nutritional security are required. Also needed is a strategic framework that recognizes that several micronutrient deficiencies are often clustered in the same underprivileged population and the biological interactions among the nutrients occur. Advocacy for the control of iron deficiency should address these issues.

A number of approaches must be used in a carefully planned and integrated approach to prevent effectively iron deficiency in children and women. The unfortunate misconception that effective approaches to iron deficiency are not available is due to the fact that iron deficiency cannot be effectively addressed by one or two universal actions as is the case for the control of iodine deficiency (universal iodization of salt) or vitamin A deficiency (supplementation or fortification). Under most real life situations there is no single effective intervention for the elimination of iron deficiency. An appropriate set of intervention strategies must be selected, weighed, integrated and adapted to the needs of different populations, environments and the availability of resources. The importance was stressed of expanding the focus on iron deficiency from supplementation during pregnancy only to the prevention of anemia in young children because of its impact on cognitive development and in non-pregnant women because of the need to have them enter pregnancy with adequate iron stores.

The introduction stressed the feasibility of building effective programmes for the elimination of iron deficiency as a public health problem in most countries. However, they require a combination of food-based approaches including fortification, dietary change, new agricultural technologies and health-based interventions such as supplementation, disease control and reproductive health initiatives. Unless circumstances are exceptional, the single intervention and single

nutrient approach to the control of nutritional anemias and micronutrient deficiencies, including iron deficiency, must be considered obsolete and should be abandoned. The combined interventions now available lend themselves to dealing simultaneously with deficiencies of iron and zinc as well as folate and other B vitamins. Where vitamin A deficiency exists, its correction can benefit iron deficiency control programmes and vice versa. Control of infectious diseases will benefit the status of most nutrients. Recent data show that iodine deficiency affects iron status, as well as thyroid function. Other health measures such as immunization and sanitation to reduce infections and the treatment of parasites also have multiple nutritional benefits.

The working group agenda was structured to promote open and critical discussion aimed at helping build consensus around an integrated, sustainable strategy for overcoming iron and related nutrient deficiencies.

The rapporteurs presented the integrated strategic framework shown in Figure 1 to guide all presentations and discussion. When the report was subsequently presented to the SCN, its applicability to integrated programmes for the joint prevention of vitamin A deficiency and iron deficiencies was noted.

Bruno de Benoist, Micronutrients Focal Point, WHO Geneva, presented a summary of preliminary information on iron deficiency from a new database in WHO Geneva. It was noted that current figures are often subnational, unrepresentative and sometimes from biased sources and that WHO is still working try to resolve such data related issues, Table 1 summarizes some of the WHO data:

 Table 1 Prevalence Estimate of Anemia (percent of populations)

It was emphasized that:

• There is a need to mobilize more countries to provide data on anemia although this should not delay action.
• There is a need for better overall strategies and ideally a more standard overall strategy for the prevention and control of IDA.
• There is a need to put greater emphasis on improving iron nutrition and controlling anemia in children and in women of childbearing age.

Fernando Viteri, Coordinator of UNU's Programme for the Control of Iron Deficiency, introduced the issue of dietary practices and agricultural developments and reported on recent studies of the bioavailability of iron in foods. Dietary improvement, with emphasis on meal composition, should be part of all major anemia prevention strategies. Some "knowledge, attitude and practice" (KAP) studies are in progress that look at diet and iron deficiency in various populations, but more such studies are needed. However, there are no solid evaluations on the impact of nutrition education on the prevention of iron deficiency and iron deficiency anemia. One study has shown, not unsurprisingly, that higher meat intake markedly improves iron nutrition in late infancy.

The fact that, in many parts of the world, diets containing a nutritious variety and adequate amounts of healthy foods are simply not affordable was stressed. In many societies, including some in developed countries, even where healthy diets are affordable, eating patterns and other factors unrelated to diet result in high levels of anemia, especially among young children, adolescent girls and women of child bearing age, whether or not they are pregnant. In other societies, inequitable practices in household food distribution result in nutrition problems even when the ingredients necessary for a healthy diet are available in the home. Overall, it was seen as very unfortunate that there are no current data to support the position that dietary education alone is sufficient to improve the iron status of populations.

