Global Nutrition Cluster


© UNICEF/NYHQ2009-0604/Noorani

Multiple supplementation
Vitamin A
Vitamin C


Deficiencies of micronutrients are a major global health problem with many people living in low income countries deficient in key vitamins and minerals, particularly vitamin A, iodine, iron and zinc. Deficiencies occur when people do not have access to micronutrient-rich foods such as fruit, vegetables, animal products and fortified foods and increase the general risk of infectious illness and of dying from diarrhoea, measles, malaria and pneumonia. The groups most vulnerable to micronutrient deficiencies are pregnant women, lactating women and young children, mainly because they have a relatively greater need for vitamins and minerals and are more susceptible to the harmful consequences of deficiencies.

Micronutrient deficiencies can easily develop during an emergency or be made worse if they are already present. This happens because livelihoods and food crops are lost; food supplies are interrupted; diarrhoeal diseases break out, resulting in malabsorption and nutrient losses; and infectious diseases suppress the appetite whilst increasing the need for micronutrients to help fight illness. For these reasons it is essential to ensure that the micronutrient needs of people affected by a disaster are adequately met.

Multiple Micronutrient supplementation

Joint Statement by WHO, WFP & UNICEF: Preventing and controlling micronutrient deficiencies in populations affected by an emergency [pdf]
Statement on multiple vitamin and mineral supplements for pregnant and lactating women, and for children aged 6 to 59 months in emergencies.

Joint Statement by the Micronutrient Initiative, International Nutrition Foundation and the Sprinkles Global Health Initiative at Sick Kids [pdf]
Home Fortification with Multiple Micronutrients: Effectively Preventing Iron Deficiency Anaemia in Infants and Young Children

Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6-23 months of age
This guideline provides global, evidence-informed recommendations on the use of multiple micronutrient powders containing iron, vitamin A and zinc for home fortification of foods consumed by infants and young children 6–23 months of age. This document presents the key recommendation and a summary of the supporting evidence.
This guideline produced by WHO is available in English [pdf], or a reduced version in Spanish [pdf].

Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations 
This manual was developed by CDC and the Micronutrient Initiative (MI) focusing on the design and implementation of surveys to assess vitamin and mineral deficiencies.

Assessing Micronutrient Deficiencies in Emergencies, Current Practice and Future Directions, 2007 [pdf]
This document concisely explores options available to investigate micronutrient deficiencies, draws attention to best practices and includes references to practical tools and guidelines.

Use of Lipid-based Nutrient Supplements (LNS) to Improve the Nutrient Adequacy of General Food Distribution Rations for Vulnerable Sub-groups in Emergency Settings [zip]
The focus of this document is the potential role of LNS in improving the nutritional content of foods provided in response to emergencies, with a goal of preventing malnutrition in emergency-affected populations. It presents recommended nutritional formulas of LNS and also discusses bioavailability, the possibility of chronic excess intake, acute toxicity, stability and shelf life considerations, and finally, cost implications for the addition of LNS to current food aid “baskets” for vulnerable groups.

Investing in the Future: A United Call to Action on Vitamin and Mineral Deficiencies (2009)
This report details the scope of under-nutrition in the developing world due to a lack of vitamins and minerals and provides tangible recommendations to improve the delivery of supplements and fortified food and improve the health of women and children around the world. The report was released at the 2009 Micronutrient Forum in Beijing and was developed in partnership with the Flour Fortification Initiative, USAID, GAIN, WHO, The World Bank, and UNICEF. Available in English and French.

Lack of iron eventually results in iron-deficiency anaemia. Typical signs are: paleness, tiredness, headaches and breathlessness.

Oral iron supplements for children in malaria-endemic areas, Cochrane Review, 2011 [pdf]
In recent years, there has been some debate over the use of iron supplementation for children in malaria-endemic areas, due to the potential to increase the severity of infectious disease. However, this recent Cochrane Review, although limited by the research available, suggests that routine iron supplementation should not be withheld from children living in countries where malaria is prevalent.

Assessing the Iron Status of Populations, 2004 WHO & CDC Technical Consultation
The objectives of the Consultation were:  to review the indicators currently available to assess iron status;  to select the best indicators to assess the iron status of populations;  to select the best indicators to evaluate the impact of interventions to control iron deficiency in populations; to identify priorities for research related to assessing the iron status of populations. The report includes literature reviews on indicators of iron status, including RBC parameters, ferritin, free erthyrocyte protoporphyrin, serum and plasma iron, total iron binding capacity, transferrin saturation and serum transferrin receptor as well as a review on the interpretation of indicators of iron status during an acute phase response.
This technical consultation produced both a summary report as well as a full report, both available here.

Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia, INACG, WHO & UNICEF, 1998
These guidelines address the appropriate uses of iron supplements to prevent and treat iron deficiency anemia in the context of public health programmes. While the main focus of these guidelines is on iron supplementation programmes and parasite control, these guidelines acknowledge the beneficial role food fortification and dietary diversification can have in controlling iron deficiency anemia.

Overview of Efficacy, Effectiveness and Safety of Micronutrient Powders [pdf]
The presentation coverquestions of efficacy, effectiveness and safety “Sprinkles” for the prevention and treatment of anaemia.

Vitamin A
Lack of vitamin A results in xeropthalmia. The signs in order of presentation are: night (xeropthalmia) blindness, Bitots spots (dryness and foamy accumulations on the inner eyelids), corneal xerosis (dullness or clouding of the cornea), keratomalacia (softening and ulceration of the cornea), permanent blindness.

