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SCN Working Group on Micronutrients
held during the ACC/SCN's 29th Session in Berlin, Germany, March 2002
Chair: Dr. Ian Darnton-Hill, Columbia University, NY,
Co-Chairs: Dr. Bruno de Benoist, WHO and Dr. Werner Schultink, UNICEF (not
present)
Rapporteur: Zeina Sifri, HKI
The overall recommendation from the 28th session in Nairobi was that the WG
would focus on 'integrated interventions, including food-based approaches,
rather than interventions involving single micronutrients'. To do this, an
agenda had been designed that gave an overview of the global situation, reports
on multimicronutrient research, food-based approaches and an overview of
activities regarding iron, zinc and the B vitamins. There was a short
presentation from ICCIDD to ensure iodine was addressed. The Chair introduced
the agenda and the thematic topics that were to be covered, including
highlighting the UN World Summit on Children Micronutrient goal: "Achieve
sustainable elimination of iodine deficiency disorders by 2005 and vitamin A
deficiency by 2010; reduce by one third the prevalence of anemia, including iron
deficiency, by 2010; and accelerate progress towards reduction of other
micronutrient deficiencies, through dietary diversification, food fortification
and supplementation". The agenda was amended to allow a short presentation
on the Global Alliance for Improve Nutrition (GAIN) initiative.
Dr. Barbara Underwood, NAS, presented the GAIN initiative that intends to
support developing countries in implementing large-scale fortification of
existing staple foods with micronutrients. This alliance of public and private
sector organizations focuses on support for country-led initiatives that are
part of a larger strategy for the elimination of micronutrient deficiencies. The
Board of Directors has 1 member from each constituent group and 4 members from
developing countries (with one of these representing consumers).The official
launch of GAIN will take place at the same time as the UN Special Session on
Children in May 2002 and the RFA will be posted around the same time on the web
(http://www.gainhealth.org)
Professor John B. Mason, Tulane University School of Public Health and
Tropical Medicine, presented an overview of trends in micronutrient deficiencies
and in control programs. The presentation referred to the recent 'The
Micronutrient Report' (Tulane University/MI/UNICEF) and then highlighted the 3
methods for measuring trends including: comparing national surveys at different
times; fitting regression to diverse national results; and, interpolating
regional estimates at different times for comparison. The prevalence of clinical
vitamin A deficiency is declining relatively rapidly, with the trend starting in
the 70s or 80s before large-scale micronutrient deficiency control programs were
initiated. Consequently, the goal of the International Conference on Nutrition
and World Food Summit goals of eliminating clinical vitamin A deficiency seems a
possibility. On average approximately 100 million vitamin A capsules were
distributed in the 1990s, along with other measures such as improved nutrition,
that help reduce vitamin A deficiency. The trends are showing much less progress
towards the control of iron deficiency and other forms of anaemia. There appears
to be no really good methods for controlling anaemia at a public health level,
and better data are also needed. Priority should be given to improve the
database. With iodine deficiency disorders, looking at the available data, it
would appear that prevalence of goiter is increasing, but this is actually a
result of improved detection of goiter. Where there is successful salt
iodization there is impressive reduction in goiter. Although iodized salt is
widely adopted, approximately 50% of people are not getting iodized salt and
there is still a gap that needs to be filled. This usually represents the
poorest and most difficult to reach. Importantly, it was noted that there are
overlaps between deficiencies and some 25% of children worldwide suffer from 2
or more deficiencies so there is a need for more integrated approaches. Looking
at 99 countries, 28 (1/3) of them have legislation or other regulations dealing
with the 3 micronutrients in question. Because of increasing coverage rates for
micronutrients, there is a need to go from research and development of
approaches to trials of these approaches to confirm their effectiveness. As
efficacious methods are not necessarily effective methods, there is a need to
move from research and development to trials, and to large-scale programs, in
this order.
