Nita Dalmiya

Multiple micronutrient supplementation during pregnancy in developing-country settings: Policy and program implications of the results of a meta-analysis

Background An independent Systematic Review Team performed a meta-analysis of 12 randomized, controlled trials comparing multiple micronutrients with daily iron–folic acid supplementation during pregnancy. Objective To provide an independent interpretation of the policy and program implications of the results of the meta-analysis. Methods A group of policy and program experts performed an independent review of the meta-analysis results, analyzing internal and external validity and drawing conclusions on the program implications. Results Although iron content was often lower in the multiple micronutrient supplement than in the iron–folic acid supplement, both supplements were equally effective in tackling anemia. Community-based supplementation ensured high adherence, but some mothers still remained anemic, indicating the need to concomitantly treat infections. The small, significant increase in mean birthweight among infants of mothers receiving multiple micronutrients compared with infants of mothers receiving iron-folic acid is of similar magnitude to that produced by food supplementation during pregnancy. Larger micronutrient doses seem to produce greater impact. Meaningful improvements have also been observed in height and cognitive development of the children by 2 years of age. There were no significant differences in the rates of stillbirth, early neonatal death, or neonatal death between the supplemented groups. The nonsignificant trend toward increased early neonatal mortality observed in the groups receiving multiple micronutrients may be related to differences across trials in the rate of adolescent pregnancies, continuing iron deficiency, and/or adequacy of postpartum health care and merits further investigation. Conclusions Replacing iron–folic acid supplements with multiple micronutrient supplements in the package of health and nutrition interventions delivered to mothers during pregnancy will improve the impact of supplementation on birthweight and on child growth and development.

The use and interpretation of serum retinol distributions in evaluating the public health impact of vitamin A programmes

OBJECTIVE Developing countries have adopted universal, high-potency vitamin A (VA) supplementation and food fortification as major strategies to control deficiency, prevent nutritional blindness and reduce child mortality. Yet questions persist regarding how best to measure impact and when to phase out supplementation. The present paper provides guidance on the use and interpretation of serum retinol (SROL) distributions as indicators of both programme impact and adequate VA intake in a population. DESIGN We reviewed extant data on SROLs response to high-potency VA supplementation and VA-fortified foods in children. RESULTS Supplementation virtually eliminates xerophthalmia and reduces child mortality; however, it shifts the SROL distribution only transiently (<2 months). Regular consumption of VA-fortified foods prevents xerophthalmia, lowers mortality and sustainably improves SROL distributions, from which both compliance and public health impact can be inferred. CONCLUSIONS Given SROLs limited responsiveness to high-potency VA supplementation, target population coverage remains the preferred performance indicator. However, periodic SROL surveys do reflect underlying dietary risk and can guide programming: low or marginal SROL distributions in areas with high supplementation coverage do not signify programme failure, but rather suggest the need to continue supplementation while working to effectively raise dietary VA intakes. We propose that a sustained rise in the SROL distribution, defined as ≤5 % prevalence of SROL < 0·70 μmol/l among vulnerable population groups in at least two consecutive surveys (≥1 year apart), be used as an indicator of stable and adequate dietary VA intake and status in a population, at which point programmes may re-evaluate the need for continued universal supplementation.

Long-Term Intermittent Multiple Micronutrient Supplementation Enhances Hemoglobin and Micronutrient Status More Than Iron + Folic Acid Supplementation in Bangladeshi Rural Adolescent Girls with Nutritional Anemia

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Sustaining vitamin A supplementation requires a new vision

Although vitamin A supplementation has been ongoing for decades in some countries systematic scaling-up in the context of child survival programmes began in the late 1990s. There has been a renewed commitment to vitamin A supplementation and an increasing focus on achieving universal coverage as part of UNICEFs integrated health and nutrition strategy largely informed by the Lancets child survival series. When UNICEF first began reporting on progress through The State of the Worlds Children report in 2000 global coverage with at least one dose was about 50% achieved in large part by linkage of vitamin A supplementation with national immunisation days for poliomyelitis eradication. Although national immunisation days guarantee delivery of one supplemental dose only 18 countries distributed the requisite second dose in 1999 translating into roughly 16% of children receiving supplements as per international recommendations. (excerpt)

Combating hidden hunger: the role of international agencies.

