New Advances in War Against ‘Hidden Hunger’

Micronutrient Deficiencies Can Be Conquered Globally

Released in Washington, D.C.

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M.G. Venkatesh Mannar, Executive Director of The Micronutrient Initiative, and micronutrient experts from Guatemala, Venezuela and the Philippines will be in Washington Wednesday, July 30th, for interviews with journalists at the World Bank. Please call 703-820-2244 to schedule a time.

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An intensive drive to end micronutrient malnutrition, which has led to 1 million maternal deaths, up to 500,000 childhood deaths and blinded 5 million children over the past decade, is having widespread success in key countries, which can serve as a model for the rest of the world, says a new report for an upcoming conference, “Food Fortification to End Micronutrient Malnutrition: State of the Art.”

Micronutrient malnutrition — mainly the lack of sufficient iodine, iron and vitamin A — is the world’s most prevalent nutritional deficiency. More than 1 billion people suffer from mild deficiencies of these nutrients, which can result in mental retardation, nightblindness, lower IQs, lower school performances, less energy and strength, and decreased productivity.

Correction of these deficiencies requires minute amounts of these nutrients — sometimes less than a teaspoon over the course of a lifetime, says the report, supported by a unique consortia of international public health and development agencies, private companies and non-governmental organizations. At “The World Summit for Children” in 1990, more than 150 world leaders pledged their governments to eliminate micronutrient malnutrition this decade.

“If the international community can succeed in its long-term goal of bringing the needed nutrients to the developing world, at a cost of well under $1 per recipient per year, the benefits would be immense,” says M.G. Venkatesh Mannar, Executive Director of The Micronutrient Initiative, based in Ottawa. For vast populations, the benefits would include:

  • Preventing four out of 10 childhood deaths worldwide;
  • Lowering global maternal deaths by more than 1/3rd;
  • Increasing the work capacity of some populations by up to 40 percent;
  • Raising the average IQ of some populations by 10-15 points;
  • Increasing the gross domestic product (GDP) of some countries by 5 percent, with an investment of just 0.3 percent.

To discuss the recent advances in food fortification technology, successes of country programs and to plan new efforts, a conference entitled Food Fortification to End Micronutrient Malnutrition: State of the Art will be held Saturday, August 2, 1997 in Montreal, Canada. Food technology and policy experts from government, industry and research institutions will present reports on the state of fortification technology as well as provide technical overviews and experiences from a number of countries.

The conference report constitutes the first detailed information for the general public on the dramatic results achieved recently in the Philippines, Venezuela, Thailand, Guatemala, and other countries. Partnerships were formed in those nations between governments, researchers, food manufacturers and international donors to develop, test and distribute fortified foods and to educate the public about their value. These success stories include:

  • Venezuela — By putting iron in flour for bread, pasta and other products, Venezuela cut its anemia problem by 66 percent in just two years;
  • Philippines — By fortifying a low-priced brand of margarine that could be stored without refrigeration, the prevalence of vitamin A deficiency was cut by two-thirds among children;
  • Guatemala — Sugar, a staple in the Guatemalan diet, was fortified with vitamin A, and after just two years, the rate of vitamin A deficiency was reduced by 50 percent in pre-school age children;
  • Thailand — A mix of iodine, iron and vitamin A was put into seasoning packets of instant noodles, a staple in the Thai diet, to attack micronutrient deficiency rates that had caused high child mortality, low school performance and depressed economic productivity throughout the nation.

Micronutrient malnutrition is also called “hidden hunger,” because people have no innate appetite or hunger for these essential vitamins or minerals. It poses a threat to 2 billion people across the globe and affects 1 billion of them, mostly, but not exclusively, in developing countries. Most people suffering from the condition may get enough food to eat — the problem is shortages of important vitamins and minerals in their food. Besides iodine, iron and vitamin A, deficiencies of zinc, folic acid, the B vitamins and vitamin D also cause concern.