Professor Andrew Tomkins, Center for International Child Health, Institute of
Child Health reported on 'Multiple micronutrient supplementation during
pregnancy: A meeting to create a mechanism for increased collaboration amongst
ongoing efficacy trials'. Studies have shown that micronutrients are limiting in
maternal diets. In 1999 UNICEF/UNU/WHO agreed on the composition of a proposed
multi-micronutrient tablet providing 1 RDA of vitamin A, vitamin B1, vitamin B2,
niacin, vitamin B6, vitamin B12, folic acid, vitamin C, vitamin D, vitamin E,
copper, selenium, iodine; with 30 mg of iron and 15 mg of zinc. Within the
UNICEF framework of promotion of multi-micronutrient supplementation, a number
of studies have been funded with 8 studies in Asia and 3 in Africa. Efficacy
studies with randomized control trials are ongoing in Bangladesh, China, India,
Indonesia and Pakistan. Whenever possible, studies are integrated into the
existing health systems including for the operational research. The trials are
being undertaken to maximize the return on resources being invested in
micronutrient trials, to ensure comparability across trials and thus pooling of
data for a possible meta-analysis, and to relate policy/programme issues being
tackled by trials to broader policy and programme issues around protecting
foetal and infant growth. Among issues discussed were common indicators,
biomarkers, ethical considerations, protocols, pooling data, and increased
collaboration. Analytical issues covered methods of analysis of the studies,
including intent to treat analysis, following the CONSORT guidelines for trial
presentation and specific issues around birth weight, gestational age, mortality
data and survival analysis. The indicator of greatest interest for these trials
is prevalence of low birth weight, but it was felt that this indicator was not
sufficient so the following from the many that the different studies will
continue measuring, were added: maternal mortality and morbidity, infant and
young child mortality and morbidity, maternal nutrition, breastmilk nutrition,
anemia, vitamin A deficiency, and child development. Policy change will be
necessary for the success of this approach if shown efficacious and effective. A
special emphasis was placed on the importance of the affordability of the
supplement and the crucial role of strategic partnerships. Integration of
multi-micronutrient supplementation is possible with other sectors using the
'cuckoo strategy' or 'piggy-backing' on programmes such as health, social
development, etc for malaria control, HIV control, deworming, etc. The
presentation ended with the following next steps: - Network of exchange of
information between investigators. - Meeting to examine progress in 1 year. -
Focus on efficacy and operations research where effectiveness trials are
underway. - Early review of policy implications. - Keeping an eye out for new
legislation and results.(The European Union is said to be considering a ban on
the sale of multi-vitamins).
Dr. Heather Goldman, USAID, presented USAID's work on behalf of Dr Frances
Davidson. USAID is supporting research and operational efforts to scale-up,
improve delivery, and develop technology for micronutrient deficiency control
programs. With its partners, it is striving to find best approaches to decrease
vitamin A and iron deficiency in the context of widespread poverty, high burden
of infectious disease, including HIV/AIDS, and inadequate micronutrient content
of food. Much work needs to be done to understand how to improve the outreach of
iron-folate supplementation and the fortification vehicles for vulnerable
groups. USAID, along with others, is funding trials to improve our understanding
of the efficacy (and effectiveness) of multiple micronutrients. USAID is also
assisting researchers in many countries through MOST, HKI, and JHU projects.
Through technical assistance, monitoring, operational research, and information
sharing, USAID is helping countries determine how different delivery systems for
vitamin A supplements will be successfully implemented, reach the intended
populations, and have the desired impact. USAID is also exploring post-NID
delivery strategies for vitamin A. The extent of micronutrient deficiencies,
particularly iron deficiency and sub-clinical vitamin A deficiency is such that
partnerships must be formed that combine the strengths of public and private
sector organizations.
Professor Jack Ling, Chair, International Council for Control of Iodine
Deficiency Disorders presented an update on IDD elimination, that demonstrated
that globally there has been a very substantial progress in the effort to
virtually eliminate iodine deficiency. Two-thirds of the households in the world
now use adequately iodized salt. Latin & South America takes the lead with
86%, East Asia & Pacific second with 76%, and West & Central Asia 70%.
The lowest rates are 21% in Central/Eastern Europe, the Commonwealth of
Independent States and Baltic States. This means that some 90 million newborns
last year were protected against the risk of brain damage, but 50 million
newborns still did not get this protection in 2001. There have been some
setbacks in countries like India where the Central Government lifted its ban on
non-iodized salt last year. Of serious concern globally is a lack of appropriate
strategy for sustained elimination. In countries that declared success only a
short time ago, Bolivia and Vietnam show a backsliding of household usage of
iodized salt from 90% to below 70%. The goal of sustained elimination cannot be
attained until there is widespread availability of iodized salt, the necessary
legislative and managerial support and appropriate technical services, along
with much broader base of public education must first be in place to empower
people e.g. to reduce the persistent perception of equating iodine deficiency
with visible goiter. A giant step in harmonizing and coordination has been the
formation of the Global Network for Sustained Elimination of Iodine Deficiency.
