United Nations System
Standing Committee on Nutrition

SCN Working Group on Micronutrients

held during the ACC/SCN's 28th Session in Nairobi, Kenya, on Wednesday 4 April 2001

Chair: Ian Darnton-Hill, HKI
Co-Chairs: Bruno de Benoist, WHO; Werner Schultink, UNICEF
Rapporteurs: Arjan de Wagt, UNICEF, Shawn Baker, HKI

The chair began by explaining that the Working Group agenda this year is organized around themes - further, that issues raised last year, as well as on-going agency work, would be dealt with under each thematic topic.

Iodine:

Two presentations on control of iodine deficiency disorders (IDD) were made by Bruno de Benoist and by Judith Mutamba of the International Council for the Control of Iodine Deficiency Disorders (ICCIDD). In general, there has been major progress in controlling IDD, predominantly through iodization of salt. The main challenges for the future include:

Providing special support to countries affected by IDD but which have no control programme in place
Ensuring sustainability of salt iodization.

These can be addressed through the following actions:

Mobilizing the international community
Developing partnerships of various stakeholders, including salt producers
Reinforcing the capacity of laboratories at country, regional and international level
Undertaking independent assessments of progress made by countries.

Indicators for monitoring and evaluating progress towards IDD control were discussed. It was felt that there is still a place for supplementation with iodized oil capsules in highly affected areas not yet reached by iodized salt or iodinated water. These needs will reduce as salt iodization becomes truly universal.

The Working Group noted the importance of the following standing recommendations:

Support to small-scale salt producers should be increased
Potassium iodate should be sourced at low prices and excise duties waived
Community-level salt iodization should be piloted where appropriate
Collaboration with the salt industry should be institutionalized
The availability of salt testing kits should be ensured, through local production if possible
Monitoring of salt iodization legislation should be continued
From a human rights perspective, we cannot be satisfied with 90% of households using iodized salt (an established indicator of program success), but must ensure that 100% of households are covered.

Iron:

Cutberto Garza (UNU) gave a presentation and distributed a report prepared by Nevin Scrimshaw (UNU) and Gary Gleason (International Nutrition Foundation). The presentation focused on the need to ensure a strong goal for reduction of iron deficiency anaemia (IDA) in the outcome document for the upcoming United Nations Special Session on Children, September 19-21, 2001. New language was proposed "Reduction in the prevalence of anaemia, including iron deficiency in pregnant women and children less than two years of age by at least one third of the 2000 level by 2010". The Working Group did not agree to support this amendment, nor to support the language in the current draft - "Strengthen public-private partnership to accelerate progress towards the sustainable elimination of iodine deficiency disorders by 2005, vitamin A deficiency disorders and anaemia, including iron deficiency, by 2010". It was noted that there is a third preparatory committee meeting June 11-15, 2001, which offers an opportunity to debate the language of the outcome document.

Subsequently this matter was discussed during the SCN plenary on April 6. It was decided that Milla McLachlan (World Bank) and Ian Darnton-Hill would draft new wording, seeking the assistance of others if needed. The new wording would be put on the SCN's webpage, and conveyed by letter to Kul Gautam (UNICEF), as one of the strategy/activity statements (there are only 5 over-arching goals in the document). The letter would also commend the nutrition content of the draft outcome document. A conference call was convened on April 11 involving Milla McLachlan (Bank), Ian Darnton-Hill (HKI), Gary Gleason (INF/UNU), David Haxton (MI/PAMM consultant) and Venkatesh Mannar (MI). This wording was agreed to, and will be transmitted to Dr. Gautam:

"Through public/private collaboration, ensure progress toward substantial reduction in anaemia, including iron deficiency, in women and children, and the elimination of vitamin A deficiency disorders, by 2010; and achieve sustained elimination of iodine deficiency disorders by 2005".

Discussants at the Working Group pointed out that there have been a number of important activities in the area of control of anaemia and iron deficiency in the past year. However, iron is still the 'orphan' among the three main micronutrients. We do not have demonstrated programmatic impact of iron programmes. There is a need to better document existing programmes, to address all causes of anaemia, including iron deficiency, and to mobilize the same level of support for anaemia, including iron deficiency, as has been mobilized for vitamin A and iodine. From discussions, the rapporteurs have summarized the following recommendations:

Increase efforts to document activities control anaemia and iron deficiency, including programme impact, and develop more "lessons learned"
Increase mobilization for programmes to control anaemia and iron deficiency
Develop programs to address all causes of anaemia, including iron deficiency. Practitioners and researchers should develop a package of interventions for anaemia control
Reviews of policy and practice in anaemia and iron deficiency control should be undertaken in all countries.

