Prevention of Micronutrient Deficiencies Tools for Policymakers and Public Health Workers (1998) / Chapter Skim
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2 KEY ELEMENTS IN THE DESIGN AND IMPLEMENTATION OF MICRONUTRIENT INTERVENTIONS
2 KEY ELEMENTS IN THE DESIGN AND IMPLEMENTATION OF MICRONUTRIENT INTERVENTIONS
Pages 11-42
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From page 11... ...
Experience to date has shown that "how" an intervention is implemented may be as important, or in some cases more important, than "what" is implemented. Some research has already been conducted on elements of successful nutrition interventions generally; in 1989, the USAID International Nutrition Planners Forum held a workshop in Seoul, South Korea, on "Elements of Successful Community Nutrition Programs."3 Similarly, a World Bank-funded project entitled "Successful Nutrition Programs in Africa: What Makes Them Work?
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From page 12... ...
The approaches examined included foodbased strategies such as dietary change and fortification, supplementation, and other public health measures, including parasite control and delayed umbilical cord ligation. Working Group II looked more broadly at the major elements of success and constraint in past programs.
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From page 13... ...
Other consequences of iron deficiency are impaired physical growth; potentially permanent adverse effects on neurological functions involving cognition, emotional behavior, reaction to and reception of stimuli, attention span, learning capacity, and neuromotor development and function; decreased capacity for physical work; lowered immunity, resulting in increased susceptibility to infections; and alterations in the reproductive process.
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From page 14... ...
THE CONTINUUM OF POPULATION RISK The nutrition status of all populations is in flux. Groups are in continuous movement along a continuum of nutritional risk, extending from a situation of severe micronutrient malnutrition, through a wide spectrum of presumed nutrient adequacy, to one of nutrient overload and toxicity.
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From page 15... ...
For example, a given country may have populations at Level II with respect to iodine status, while the same or other populations are at Level III with respect to iron status. The criteria in Table 2-1 are based on prevalence rates of specific clinical and subclinical signs of iron, vitamin A, and iodine deficiency in specified subpopulations.
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From page 17... ...
In addition, the focus on both clinical and subclinical signs as criteria for determining severity of micronutrient status is a deliberate one. Workshop participants concluded that the prevailing focus of past intervention efforts on frank clinical signs of micronutrient malnutrition as a basis for determining need, while important for their severe health consequences and for serving as indices of risk in the community, has often resulted in neglect of the vast hidden problem of subclinical micronutrient malnutrition.
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From page 18... ...
Periodic distribution of high-dose vitamin A supplements, either universal to all children of a specified age range or targeted to high-risk groups, has been the most widely applied intervention for treatment, prevention, and control of VAD. Supplementation of iodine using iodized oils by injection; drops of Lugol's solution; and tablets of salts of iodine, sometimes disguised with chocolate, have been less frequently used than supplementation for iron and vitamin A, but it can be an effective stopgap measure in populations with severe iodine deficiency until salt iodization can become effective.
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From page 19... ...
Foods should be selected for fortification on the basis of the food consumption practices, stability, production and marketing characteristics, and cost. Experience has shown food fortification to be a useful bridge to sustainable, long-term dietary change in populations at moderate and low levels of iron and vitamin A deficiencies (Level III to I)
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From page 20... ...
iron could potentially be a satisfactory fortificant once supply and cost issues are solved. Nevertheless, iron fortification of foods continues to be plagued by the absence of ideal compounds that would be favorably absorbed, stable and ~,onreactive, with little color and taste of their own, easily measurable for monitoring purposes, and inexpensive.
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From page 21... ...
In the case of iodine deficiency resulting from the low iodine content of water supplies arid locally produced foods, however, dietary change based on local foods is not an option. Changes in food-based strategies also have only limited, short-term application for the prevention of iron deficiency when there are economic or religious constraints on increasing animal protein intake.
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From page 22... ...
Similarly, treatment of hookworm infection and prevention of reinfection have been shown to decrease iron loss, and thus complement iron replenishment strategies (see Chapter 3~. Since correction of micronutrient deficiency, in turn, improves response to immunization and other public health measures, simultaneous attention to improving nutrition status and ensuring effective public health measures can offer the most cost-effective interventions in deprived populations.
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From page 23... ...
Distribution of vitamin A supplements was least costly, followed by PHC and nutrition education. Similarly, when costs and effectiveness of three vitamin A interventions- sugar fortification, capsule distribution, and gardening plus nutrition education were examined in a study in Guatemala, the analysis reported cost per high-risk person achieving adequate vitamin A status to be US$0.98/year for fortification, US$1.86/year for capsule distribution, and US$2.71/year to US$4.16/year for gardens.
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From page 24... ...
nutrition education (high-risk per sons) Iron Salt fortification Flour fortification Sugar fortification Sugar fortification Tablets India 1980 Turkmenistan 1977 Guatemala 1980 0.12 l 980 l 980 1.00 0.12 0.16 0.12 n.a.
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From page 25... ...
Gained Iron deficiency Supplementation of pregnant women only 800 13 Fortification 2,000 4 iodine deficiency Supplementation (reproductive-age women 1,250 only) Supplementation (all people under age 60)
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From page 26... ...