The importance of micronutrient deficiencies or “hidden hunger” was clearly emphasized by the inclusion of specific goals on iron, vitamin A, and iodine deficiency at the 1990 World Summit for Children and other major international nutrition conferences. Significant progress has since been made toward eliminating vitamin A and iodine deficiencies, with less progress made toward reducing the burden of iron-deficiency anemia. The role of international agencies, such as the World Health Organization, United Nations Childrens Fund, Food and Agricultural Organization, and World Bank in assisting countries to make progress toward the World Summit for Children goals has been very important. International agencies have played a critical role in advocating for and raising awareness of these issues at the international, regional, and national levels among policymakers and the general population. Using a rights-based approach, UNICEF and other agencies have been instrumental in elevating to the highest political level the discussion of every childs right to adequate nutrition. International agencies have also been very supportive at the national level in providing technical guidance for programs, including monitoring and evaluation. These agencies have played a critical role in engaging the cooperation of other partners, including bilateral donors, non-governmental organizations, and the private sector for micronutrient programs. Furthermore, international agencies provide financial and material support for micronutrient programs. In the future, such agencies must continue to be heavily involved in programs to achieve the newly confirmed goals for 2010. The present paper focuses on the role of international agencies in combating micronutrient deficiencies, drawing on the lessons learned over the last decade. The first section of the paper summarizes the progress achieved since 1990, and the second section describes the specific role of international agencies in contributing to that progress.

Multiple micronutrient supplementation during pregnancy: a decade of collaboration in action.

The starting point for this collaboration was recognition that deficiencies of vitamins and minerals beyond iron deficiency are widely prevalent among women of reproductive age, particularly pregnant and lactating women in developing countries, and that some of these deficiencies have a negative impact on pregnancy outcomes, such as low birthweight. There was a consensus that there was a need to supplement pregnant women with vitamins and minerals other than iron–folic acid and that combining different vitamins and minerals into one supplement would be an efficient approach. With this in mind, a multivitamin and mineral supplement designed for use by pregnant women in developing countries was developed and made available for the various trials through UNICEF. This multivitamin and mineral supplement was then tested in a series of 12 efficacy and 6 effectiveness trials covering 12 countries and spanning 3 continents—Asia, Latin America, and sub-Saharan Africa. The overall objective of these trials was to determine whether the use of a multivitamin and mineral supplement in pregnancy could not only improve critical outcomes such as birthweight but also improve adherence to the supplements in pregnancy, improve micronutrient status beyond anemia, increase gestational age at birth, and reduce the number of stillbirths and neonatal deaths. From a rights perspective, the idea was to take what women in industrialized countries and affluent women in developing countries take for granted as part of antenatal care and see how the same standard of care could be made available for women in developing countries. Ten years later, with less than halfway to go before the Millennium Development Goal of 2015, what have we learned and what can we tell policy makers at the country level, international development agencies, and donors as a result of this investment? First, this systematic review of multiple micronutrient supplementation during pregnancy in developing countries contributes significantly to a body of evidence which shows that supplementing women in pregnancy can improve outcomes beyond anemia, including deficiencies of other vitamins and minerals and birthweight. The multivitamin and mineral supplement worked as well as, if not better than, the currently recommended iron–folic acid supplement in terms of reducing anemia. In the Copenhagen Consensus 2008 Perspective paper [1], Martorell goes on to conclude that “iron folic acid supplementation during pregnancy will not only improve iron status but also have a small effect on birth weight. Multiple micronutrient programs may yield significantly greater benefits on birth weight compared with iron.” Second, the evidence once again confirms that adherence to supplement use is possible when supplements are made available in program settings and women are adequately counseled on their use. Third, in recent years evidence has come to light to show a positive effect on the functional and developmental milestones of children whose mothers were supplemented in pregnancy. A recent follow-up of Nepalese children whose mothers were supplemented with multiple micronutrients showed small improvements in weight and a decrease in peripheral adiposity after two years. Although the public health significance of this result is not yet known, the use of multiple micronutrient supplements by their mothers may have set these children onto a different development trajectory that could potentially mitigate the risk of chronic disease in adult life. Fourth, the results allude to how the multivitamin and mineral supplements could potentially have had a greater impact. Further improvements in anemia and birthweight might have been seen had women had access and started the use of the supplements in Nita Dalmiya, Ian Darnton-Hill, Werner Schultink, and Roger Shrimpton

Evolution of the Child Health Day Strategy for the Integrated Delivery of Child Health and Nutrition Services

Background In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-to-reach and older children who are often missed by routine, fixed-site health services. Objective To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. Methods We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010 from global monitoring databases for vitamin A and immunization. Results Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. Conclusions The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.