Vitamin A:

Ian Darnton-Hill reviewed advances and evolution of thinking in vitamin A area. These main points were covered:

Much progress has been made towards controlling vitamin A deficiency, accelerated by national immunization days (NIDs) and innovations such as national micronutrient days and child health weeks
There is consensus to accept new terminology: vitamin A deficiency disorders or VADD, will replace both "clinical deficiency" and "sub-clinical deficiency"
WHO is preparing an update on vitamin A supplementation guidelines. The major changes are to recommend three doses of 50,000 IU for children 0-5 months, at immunization contacts and to provide post-partum women with two doses of 200,000 IU at a minimum 24-hour interval
There is growing consensus for the need to pursue a package of approaches including supplementation, food fortification and dietary diversification
For assessment, it is increasingly felt that dietary assessment cannot be used to assess levels of VADD. A rate of > 15% of children with serum retinol < 0.7 µmol/L should be considered indicative of a need for intervention. A prevalence of maternal night blindness >5% should be used as a similar threshold value. All countries with an underfive mortality rate >50 per 1,000 should consider that they have a VADD problem. Rapid dark adaptation may be a useful tool for the field but needs more programme experience. Other field methods are being developed but are still not adequately validated
VADD in women is increasingly seen as a major public health problem that needs to be addressed
Estimates of people with VADD have not yet been produced. While there may a decrease in numbers of children affected due to successful programmes, the new terminology implies a new approach to deriving estimates, especially for women and adolescents.

The Working Group discussed the importance of food-based approaches, reiterating the centrality of exclusive and prolonged breastfeeding to control VADD, the importance of disease control in addressing VADD, the importance of integrating multiple approaches and the need for developing strategies for the post-NIDs era.

These recommendations were made for work in the upcoming year:

For food-based approaches, measurement of impact needs continued work and broadening of types of indicators used
Breastfeeding and promotion of animal sources of vitamin A should be integral parts of food-based approaches
Continue to promote the implementation of multiple approaches to control VADD
The phasing out of NIDs presents a challenge to develop other strategies to maintain high coverage levels of vitamin A supplementation
It is necessary to accelerate efforts to document the problem of VADD in women, and develop programs that include women and adolescent girls.

Fortification:

Jenny Cervinskas (MI, Ottawa) and Brian Thompson (FAO) gave presentations. The first presenter emphasized that food fortification should be part of a broader development strategy:

Part of an overall health and nutrition strategy including dietary improvement, supplementation and public health measures
Part of a national plan of action for nutrition
Part of an overall food-based strategy that includes improved agricultural practices such as enhanced production of micronutrient-rich foods and plant breeding to improve micronutrient density, improved food processing and storage and consumer education.

Major fortification activities during the past year included:

Salt 2000 where partners from public, private and civic sectors reaffirmed their commitment to achieve and sustain the IDD goal. The round table meeting lead to formation of an alliance and a constitutive board
Feasibility trials on double and triple fortification of salt
An increasing number of countries have started flour fortification initiatives
Technical feasibility studies on cooking oil fortification and start of fortification projects in several countries
Continued sugar fortification in Latin America and Zambia and the initiation of sugar fortification in several other countries
Continuation of pilot projects on small-scale fortification in several African countries
Plans to establish a global fortification coalition for coordinated and strong support to food fortification worldwide
Research on "bio-fortification" (increasing the micronutrient content of crops through traditional plant breeding).

The second presenter reminded the Working Group that fortification is only one element of a food-based strategy. Fortification is not an alternative to the overall goal of improving nutrition through the consumption of a nutritionally adequate diet. Limitations of fortification were identified, including:

The poor have restricted access to fortified foods
Multiple micronutrient deficiencies may not realistically be addressed through fortification
Many micronutrient deficiencies are primarily a result of insufficient food intake
There is still need to refine fortification technologies
Often there is a failure to gain wide public involvement.

Some Working Group participants expressed worries about the global alliance for fortification. It may be beneficial to take a cautious approach because of issues related to market protection, and liberalization of food trade. It was expressed that too little attention is paid to food composition databases and that knowledge on indigenous foods is quite poor. It was felt that fortification efforts also need to emphasize technologies for small-scale fortification to target those who lack access to centrally processed foods.

Multiple Micronutrient Deficiencies:

A presentation was made by Rainer Gross of the German Agency for Technical Cooperation (GTZ) and the Universidad Nacional Agraria La Molina. Reasons why many populations suffer from concurrent micronutrient deficiencies were reviewed. In these cases, intervention with only one micronutrient can have only limited impact.

Characteristics of a multiple micronutrient strategy include:

Not just curative but also preventive. This means working with not just the most vulnerable groups, but also with less vulnerable groups (adolescents, non pregnant women, school children)
Not just one approach but rather several approaches
Not just distribution but also information, education, communication
Not just action but also monitoring and evaluation
Not just efficacy, nor only effectiveness, or even efficiency, but also affordability
Not just single micronutrients but also multiple micronutrients.

The presenter made the following recommendations:

There is a need to develop assessment analysis methods for multi-micronutrient deficiencies in the community
More activities are needed to develop and promote food-based strategies
There is a need for a comprehensive micronutrient strategy that integrates supplementation, fortification and food-based approaches.

The discussions supported the need for community-based approaches integrating multiple interventions and various target groups.

Main recommendation for the next meeting:

The Working Group agreed that the next meeting should focus on integrated interventions, including food-based approaches, rather than interventions involving single micronutrients. A call for abstracts may be a good mechanism to solicit the best material for this discussion.

United Nations System Standing Committee on Nutrition