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Prevention of Micronutrient Deficiencies: Tools for Policymakers and Public Health Workers (1998)
Institute of Medicine (IOM)

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Prevention of Micronutrient Deficiencies

Tools for Policymakers and Public Health Workers

Committee on Micronutrient Deficiencies

Board on International Health

Food and Nutrition Board

INSTITUTE OF MEDICINE

Christopher P. Howson, Eileen T. Kennedy, and Abraham Horwitz, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1998

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I

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--> Prevention of Micronutrient Deficiencies Tools for Policymakers and Public Health Workers Committee on Micronutrient Deficiencies Board on International Health Food and Nutrition Board INSTITUTE OF MEDICINE Christopher P. Howson, Eileen T. Kennedy, and Abraham Horwitz, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1998

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the U.S. Agency for International Development. The views presented in this report are those of the Institute of Medicine Board on International Health and are not necessarily those of the funding organization. International Standard Book No. 0-309-06029-X Additional copies of Prevention of Micronutrient Deficiencies: A Toolkit for Policymakers and Public Health Workers are available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055; Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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--> Committee On Micronutrient Deficiencies ABRAHAM HORWITZ (Chair), Pan American Health Organization, Washington, D.C. JOSEPH A. COOK, Program for Tropical Disease Research, The Edna McConell Clark Foundation, New York City JOHN DUNN, University of Virginia Health Sciences Center JOHN W. ERDMAN, JR., Division of Nutritional Sciences, College of Agriculture, University of Illinois at Urbana-Champaign OSMAN M. GALAL, Department of Community Health Services, School of Public Health, University of California at Los Angeles JAMES GREENE, Chevy Chase, Maryland E. C. HENLEY, Protein Technologies International, St. Louis, Missouri EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, D.C. REYNALDO MARTORELL, Department of International Health, The Rollins School of Public Health, Emory University NEVIN S. SCRIMSHAW,*† The United Nations University, Food and Nutrition Program for Human and Social Development, Boston KEITH P. WEST, JR., Division of Human Nutrition, The Johns Hopkins University School of Hygiene and Public Health Staff CHRISTOPHER P. HOWSON, Director, Board on International Health STEPHANIE Y. SMITH, Administrative/Research Assistant SHARON GALLOWAY, Financial Associate *   Member, Institute of Medicine. †   Member, National Academy of Sciences.

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--> Board On International Health BARRY R. BLOOM (Cochair),* Howard Hughes Medical Institute, Albert Einstein College of Medicine HARVEY V. FINEBERG (Cochair),* Harvard University School of Public Health JACQUELYN CAMPBELL, The Johns Hopkins University School of Nursing JULIO FRENK,* Fundación Mexicana para la Salud, Mexico, D.F. DEAN T. JAMISON,* Center for Pacific Rim Studies, University of California at Los Angeles EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, D.C. ARTHUR KLEINMAN,* Harvard University Medical School BERNARD LIESE, Health Services Department, The World Bank, Washington, D.C. WILLIAM E. PAUL,* National Institute of Allergy and Infectious Diseases and Office of AIDS Research, National Institutes of Health, Bethesda, Maryland ALLAN ROSENFIELD, Columbia University School of Public Health PATRICIA ROSENFIELD, The Carnegie Corporation of New York, New York City THOMAS J. RYAN, Boston University School of Medicine, and Senior Consultant in Cardiology, Boston University Medical Center JUNE E. OSBORN (Institute of Medicine Liaison),* Josiah Macy, Jr., Foundation, New York City JOHN H. BRYANT* (Ex-Officio), Moscow, Vermont WILLIAM H. FOEGE* (Ex-Officio), Task Force on Child Survival, The Carter Center, Emory University DAVID P. RALL (Institute of Medicine Foreign Secretary),* National Institute of Environmental Health Sciences (retired), Washington, D.C. Staff CHRISTOPHER P. HOWSON, Director STEPHANIE Y. SMITH, Administrative/Research Assistant SHARON GALLOWAY, Financial Associate *   Member, Institute of Medicine.