“The global crusade to iodize nearly all the world’s table and animal salt has taken less than a decade, and fortification of other staple foods with multiple micronutrients is fast gaining ground,” says Glen Maberly, of Emory University’s Programme Against Micronutrient Malnutrition (PAMM). “No magic bullet exists to overcome the widespread micronutrient deficiency problem, but we have shown that different models can be tailored for each individual country or region and can succeed quickly.”

The Conference is jointly sponsored by public and private sector organizations, including The Micronutrient Initiative, based in Canada; the U.S. Agency for International Development’s (AID) Opportunities for Micronutrient Interventions (OMNI); F. Hoffmann-LaRoche, a supplier of micronutrients; and non-profit groups such as PAMM, Helen Keller International and the International Life Sciences Institute (ILSI).

Fortification technology, in which essential vitamins and minerals are added to foods during processing, is not new. The United States, Canada and Western Europe began to fortify foods in the first half of this century. Developing countries and international donors, on the other hand, directed most of their nutritional efforts over the past 50 years in getting people enough to eat. “Today, with increased scientific knowledge, we can focus on the quality of food as well as the quantity,” says Suzanne Harris of ILSI.

“Since micronutrient malnutrition is a ‘hidden hunger,’ political leaders, scientific groups and the general public are often unaware of its devastating impacts, and don’t know about the relatively simple and easy solutions,” says Dr. Frances Davidson of U.S. AID. Also, for reasons of cost, customs or concerns over the “adulteration” of foods, many countries are not yet fortifying food staples with micronutrients.

There are few limitations in our capacity to manufacture sufficient micronutrients to eliminate this worldwide scourge. “While vitamin A deficiency constitutes a true plague on the children of the developing world, 80 percent of our market for vitamin A is in animal and poultry feed. We need to take care of people,” says Alberto Nilson, from F. Hoffman LaRoche.

Iron deficiency — Iron Deficiency Anemia (IDA) is the world’s most prevalent nutritional deficiency, causing one-half of all the different types of anemia. More than 2 billion people worldwide are at risk from a lack of iron or have anemia. One-half of all women and children of pre-school age in developing countries have anemia. Childhood anemia can retard physical growth, retard development of cognitive abilities and lessen resistance to infections. IDA in adults causes fatigue and contributes to low work capacity.

In women, anemia is an important predisposing factor for unacceptably high maternal mortality in many developing countries. It is a leading cause of death among the more than half-million women who die in childbirth each year. It may also be a risk factor for infections before, during and after childbirth and can lead to intra-uterine growth retardation, low birth weight and increased rates of perinatal mortality.

Iron is found in animal products such as red meat and in vegetables, grains and legumes. Red meat provides readily absorbable iron, but iron from plant sources is much less absorbable. A major cause of IDA is the low bioavailability of iron in the largely cereal and legume-based diets among the world’s poor.

Iodine deficiency — Some 1.6 billion people in 95 countries are at risk of iodine deficiency, especially those living in mountainous or flood-prone areas where the soil lacks iodine. Lack of iodine can permanently lower the IQ of children by at least 10 points. Some 655 million people suffer from goiter, a swelling of the thyroid gland in the neck caused by a lack of iodine. It is also the most common cause of preventable mental retardation. Today, there are 43 million cases of mental retardation and 6 million cases of cretinism.

Iodine deficiency can be eliminated by the addition of iodine to table salt. One goal of international agencies and the nearly 160 government signatories of The World Summit for Children is to ensure iodization of 90 percent of the salt — which acts almost like immunization — in 90 percent of the countries where lack of iodine has been a problem. Governments of developing countries, international agencies such as UNICEF, the World Bank and the World Health Organization (WHO), bilateral donors such as Canada and the United States and private food companies have contributed more than $1 billion for the effort.