Viteri reported new plant based approaches that include selection of bean varieties that have up to five times the content of iron and zinc. Some plants have been identified that are highly effective in absorbing minerals from the soils. There are also newly developed mutants such as corn varieties that are significantly lower in phytates, and varieties of the genus Brassica that have levels of iron that open a better opportunity for sufficient dietary iron for vegetarians.

The potential health and development risks vs benefits of mutant varieties were questioned mostly on the basis of their phosphate content. Viteri replied that the seeds of the low phytate mutant corn seed do not have a lower phosphate content when compared to non-mutant equivalent varieties, and that there was no evidence that the lower phytate mutant had any negative effect on health.

Venkatesh Mannar, Executive Director of the Micronutrient Initiative, described activities related to food fortification as an important approach to the prevention of iron deficiency. Technologically, the addition of iron to modern flour mills is not difficult and an iron premix costs less than US$0.36/1000 kg. The most common fortificants for wheat flour are elemental iron and ferrous sulphate.

A recent study in Venezuela showed a highly significant decrease in anemia rates among children two years after national introduction of iron fortified flour.

Wheat consumption has increased dramatically in Asia, making this grain a more effective vehicle for fortification to bring iron and other micronutrients to populations at risk. It was universally agreed by participants that folate should be combined with the various iron compounds used to fortify cereals because of the known health benefits of this substance and the risks of brain stem defects associated with inadequate folate status.

The current status of iron fortification in the developing world includes good progress in Latin America, newly developed policies in the Middle East and recent moves toward wide scale fortification of wheat flour in the new republics in Central Asia, South Africa, and Indonesia.

EDTA iron is produced in large quantities for agricultural purposes, and if used widely for flour fortification would solve several problems related to stability and interactions of reactive iron with other elements in flour. More importantly, it is much better absorbed and improves the absorption of non-heme iron. Progress is being made on obtaining a "Generally Recognized as Safe (GRAS)" rating for it in the U.S.

China has decided to fortify all soy sauce with EDTA iron. Vietnam is considering a similar type of fortification with EDTA iron of fish sauce. There was a concern in the U.S. that EDTA consumption in food is already high, but recent data show that this is not the case.

Mannar reported that China is building a large plant for the production of EDTA iron and should have significant capacity for export. MI has made progress in the development of a "sprinkled" form of supplement/fortificant that can contain multiple micronutrients and be convenient for use with young children.

There was agreement that all strategies for the prevention of iron deficiency and iron deficiency anemia should include a strong component for improving diets. Good nutrition should be about the universal availability of nutrients through the consumption of a healthy variety of foods.

Field trials and absorption studies:

Viteri noted that iron supplements are well justified as part of most integrated approaches to the prevention of iron deficiency. Data show that even in developed countries a significant number of women enter pregnancy with iron deficiency. The level of hemoglobin and iron stores of a woman at the start of pregnancy is the strongest indicator of her iron status at term, regardless of supplementation during the pregnancy period. Iron deficiency prevention strategies, therefore, need to focus not only on pregnant women but also on preventing women from entering pregnancy deficient in iron. This requires a programme focus on women=s entire reproductive cycle and on iron deficiency in children.

Viteri also presented a summary of the research on supplementation effectiveness and strategies for delivering iron supplements. He reported that all studies of weekly iron supplementation have been efficacious. These include three in infants in three countries (Brazil, China, Indonesia), three in preschool children in three countries (Bolivia, China, Indonesia), five in school children in four countries (Indonesia, Guatemala, Mali, Panama,), four in women 13-45 years of age in four countries (India, Indonesia, Tanzania, USA) and five studies in pregnancy in five countries (China, Indonesia, Guatemala, Malawi, Mexico). This amounts to a total of 20 studies in 10 countries (Bolivia, China, Guatemala, India, Indonesia, Malawi, Mali, Mexico, Thailand, USA). Six additional studies are in progress, including two in pregnancy, in five countries (Kazakhstan, Peru, Philippines, Uruguay, Vietnam).