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--> Food And Nutrition Board CUTBERTO GARZA (Chair), Division of Nutrition, Cornell University JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois LINDSAY H. ALLEN, Department of Nutrition, University of California at Davis BENJAMIN CABALLERO, Center for Human Nutrition, The Johns Hopkins University School of Hygiene and Public Health FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida MICHAEL P. DOYLE, Department of Food Science and Technology, Center for Food Safety and Quality Enhancement, The University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, and Departments of Medicine and Community Health, Tufts University Medical School and School of Nutrition Science and Policy SCOTT M. GRUNDY,* Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas CHARLES H. HENNEKENS, Harvard University Medical School and Brigham and Women's Hospital, Boston JANET C. KING,* University of California at Berkeley, and U.S. Department of Agriculture Western Human Nutrition Research Center, San Francisco SANFORD A. MILLER, Graduate School of Biomedical Sciences, University of Texas Health Science Center, San Antonio ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington A. CATHERINE ROSS, Department of Nutrition, The Pennsylvania State University ROBERT E. SMITH, R. E. Smith Consulting, Inc., Newport, Vermont VIRGINIA A. STALLINGS, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia VERNON R. YOUNG,† Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology STEVE L. TAYLOR (Ex-Officio), Department of Food Science and Technology and Food Processing Center, University of Nebraska at Lincoln *   Member, Institute of Medicine. †   Member, National Academy of Sciences.

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--> HARVEY R. COLTEN* (Institute of Medicine Council Liaison), Northwestern University Medical School Staff ALLISON A. YATES, Director GAIL A. SPEARS, Administrative Assistant CARLOS GABRIEL, Financial Associate

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--> Acknowledgments The committee is grateful to the many individuals who made substantive and productive contributions to this project. Particular thanks are in order to the authors of the background papers, whose effective efforts provided important information bearing on the topic of this report: John Stanbury; Barbara Underwood, National Institutes of Health; and Fernando Viteri, University of California-Berkeley. The committee gives special thanks to the following workshop participants: Lindsay Allen, University of California at Davis; Frances Davidson, USAID; Johanna Dwyer, New England Medical Center; Miguel Gueri, Pan American Health Organization; Suzanne Harris, International Life Sciences Institute; James Olson, Iowa State University; Margaret Burns Parlato, Academy for Educational Development; Soekirman, World Bank; and Rebecca Stoltzfus, Johns Hopkins School of Hygiene and Public Health. The committee would also like to thank Christopher Howson, project director; Stephanie Smith, project assistant; Sharon Galloway, financial associate; Michael Edington, managing editor; Claudia Carl, staff associate for report review; and Caroline McEuen, contract editor.

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DEDICATED TO Abraham Horwitz, M.D. For his extraordinary commitment to this report and to the ideal of health for all.

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--> Contents 1 SUMMARY   1     Project Charge   1     Organization of the Report   3     Findings and Recommendations   3 2 KEY ELEMENTS IN THE DESIGN AND IMPLEMENTATION OF MICRONUTRIENT INTERVENTIONS   11     The Importance of Iron, Vitamin A, and Iodine to Health   12     The Continuum of Population Risk   14     Options for Successful Interventions   17     Costs of Interventions   22     Feasibility of Involving Key Societal Sectors in the Planning and Implementation of Micronutrient Interventions: A Guide to Decisionmaking   26     Elements of Successful Interventions Across the Continuum of Population Risk   27     Common Elements of Successful Micronutrient Interventions   33 BACKGROUND PAPERS     3 PREVENTION OF IRON DEFICIENCY Fernando E. Viteri   45     Diagnosis of Iron Deficiency and Anemia   46     Causes of Iron Deficiency   48     Iron Excess   53

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-->     Prevention of Iron Deficiency in At-Risk Groups   54     Sustainable Approaches to the Elimination of Iron Deficiency   67     Benefits and Costs of Preventing Iron Deficiency   79     Suggested National Goals   81     Appendix   83 4 PREVENTION OF VITAMIN A DEFICIENCY Barbara A. Underwood   103     Major Health Consequences   103     Magnitude and Epidemiology of the Problem   105     Economic Costs of VAD   111     Indicators of VAD   111     Critical Elements for Successful Nutrition Intervention Programs   115     Approaches to the Prevention or Correction of VAD   115     Other Countries' Experiences   120     Complementarity of Interventions   143     Costs and Benefits   145     Balancing Approaches to Country-Specific Circumstances   148     Summary   152 5 PREVENTION OF IODINE DEFICIENCY John B. Stanbury   167     Requirements for Iodine   167     Consequences of Iodine Deficiency and Its Correction   168     Consequences of the Correction of Iodine Deficiency   170     Interaction with Other Micronutrients   171     Extent of Iodine Deficiency   171     Indicators of Iodine Deficiency and Impact of Prevention   175     Prevention and Correction   176     National Programs: Some Examples of Success and Failure   180     Structure of Preventive Programs   186     Impediments to IDD Control   188     Action Plans for the International Agencies   192     Summary   195     Appendix: ICCIDD Guidelines for Assessment of Progress Toward IDD Elimination   196 APPENDIX: WORKSHOP AGENDA   203

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Prevention of Micronutrient Deficiencies Tools for Policymakers and Public Health Workers

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