Vitamin A deficiency (VAD) — This deficiency, which exists in 60 countries, begins as a silent, unseen threat that, if untreated, can eventually rob children of their eyesight and their lives. According to WHO, some 2.8 million children up to age 4 have severe vitamin A deficiency, and 251 million others have severe to moderate effects. VAD blinds between 250,000 to 500,000 children every year, with two-thirds of them dying shortly thereafter, especially in Bangladesh, India and Indonesia and parts of Africa. Without adequate vitamin A in the diet, there is a 23 percent greater chance of early death.

Vitamin A deficiency occurs mostly in areas where consumption of liver and retinol-rich animal products, yellow fruit and dark green, leafy or yellow vegetables is low. VAD also contributes to stunted physical growth, to increased severity of infections, and to raised mortality rates in infants and young children.

The three main intervention strategies to combat micronutrient malnutrition are:

  • Direct supplementation of vulnerable populations or groups with micronutrient supplements, which often requires a large foreign currency input and an elaborate and costly distribution system that depends largely on the public health infrastructure;
  • Dietary improvement, which involves changes in the dietary behavior of the targeted populations to eat appropriate foods, and therefore requires a relatively long time to achieve concrete results;
  • Fortification of common foods with micronutrients, which is often the quickest and most cost effective intervention.

The Montreal conference, Food Fortification to End Micronutrient Malnutrition, focuses on communicating information to assist countries in developing new ways to fortify popular commercial food commonly eaten staple foods because, if the right food that is consumed regularly by target populations is selected, high coverage is assured, improvement is immediate, and costs compared to benefits are very low. The programs are also self-sustaining because once the initial research is completed, the primary investment will come from the food processing and distribution sectors. Fortification adds little if any to the final cost of the product. Even if a product costs more, the increase is usually pennies per year, and is therefore affordable for the poor. Any price increases could easily be absorbed within normal market price fluctuations.

Iodizing salt, first undertaken in the 1920s, showed immediate and spectacular results in North America and Europe. Fortification of margarine with vitamin D, for example, is thought to have eliminated rickets from Britain, Canada and Northern Europe early in this century. Fortification of refined flour with iron in Sweden and the United States brought a dramatic reduction in iron deficiency anemia. The United States began to fortify bread with iron because WW II recruits showed high rates of anemia.

A new awareness of the devastating human and economic impact of micronutrient deficiencies in the developing world has resulted in the creation of innovative partnerships between the public and private sectors. Some of the many success stories follow.

Venezuela — Pre-cooked corn flour (PCF) is a Venezuelan staple that is mainly used in the preparation of arepa, a popular type of bread. Traditional PCF was more than 80 percent carbohydrate and had a low nutritional content, with less than 5 milligrams (mg) of iron per 100 grams (g) of flour, and no significant amount of vitamin A.

In 1992, the government formed the Commission for the Nutritional Enrichment of Foods, (CENA), to coordinate efforts by the official and private sector in food enrichment.

“The Commission worked out a formula to enhance the PCF, which was made mandatory throughout the nation in 1993; each kilogram (2.2. lbs.) of PCF had to be fortified with 1.5 mg (milligrams) of thiamin; 2 mg of riboflavin; 20 mg of niacin; and 20 mg of iron, says Jose Felix Chavez, MD, Director of the National Nutrition Institute of Venezuela. “A preliminary survey carried out in Caracas in 1994 showed the prevalence of anemia was cut from 37 percent among school children to 15 percent in 1994.”

Guatemala — To protect the Guatemalan population from the consequences of vitamin A deficiency, sugar was chosen to be fortified with vitamin A. From 1975-77, more than 70 percent of sugar produced in the country was fortified. The fortification produced significant results, reducing vitamin A deficiency in children by 50 percent. Unfortunately, fortification ceased after 1977. By the mid-1980s, research demonstrated the vitamin A deficiency was once again assuming serious proportions. Sugar fortification was made mandatory again in 1987. In return for fortifying sugar for the local market, private sugar producers were exempted from paying import duties on machinery, vitamin A concentrate and other imports required for sugar fortification. As a result, the VAD rate has been cut in half once again.