A Changing Landscape for Vitamin A Programs Implications for Optimal Intervention Packages, Program Monitoring, and Safety

Background: Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options. Objective: This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs. Methods: We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk. Results: Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented. Conclusions: Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.

The Role of Child Health Days in the Attainment of Global Deworming Coverage Targets among Preschool-Age Children.

Background Global deworming programs aim to reach 75% of at-risk preschool-age children (pre-SAC) by 2020. The 2013 global pre-SAC deworming coverage initially published by the World Health Organization (WHO) was 23.9%, but this estimate inadequately captured deworming delivered through Child Health Day (CHD) platforms. Objective To update global and regional coverage estimates of pre-SAC deworming in 2013 by supplementing data from the WHO Preventive Chemotherapy and Transmission Control (PCT) databank with national CHD data. Methods UNICEF country offices (n = 82) were mailed a questionnaire in July 2014 to report on official national biannual CHD deworming coverage as part of the global vitamin A supplementation coverage reporting mechanism. Coverage data obtained were validated and considered for inclusion in the PCT databank in a collaboration between UNICEF and WHO. Descriptive statistical analyses were conducted to update the number of pre-SAC reached and the number of treatments delivered. Results Of the 47 countries that responded to the UNICEF pre-SAC deworming questionnaire, 73 data points from 39 countries were considered for inclusion into the WHO PCT databank. Of these, 21 new data points were from 12 countries were newly integrated into the WHO database. With this integration, deworming coverage among pre-SAC increased to 49.1%, representing an increase in the number of children reached and treatments administered from 63.7 million to 130.7 million and 94.7 million to 234.8 million, respectively. The updated databank comprised 98 mass deworming activities conducted in 55 countries, in which 80.4% of the global pre-SAC population requiring deworming reside. In all, 57 countries requiring deworming were not yet represented in the database. Conclusions With the inclusion of CHD data, global deworming programs are on track to achieving global pre-SAC coverage targets. However, further efforts are needed to improve pre-SAC coverage reporting as well as to sustain and expand deworming delivery through CHDs and other platforms.

Effect of Long-Term Intermittent Multiple Micronutrient Supplementation in Bangladeshi Rural Adolescent Girls with Nutritional Anemia

Abstract of paper that presented at 20th International Congress of Nutrition, Granada, September 2013.Background and Objectives: Indonesia is one of the countries facing nutrition transition with an increased proportion of the middle-class population. Few studies explored young child feeding practice amongst middle class families in developing countries. This study aims to assess child feeding practices and their associations with child nutritional status in urban area of Indonesia. Methods: The study was designed as a mixed-method study in an urban middle-class community, comprising of a qualitative study amongst 26 families of young children and a case-control study involving 288 (109 cases and 179 controls) children aged 12-36 months. Cases were mild to moderately underweight children, while controls were normal weight children. The data collection methods consisted of in-depth interview for the qualitative phase and anthropometry measurements, structured interviews pertaining to child feeding practices and 24-hours recall for the quantitative phase. Results: The qualitative study suggested that mothers appeared to have positive attitude and were familiar with many brands of toddler formula milk. Mothers reported challenges in encouraging their children to eat and relied on formula milk to increase child’s food intake.The results of the case-control study showed that only 10.4% children received six-month exclusive breastfeeding and there was a significantly higher proportion of control than case children who were offered formula milk within their first month of life. Almost all children (91.7%, CI = 87.7 – 94.5) had low dietary diversity (consumed 1-3 food groups) in the last 24 hours. Formula milk was the largest contributor to child’s energy intake amongst the control children. Conclusions: The low dietary diversity warn potential problems for the health of Indonesian children. A large government strategy on complementary feeding practices including controlling the marketing activities of formula milk need to be enhanced.