The results of these studies provide overwhelming evidence to make weekly iron supplements an option for iron deficiency anemia if high compliance levels can be sustained. Based on the known difficulties in achieving significant iron status improvements through large scale daily supplementation programmes, research on alternative dosage amounts and period has accelerated significantly in the past few years. The efficacy of weekly supplementation with doses lower than those received through a daily regime is an extremely important finding because of its potential for lowering supply costs. Its lesser frequency and lower side-effects should make it possible to achieve better compliance by developing effective communication support strategies and involving the community. However, its large scale feasibility and sustainability for mass use are still to be demonstrated.

Ray Yip reported on the ineffectiveness, in Vietnam, of daily supplementation without any educational or motivational component. Obviously, non-compliance in taking an individual dose has greater negative effect in a weekly regime. In general, strategies including supplementation that ignore or underplay various forms of education and supervision, do not appear to be successful in reducing anemia. "Supervised" distribution through schools and work places works well. Mass communication and community channels that can educate and motivate women and mothers to comply in taking supplements and administering them to children were seen as essential. Community involvement in such programmes is a must. A weekly dose regime is more amenable than daily supplementation to promotion in the form of a weekly "event" focused on reminding individuals to take, or administer to children, weekly iron supplements. The weekly dose regime is also freer of side effects that deter compliance.

Discussions led to a consensus that whether daily or weekly supplementation, the framework of an integrated iron deficiency strategy includes attention to assure that target groups are given the information and motivation for compliance. Revisits and reminders from health care providers and other community members and counseling of mothers were noted as essential. Health education for anemia control can also help reverse recent undesirable trends in some countries away from integrated prenatal care and toward a focus on building systems for dealing with obstetrical emergencies.

Most existing programmes using supplementation as a major strategy for anemia prevention were seen as exhibiting an imbalance of emphasis on supplies and distribution compared to information, education and communication in support of compliance in taking the supplements and in promotion of improved dietary practices.

The majority of the group agreed that the potential for adding additional micronutrients where multiple forms of micronutrient deficiency are present should be more strongly emphasized and that appropriate supplements and fortification premixes supplying some other vitamins and zinc should be encouraged.

Other information and points raised in discussion of this issue included:

• New recommendations for supplementation dosages for pregnant women are available from a recent meeting in PAHO on iron deficiency anemia.
• Iron deficiency prevention strategies need stronger components of monitoring and evaluation both in terms of programme process and impact.

Rainer Gross, GTZ emphasized that:

• There is increasing evidence that the option of weekly dosing works also with other elements such as zinc. This opens the possibility for weekly multi-micronutrient dosing with the advantage of reduced costs and lower side effects. Operational research should be encouraged on multi-micronutrient supplementation.
• Either daily or weekly dosing requires adequate education and counseling strategies. Much greater efforts are needed to implement communication strategies in support of supplementation interventions. No supplement distribution should be done without including an educational component.
• Until now, most iron supplementation programmes evaluate their efforts by the number of tablets distributed. Only limited information is available on the impact of these programmes on anemia reduction. Most often nothing is learned about factors affecting compliance or even compliance rates. No supplements should be distributed without process evaluation that includes at least compliance by a qualitative measure of iron in stool on a subsample. A subsample should also be measured quantitatively for the effect on hemoglobin and ferritin.
• Anemia prevention programmes will be significantly improved If iron is combined with other micronutrients through fortification and supplementation, and adequate communication strategies are put in place and carried out and process evaluation is implemented through a "Triple A" approach.

Gary Gleason of the International Nutrition Foundation (INF) presented progress on development and implementation of the integrated strategy proposed by UNICEF for iron deficiency anemia prevention and control in the Central Asian Republics and Kazakhstan that was outlined at the 24th SCN meeting in 1997. The strategy has now formed the basis for a set of five interrelated national projects that are moving into phased implementation that began in May 1997 starting with one oblast of Kazakhstan. The initial impetus for design of this strategy was the findings of the USAID funded DHS surveys in Kazakhstan and Uzbekistan that for the first time included hemoglobin testing of national samples and revealed high rates of iron deficiency anemia in both women and children.

Ray Yip, UNICEF Indonesia, summarized key issues that affect the use and success of an integrated approach to achieving and sustaining iron deficiency anemia prevention and control.