The Philippines — The experience in the Philippines demonstrates the value of fortifying commonly consumed commercial or traditional products that already reach the poor and high risk groups, or have the potential to do so. In the Philippines, one brand of margarine, Star Margarine, met the criteria of being feasible for fortification, packed in a plastic container that protects the product from undue exposure and does not require refrigeration, is centrally produced by one manufacturer and has proven popular among the lowest socio-economic strata.

The manufacturer and the government opted for a one-year trial to test if the margarine could retain and keep stable higher levels of vitamin A enrichment, instead of an immediate program with lower levels of the vitamin. The first field trials were conducted in 1992, using a double-masked before-and-after intervention comparison between experimental and control groups in six villages of the rural town of Silang in Southern Luzon.

At the same time, the government advised the manufacturer to undertake public relation campaigns to inform the nation about the importance of vitamin A to the human body, especially its effect on vision and health. The manufacturer produced 30-second radio and TV spots on vitamin A.

“After six months, the prevalence of a lack of vitamin A decreased from 25.7 to 10.1 percent in the experimental group that received fortified margarine, but remained unchanged, at more than 25 percent among the control group,” says Florentino Solon, M.D., director of the Nutrition Centre of the Philippines. In addition, no children who received the experimental margarine developed symptoms of vitamin A deficiency, such as the inability to see in dim light, but nearly 2 percent of the control children did.”

Because of the success of this trial, an effort to fortify margarine nationwide was begun, with the goal of eliminating VAD as a public health problem by the year 2000.

Thailand — Successful cooperation between the government, universities and food producers in Thailand in a fortification program also resulted in a “win-win situation” that benefited everyone, especially children.

Although the malnutrition problem in economically vibrant Thailand has improved considerably in recent years, dietary deficiencies in iodine, iron and vitamin A still caused considerable problems, especially in more remote areas of the country.

“Children and pregnant women were suffering widely from iron deficiency; between 12 and 24 percent among preschool children in 1995, and between nine and 17 percent among pregnant women,” says Visith Chavasit, Ph.D., of the Thai Institute of Nutrition. “In 1995, incidences of goiter averaged 5.7 percent among primary school children, rising to 7.6 percent in northern Thailand, and hitting 28 percent in one province. In 1995, moderate, subclinical vitamin A deficiency affected some 20 percent of preschool children.”

Thailand has made major strides towards elimination of iodine deficiency during the past decade through salt iodization that covers vulnerable groups of population. In 1993, Thailand’s Ministry of Public Health appointed a committee of government representatives, the Federation of Thai Industries and the Institute of Nutrition at Mahidol University to develop more effective ways to fortify food with other micronutrients.

The committee decided on an urgent basis to test a program that fortified instant noodles, a popular food that came in ready-to-prepare packages. In 1993, instant noodle consumption in Thailand totaled 30 packages per capita.

The committee decided to add the fortification to the seasoning packet, since the seasoning does not undergo much cooking before consumption, and is protected within a separate container inside the noodle package. The committee also organized a media campaign to introduce the new product to the Thai public, with manufacturers assisting in the cost. To keep costs down, the government reduced the taxation rate from 45 to 10 percent on instant noodles. The government will conduct studies over coming years to determine the effectiveness of the fortified noodles.

“The object of this micronutrient crusade is to establish fortified foods as a standard product that consumers will expect and demand, and as the standard way of business for producers,” says Mr. Venkatesh Mannar. “This would maximize the outreach of micronutrients to those who need them most and eliminate micronutrient deficiencies across the world, thereby making a significant contribution to the physical, social and economic well-being of mankind.”

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The Micronutrient Initiative is an international secretariat supported by the Canadian International Development Agency (CIDA), International Development Research Centre of Canada (IDRC), United Nations Development Programme (UNDP), United Nation’s Children’s Fund (UNICEF), USAID and the World Bank, committed to the global elimination of micronutrient deficiencies.

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