The nine founding members of the Network are: European Salt Producers
Association, Salt Institute with its international membership and China National
Salt Association, WHO, UNICEF, ICCIDD, CDC, MI, and Kiwanis International. It
will begin a series of national assessment reviews led by ICCIDD, the first of
which will take place in Panama. It was noted that the Secretary General of the
United Nations, Kofi Annan, in his address to world economic leaders last month
chose to cite the collaboration between salt producers and development agencies
for iodine deficiency elimination as a prime example of successful
public/private partnership for development.
Dr. Saskia de Pee, Helen Keller International, Asia-Pacific Regional Office
presented the compelling evidence for the impact of homestead food production on
micronutrient deficiencies and health. Homestead food production (HFP) has been
shown to be important as it leads to increased consumption of micronutrient rich
foods for combating micronutrient malnutrition. It also helps with food
security, income, and supports the participation of women in decision making. Millennium
development goals (MDGs) for reducing poverty by 2015 were set at the G8 Summit
held in Okinawa in 2000. HFP contributes to meeting 5 of these goals. HFP was
shown by Dr. de Pee to reduce mortality of infants, children and mothers (MDG 4
& 5). Malnutrition increases the likelihood of mortality from a number of
diseases and is associated with up to 56% of all childhood mortality. HFP
decreases the risk of micronutrient malnutrition as it increases production and
consumption of vegetables and fruits. The increased consumption of vitamin
A-rich vegetables and fruits is associated with reduced risk of vitamin A
deficiency disorders. In Bangladesh, children 12-59 months, not receiving a
vitamin A capsule, had lower risk of vitamin A deficiency when their household
had a garden or poultry. HFP increases production of vegetables and fruits,
increases income, which is often used to purchase other foods, which in turn
contributes to improving micronutrient status. HFP reduces extreme poverty (MDG
1). It is implemented by households of lower socio-economic status, and on very
small plots of lands, even on roofs. HFP also increases income and replaces some
of the foods usually purchased. Such programmes empower women and contributes to
achieving gender equality (MDG 3), as it is mainly a woman's activity that
includes deciding on the use of the resources generated. It is also usually
implemented in an environmentally friendly way (MDG 7). The important steps for
a successful HFP program are to first make sure that food availability is main
constraint for increasing production. Then, build on existing practices for food
production (generally not introducing new foods), and use locally available
organizational infrastructure, techniques and resources. Homestead food
production complementary to other strategies.
Dr. Richard Deckelbaum, professor of Human Nutrition, Columbia University and
Chair of the Steering Committee, March of Dimes Task Force on Nutrition and
Optimal Human Development identified the pros and cons of a food-based approach
while presenting the report 'Nutrition Today Matters Tomorrow - A Lifecycle
Approach' from the March of Dimes. The Report proposes a paradigm shift in our
interventions focusing on promoting healthy lifestyles, focusing on prevention,
and targeting the pre-conceptual woman, thus offering enormous potential for
achieving significant improvements in health and nutrition worldwide. The Report
highlights food-based dietary guidelines that may include fortified foods and
that offer a feasible, effective, and sustainable approach to promote healthy
eating by the population in general and addresses nutrition problems in
vulnerable groups. The emphasis remains on the lifecycle perspective, from the
pre-conceptual woman to pregnancy to infancy to adulthood. Overweight and
obesity in women pre-pregnancy, which increases complications in pregnancy, but
also doubles the risk of premature babies, with a 2-3 fold increase in serious
congenital malformation. While addressing iron, iodine, zinc, vitamin A, folate,
vitamin D, and calcium, the importance of food based dietary guidelines and that
approach was emphasized. The advantages of food based approaches are that they
focus on food groups and not single nutrients, leading to covering all or most
micronutrient requirements, with no high doses or adverse effects. The main
disadvantages are that availability, access, cost, and socio-cultural factors
and bioavailability of foods may be limiting.