Major Issues of Programme and Intervention Focus include:

• The focus has been on anemia in pregnancy with not enough attention on infancy and early childhood.
• Focus on any one approach such as fortification or supplementation is likely to be ineffective; programmes require greater attention to integrating additional approaches into the overall strategy.
• The strong research focus on the dosage and frequency of supplementation should now shift to summarizing the results into practical programme options and guidelines and a shift made to needed issues of programme effectiveness.
• To obtain sufficient compliance to be effective iron supplementation requires supervision, education and communication.
• Programmes aimed at preventing and controlling iron deficiency anemia can be strengthened by a stronger linkage to other health activities.

Iron Deficiency in Early Childhood

• There is research support and consensus on the fact that without specific preventative measures the majority of infants in many populations will develop iron deficiency anemia.
• To address this there are specific measures under development that need greater attention including:

  • improving complementary feeding
  • supplementation or use of fortified products- the opportunity to improve multiple micronutrients particularly zinc.

Anemia and pregnancy:

• Greater attention is needed toward programme effectiveness
• Reduction of maternal anemia rates will require improvement of women's iron status before pregnancy
• Both supplementation and fortification are avenues for improving iron status before pregnancy.

Why Multiple Micronutrients should be considered:

• In developing countries iron is not the only nutrient lacking from the diet.
• There is increasing evidence of the benefits from controlling other micronutrient deficiencies - zinc in infancy, and vitamin A and zinc during in pregnancy.
• It is cost-effective to use multiple micronutrients for supplementation or fortification.

Essential Steps to Move the Effort of Prevention of Iron Deficiency Forward:

• Accept the fact that no single approach will make the difference; use all that can apply.
• Link programmes to other existing efforts, safe motherhood for women, improving complementary feeding for infants, etc.
• Invest in efforts that can assure effectiveness of large-scale programme efforts.
• Use the effort and channel for iron to improve other micronutrients.

World Health Organization

• Noted the importance of the strong relationship between hookworm and anemia in areas where hookworm is prevalent.
• Recommended that the folic acid component of the FESO4 plus folic acid supplement pill be increased from 250 micrograms to 400 micrograms per tablet.
• Completed guidelines for control of IDA in Middle-East and North African Region.
• Promised that the report of a 1995 WHO/UNICEF/UNU meeting on the prevention of iron deficiency would be published in the current year.

United Nations Children’s Fund

• Noted that efforts to identify better products for use in delivering supplements to young children are continuing.
• A meeting on IDA programmes was organized with the Micronutrient Initiative for the Eastern and Southern Africa Region.
• UNICEF and other organizations are stressing the need for anemia surveys in several countries where there is insufficient data.
• An initial questionnaire was sent to all UNICEF offices and 56 responded with information related to the prevention and control of iron deficiency and iron deficiency anemia. This information is available from the Nutrition Section of UNICEF regarding such areas as the status of country programmes, policies regarding target groups for supplementation, supplementation doses and regimes, and the status of policies and efforts toward cereal flour fortification.

Food and Agricultural Organization

• Organizational policy continues to promote an overall food-based approaches to micronutrient deficiencies.
• Two hundred country level FAO projects through the agricultural sector should make more iron-rich foods available.
• A new handbook for small-scale animal husbandry is available.
• Standards for ferrous sulphate will be discussed by an expert Codex meeting in June.
• Collaboration continues with the World Bank, USAID/OMNI and Micronutrient Initiative. A joint programme with USAID in Latin America is aimed at the widespread fortification of wheat flour.
• Several new publications with ILSI and MI have been produced as well as a video aimed at expediting the operational aspects of the IDA programmes. With FAO encouragement a letter was sent to the Russian Federation from the World Bank recommending fortification of wheat flour.

Pan American Health Organization

• A meeting in Washington highlighted the need to provide folate preventively to women before pregnancy and for greater quality assurance, monitoring and surveillance in relation to flour fortification. Governments should have a specific role in quality control.

International Atomic Energy Agency

• Is supporting the use of isotopes for evaluating iron absorption and will continue collaboration with MI on the Food supplement sprinkles for young children.

United Nations University

• A field study of lysine fortification of wheat flour in Pakistan significantly increased serum transferrin and selective T-cells in men, women and children with an associated improvement in hemoglobin. Early replication in another country is planned.
• Technical cooperation with UNICEF in developing programmes for the control of iron deficiency in Central Asia will be extended to other countries and advocacy efforts will be increased.
• The efforts of the International Iron Nutrition Programme are highlighted in Dr. Viteri’s presentations.