Table 2-4 indicates that, for very poor countries, availability and access to established food industries, food marketing or distribution channels, health care systems, and developed community organizations are restricted. The overall level of literacy is also relatively low.
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From page 27... ...
The five elements are well developed and established in industrial countries. ELEMENTS OF SUCCESSFUL INTERVENTIONS ACROSS THE CONTINUUM OF POPULATION RISK This section and its accompanying tables combine information from the last three sections and offer a guide to the preferred initial approaches to prevention and control of iron, vitamin A, and iodine deficiencies in populations at the defined levels of risk.
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From page 28... ...
28 ~_~ {:L lo.
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From page 29... ...
Public health measures that aim to control infectious diseases for example, treatment of hookworm infection and prevention of reinfection and increasing measles immunization coverage should be considered an essential complement to interventions for iron and vitamin A, respectively. Interventions for Level III Populations Preferred approaches to combating micronutrient malnutrition in Level III populations include movement away from complete reliance on universal supolementation to a greater emphasis on supplementation of vulnerable groups.
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From page 30... ...
Food and nutrition education should become a more important part of the mix, while programs to enhance family capacity to grow ~utrient-rich foods should continue to be stressed. Public health control measures should continue to be considered an essential complement to interventions for iron and vitamin A
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From page 31... ...
TABLE 2-5c Preferred Initial Approaches to Prevention and Control of Iron, Vitamin A, and Iodine Deficiencies in Populations with Mild and Widespread Micronutrient Malnutrition LEVEL II Deficiency Approach Supplementation Targeted to vulnerable groups Universal Iron Vitamin A iodine +++ ++ + Fortification Targeted Universal Food-based approaches Food, nutrition education Food production Food-to-food Public health control measures Immunization Parasite Control HW/S DD/ARI Personal sanitation/hygiene +++ ++ +++ +++ + + ++++ ++++ ++++ ++++ ++++ n.a. NOTE: ++++, very strong emphasis; +++, strong emphasis; ++, moderate emphasis: +, light emphasis; , no emphasis; food-to-food fortification, mixing of staple i-oodstuffse.g., mango with gruel at the household level to enrich nutrient content; n.a., not applicable; HW/S, healthy water and public sanitation; DD/ARI, control of diarrhea!
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From page 32... ...
Interventions for Level I Populations Food-based approaches and food fortification are the approaches of choice to address micronutrient malnutrition in selected, usually deprived, populations of Level I countries. Programs directed toward iron and, to a lesser decree, vitamin A supplementation of at-risk groups should be continued as needed, as should universal public health control measures such as immunization and education on personal hygiene and sanitation.
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From page 33... ...
Nonetheless, there are areas of opportunity for cost-saving, complementary activities in assessment, program selection and design, and in delivery mechanisms to vulnerable groups where micronutrient deficiencies coexist. COMMON ELEMENTS OF SUCCESSFUL MICRONUTRIENT INTERVENTIONS This section briefly details elements that the workshop participants identified as being common to all successful micronutrient interventions (see Table 2-6~.
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From page 34... ...
Community Involvement, Participation, and Consumer Demand Involvement of the community at the point where interventions and beneficiaries intersect is a feature of some successful micronutrient programs. An excellent example was the program promoting horticultural interventions in gardens in Bangladesh.
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From page 35... ...
These include the ability to identify optional strategies and program designs, to test them out, to choose tees alternatives, and to evaluate and adjust programs on the basis of appropriate operations and management research. Selection of the most appropriate strategies and program designs also requires the capacity to adapt them to specific resource environments and constraints, along with the ability to measure program costs, efficiency, and effectiveness, as well as costs foregone through intervention outcomes.
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From page 36... ...
Process and outcome indicators including biological indicators, appropriate to monitor intervention impact will vary ill accordance with the intervention objective. Political will/stability Strategic and program planning Community involvement, participation, and consumer demand Physical and administrative infra structure Communications strategies Use of appropriate food vehicle Sustainability Information systems, monitoring, and evaluation
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From page 37... ...
Depending on the specific operational context, successful communications strategies seek to (1) generate consumer demand for improved micronutrient status and/or (2)
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From page 38... ...
and vitamin-A fortified margarine in the Philippines (see page 134) indicates, however, that selection of an appropriate food vehicle is an important determinant of program success.
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From page 39... ...
Micronutrient interventions such as the Indonesia vitamin A program, in which the donors and the host country plan for this transition from the initial stages, are the ones that have been most successful. Micronutrient interventions that continue to achieve a significant impact on the target individuals are projects that are flexible enough to respond to the changing needs of the client.
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From page 40... ...
In spite of limitations noted in the background paper on iron, serum ferritin is likely to be the best indicator for measuring iron status. In developing countries with initial high prevalence rates of anemia (and hence prevalence rates of nearly 100 percent subclinical iron deficiency)
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From page 41... ...
In contrast, median urinary iodine is reflective of current intakes of a population. Coverage can usually be monitored adequately-with least expense by nonbiological process indicators such as the number of households in which iodized salt or other fortified food vehicle is consumed.
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