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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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