Dr. Gary Gleason, International Nutrition Foundation, presented a summary
report on activities related to iron, folic acid, zinc in particular but also
touched on other micronutrients such as vitamin B12. Compiled by surveying many
partners and prepared by the IDPAS Project of the International Nutrition
Foundation, acting as an informal secretariat on issues related to iron, folate,
and zinc. The feedback received was compiled and is available in the Iron World
II CD-ROM. At the end of the last decade when the final report on the goals of
the World Summit for Children was sent to the UN Secretary General, iron
deficiency anemia was the one goal not reported upon. Thanks to the work of the
SCN and its members, there is now a new decade target for anemia that focuses on
the lifecycle and includes young children. In order to achieve the new decade
target, there is a need for increased commitment to the lifecycle approach and
to the integrated, multiple-intervention model that is strongly endorsed by the
SCN. It includes dietary diversification, food fortification, supplementation,
infection control and linkages with other public health measures guided by
monitoring and research and bolstered by well-planned communication support.
Some of the main themes emerging from the increased dialogue on iron deficiency
were identified as: the need for iron-related meetings and workshops to be more
productive, and the rapid dissemination of their reports; growth and expansion
of community efforts to effectively supplement various groups with iron and
other micronutrients; diversification in supplementation and fortification
interventions; improved advocacy and support for zinc and folic acid;
improvements in fortification formula; improvement in methods and technologies
for assessment, monitoring and evaluation; support for advocacy, program
planning, communication support and increased accessibility to technical
information; increasing focus on the linkage between prevention and control of
iron deficiency anemia and other public health issues. Some immediate challenges
noted by those surveyed included: maintaining the growing commitment to anaemia
control; translating the new decade target into effective, sustainable anemia
control; avoiding one-dimensional strategies, and building stronger alliances
with the private sector and NGOs; sharing and using existing and new guidelines
and up-to-date technical information; better two-way communication to and from
developing country researchers and project personnel; avoiding re-inventing the
wheel; maintaining conceptual commitment and technical operational linkage to an
integrated model for prevention and control of anemia including iron. Venkatesh
Mannar, of the Micronutrient Initiative (MI) then made a brief presentation
highlighting the need for a new strategy for iron. A group of agencies and
institutions have agreed to work together to focus on iron through advocacy.
Special mention was made of materials and activities of the Asian Development
Bank. Difficulties exist in programme implementation but a strategy developed by
the Manoff Group showed that the little priority given to iron control programs
is because awareness is low and simple solutions to the problem are not clear.
It should be addressed with other development goals. Important messages on iron
are needed such as: - It promotes child growth, development, and good health -
It improves learning - It reduces maternal mortality It is also important to
highlight that there are successful treatment and prevention options that are
cost-effective and to highlight benefits in the reduction of iron deficiency
such as: a better quality of life to individuals and communities, an increase in
return on investments, and stronger economies and building nations. An iron
advocacy strategy was proposed to enhance awareness of iron deficiency,
addressed to all levels of policy and decision makers. The suggested strategy
has two parts: A Global Strategy, and a Sectoral Strategy. It will build support
through the involvement of other sectors. The strategies are tailored with
information for decision makers and program implementers of school health, safe
motherhood, adolescent health, women's health, and workplace health involving
both employers and labour, and would need to be consistent with the new decade
goal.
Recommendations and next steps for the Micronutrient Working Group:
Recommendations:
- Develop a programme planning framework consistent with the new Decade
Goals to be adopted in May 2002 at UN Special Session on Children (Working
Group involving SCN Partners)
- Examine the possibility of setting-up a group to promote the integration
of the different strategies for prevention of micronutrient deficiencies to
enhance effectiveness and reduce non-productive competition (Working Group
involving all relevant SCN Partners)
- Promote coordination of efforts to develop effective strategies for
preventing anemia in children less than two years of age (IDPAS to
coordinate a Task Force of Working Group)
- Develop methods to identify groups not currently reached and the best
approaches to address their needs (Working Group coordinated by Task Force
with INACG and other relevant SCN partners)
- Examine the sustainability of IDD control programs following the
establishment in The Hague of the Global Network for Sustained Elimination
of Iodine Deficiency (IDD Task Force involving UNICEF/WHO/ICCIDD at the
minimum)
At the 30th SCN Session in Chennai this Working Group will report back on:
- New/sustainable programmes for anaemia control
- Developments regarding multi-micronutrient trials
- Adherence and compliance issues
- Expansion of a coordinated data base of advocacy materials and strategies
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