Micronutrient Initiative

• Advocacy video on iron fortification is being prepared and a publication summarizing major issues related to anemia have been produced.
• Support has been provided for a meta-analysis by George Beaton to compare the results of weekly and daily supplementation that is expected to be completed by September of 1998.
• A rapid assessment protocol has been developed to assist in the evaluation of fortification potentials and strategies at country level along with a global directory of manufacturers of premixes.
• A three volume technical manual on flour fortification is being prepared with OMNI.
• A study is being supported in Zanzibar comprising weekly and daily supplementation.

United States Agency for International Development

• Continued interest in and support for efforts to decrease iron deficiency anemia, mainly through increased collaboration with others.
• Agency emphasis is on a view of anemia as a life cycle problem with greater attention to early childhood anemia and to an integrated strategic framework .
• Supported a committee of the US Institute of Medicine on the control of micronutrient deficiencies whose report is now available.

Canadian International Development Agency

• Continued support to the Micronutrient Initiative and for supplementation and fortification commodities.
• Planning support for supplies for multiple fortification.

Asian Development Bank

• New safe motherhood projects in Pakistan and the Philippines.
• Attempting to develop food fortification partnerships at decentralized levels.
• Supporting an eight country study on childhood nutrition in Asia.

United States Centers for Diseases Control

• Releasing new guidelines for control of IDA in US on April 3^rd.
• Working on a standardized training manual to improve the quality control of capillary sampling issues.
• Working the design of interventions including malaria control in relation to iron deficiency anemia in Tanzania.

The integrated strategic framework that was presented by the rapporteurs was well accepted and used to structure the discussion. It was agreed that there had been too many programmes based mainly on only one or two elements. Monitoring of intervention processes as well as evaluation of impact was stressed. Equally essential are supervision, education and communication support not only to improve the distribution of supplements to large population groups but also to improve compliance in their consumption.

The general discussion considered many of the issues that had been raised in the introductory presentations and in the reports by organizations. Views were wide-ranging. Despite some doubts, the majority stressed that for many countries cereal fortification with iron was feasible and desirable as national policy and that much greater effort should be directed toward developing multi-nutrient premixes for use in flour fortification.

It was emphasized that despite its conceptual simplicity fortification of wheat flour was not a simple task and required considerable expert advocacy, technical assistance, solid planning, and follow-up monitoring and evaluation in order to assure that the product produced had consistent good quality, was acceptable to the population, could be sustained and made some impact on iron status of the population. It was also pointed out that fortification should not be seen as a "trivial" complement to other components of the strategy. It was estimated conservatively that flour fortified at typical levels would add the equivalent of 30 mg of iron every 21 days to the dietary intake of the average woman. The "piggy-backing" of additional micronutrients on this process was also seen as making good economic sense where appropriate because of the presence of additional micronutrient deficiencies.

It was noted that the costs of supplementation are relatively modest. Calculated on the basis of US $0.0027 per 60mg tablet, yearly supply costs are US $98.55 per thousand individuals for programmes using daily administration of 60mg FeSO4 + folate. For weekly 60mg FeSO4 + folate they are US $14.04 per 1,000 population covered. For pregnant given 120mg FeSO4 + folate weekly they cost US $28.04 per 1,000.

The linkage of a strategy to prevent iron deficiency to other related public health efforts was agreed as a key element for success. Reproductive health, immunization, the integrated management of the sick child initiative, the Baby Friendly Hospital Initiative and Breastfeeding Promotion as well as malaria control and hookworm control were among such programmes. Since hookworms contribute directly to iron deficiency anemia, incorporation of hookworm control measures as part of the anemia prevention package can help to raise the often low priority for such measures within Ministries of Health.

Although several participants pointed out the lack of evidence for the effectiveness of dietary education alone in reducing iron deficiency, there was total agreement that this component should play a key role in programme strategies. While the importance of food-based and dietary change approaches was agreed upon, it was also noted that even in the USA and Argentina where meat consumption is very large the problem of iron deficiency anemia in children and women remains significant. It was pointed out that it is important to understand and convey to Governments that not only fortification but also some supplementation should be viewed as long-term strategies and not just short term interventions. This was bolstered by studies showing that over 20 percent of women in otherwise well nourished populations may be anemic during pregnancy.

Technical points flagged for additional work included:

• Measuring hemoglobin in infants and young children.
• Achieving sustainability.
• Guidelines for better analysis of who will benefit from flour fortification and who will not.
• Improved strategies for supplement distribution (In some countries many women do not attend antenatal clinics. Exclusive use of the medical services for supplement distribution and education may very well not cover many poor populations).

Finally, it was emphasized that despite the number of meetings on iron in the past two years there remain several contentious issues including anemia treatment guidelines that urgently need to be reviewed and updated. In response, the Chairman noted that the UNU, UNICEF and MI are planning a small meeting later this year for the specific purpose of identifying and clarifying a number of these practical issues that are blocking or inhibiting more rapid programme development. It is hoped to achieve consensus on these issues in order significantly to strengthen the advocacy tools needed to further raise the issue of iron deficiency and nutritional anemias, on national and agency agendas. The outcome of the meeting should be clear and agreed upon options and a comprehensive framework for effective and sustainable programmes for iron deficiency anemia prevention and control.

1.  The SCN should recommend that national Governments, and international and bilateral agencies and NGOs working to design and implement programmes and projects aimed at reducing iron deficiency in young children and women use an integrated strategic framework to address this public health problem on a sustained basis. Such a comprehensive intervention should be based on a life-cycle approach and focus mainly on preventive measures. In particular, these should include a combination of:

• Food fortification, with an appropriate combination of micronutrients that includes iron.
• Supplementation, with an appropriate and cost effective combination of micronutrients including iron.
• Education, communication and information both in support of community involvement and programme components such as compliance and use of fortified flour and for improving dietary practices that result in greater iron intake and absorption.
• Monitoring and evaluation of programme processes and impact that include regular studies and activities to provide information for ongoing programme improvement and measure compliance, efficiency, costs and programme impact.Hookworm and malaria control should be included whenever appropriate.

2.  The SCN should recommend that, wherever appropriate, iron deficiency prevention programmes be dynamically linked with related health programmes including breastfeeding promotion, prevention of other nutritional deficiencies, reproductive health and family planning, measures to control infections, appropriate immunizations, malaria control where needed, environmental sanitation and clean water supply, promotion of breastfeeding and baby-friendly hospitals, and HIV control efforts.

3.  The SCN should recommend that in dealing with iron deficiency anemia, a life cycle approach is necessary and thatthe focus of impact evaluations and intervention planning be on:

• The adequacy of women's iron status at the time they become pregnant.
• The adequacy of infants and children's iron status between the ages of six and 36 months of age.

4.  WHO, UNICEF, UNU and other appropriate agencies need quickly to come to a consensus on the range of supplementation options that should be considered by programme planners as they attempt to develop effective, affordable and sustainable programmes for the prevention and control of iron deficiency and iron deficiency anemia in various countries and settings.

5.  WHO urgently needs to review and update its current recommendations for the treatment of iron deficiency anemia in women and children.

6. The Micronutrient Initiative is requested to accelerate and strengthen current efforts to bring EDTA iron into a position of wider acceptance, lower costs and greater availability to countries wishing to fortify cereal flours and other foods with iron. As a corollary it should support the development of technical guidelines and manuals for the use of EDTA iron as a food fortificant.

7.  UNICEF is urged to review the goals established at the World Summit for Children and ratified by the ICN on the prevention of iron deficiency in order to broaden them to include more specific targets for the reduction of anemia and iron deficiency in infants, young children and all women of child-bearing age.

8.  UNICEF is encouraged to work with appropriate partners and experts to develop a stronger "human and child rights" based linkage for programmes aimed at preventing iron deficiency and iron deficiency anemia in women and children.

9.  WHO, UNICEF and the UNU are encouraged in their planning of a technical consultation aimed at improving consensus on guidelines for addressing iron deficiency related issues at national and subnational levels and on advocacy materials for planning effective multifaceted national iron deficiency prevention programmes.