Guideline: Vitamin A Supplementation
These guidelines provide global, evidence-informed recommendations on the use of vitamin A supplements in infants 1-5 monthsof age, infants and children 6–59 months of age for the reduction of morbidity and mortality; in pregnant women for the prevention of morbidity, mortality and night blindness in populations where vitamin A deficiency may be a public health concern; in postpartum women for the reduction of maternal and infant morbidity and mortality.
These documents present key recommendations and summaries of the supporting evidence.

These guidelines are produced by WHO and available for the following groups:

Chinese & Russian are also available from the Nutrition Publications section of the WHO website.

How to Add Deworming to Vitamin A Distribution, WHO & UNICEF, 2004 [pdf]
This manual is written for health planners and aims to promote the deworming of preschool children older than 1 year  where vitamin A distribution campaigns are conducted.

Iodine deficiency causes a range of abnormalities including goitre (swelling of the (goitre and cretinism) thyroid gland in the neck) and cretinism (mental and physical disability).

Assessment of Iodine Deficiency Disorders and Monitoring their Elimination, A Guide for Programme Managers, WHO, UNICEF and ICCIDD, 2007
This document is intended primarily for managers of national programmes for the prevention and control of micronutrient malnutrition.  It sets out principles governing the use of surveillance indicators in implementing interventions to prevent, control, and monitor iodine defi ciency disorders (IDD). It presents methods for monitoring iodine status and determining urinary iodine and provides guidelines on the procedures for monitoring salt iodine content, whether at the factory, importation site, or household level. It also gives guidance on conducting surveys to assess iodine status in populations. Indicators are presented for monitoring progress towards achieving the goal of sustainable elimination of IDD as a significant public health problem.

Recommended Iodine Levels in Salt and Guidelines for Monitoring their Adequacy and Effectiveness, WHO, UNICEF and ICCIDD, 1996
This document summarizes current (produced in 1996) WHO, UNICEF and ICCIDD recommendations concerning iodine levels in salt, risk of associated iodine-induced hyperthyriodism, and requirements for monitoring both iodine status and adequacy of iodine levels in salt.

Vitamin C
Vitamin C deficiency results in scurvy. Typical signs are: swollen and bleeding gums, (scurvy) minute haemorrhages (bleeding), brittle hair, slow healing of wounds.

Scurvy and its prevention and control in major emergencies, WHO 1999 [pdf]
This document is intended primarily as a basis for ensuring adequate vitamin C intake in emergency settings. It reviews past experience with the strategies used to prevent scurvy among refugees and analyses factors influencing their success or failure. Also included are a literature review of the epidemiology of scurvy and its signs and symtoms, the properties and functions of vitamin C and recommended daily allowances, and a discussion of food sources of this vitamin and its stability. Scurvy and its prevention and control in major emergencies is the first in an occasional WHO series on the prevention and control of micronutrient deficiencies during emergencies.

Niacin deficiency results in pellagra, which affects the skin, gastro-intestinal tract and (pellagra) nervous systems. For this reason, it is sometimes called the 3Ds: dermatitis, diarrhoea and dementia. Dermatitis is the most distinctive feature causing redness and itching on areas of the skin exposed to sunlight.

Pellagra and its prevention and control in major emergencies, WHO 2000 [pdf]
This document discusses the causes of pellagra outbreaks and the risk factors involved, describe pellagra’s signs and symptoms and their devastating impact, and propose a number of preventive interventions. Also included are a review of the literature on the epidemiology of pellagra and the functions and properties of niacin and tryptophan, and a description of the food sources and availability of this vitamin.

Thiamin deficiency results in beriberi of which there are eight clinically (beriberi) recognizable syndromes.

Thiamine deficiency and its prevention and control in major emergencies, WHO 1999 [pdf]
This document is intended primarily as a basis for ensuring adequate thiamine intake among populations in emergency settings. It reviews strategies for preventing thiamine deficiency among refugees and analyses factors influencing success and failure. Also included are a review of the literature on the epidemiology of thiamine deficiency and its signs and symptoms; thiamine's properties and functions and the recommended daily allowance; and a discussion of food sources of this vitamin and its stability.
Thiamine deficiency and its prevention and control in major emergencies is the second in an occasional WHO series on the prevention and control of micronutrient deficiencies during emergencies.

Riboflavin deficiency leads to ariboflavinosis, a deficiency disease characterised by angular stomatitis that affects the corners of the mouth, which can become split or cracked. Cheilosis, scaling and cracking of the surface of the lips may be seen. Glossitis, inflammation or swelling of the tongue is also sometimes reported.

Zinc is essential for the normal growth and development of children and is naturally found in the diet, mainly in foods of animal origin. Dietary deficiency of zinc can lead to an increased risk of gastrointestinal infections and impaired gastrointestinal and immune function, including diarrhoea.

WHO/UNICEF joint statement. Clinical management of acute diarrhoea. [pdf]
These recommendations, formulated by UNICEF and WHO in collaboration with the United States Agency for International Development (USAID) and experts worldwide, take into account new research findings while building on past recommendations.
The revised recommendations emphasize family and community understanding of managing diarrhoea.

Zinc supplementation in the management of diarrhea
The mechanisms by which zinc exerts its anti-diarrhoeal effect are not fully understood, however, the use of zinc in the management of childhood diarrhoea is recommended by WHO/UNICEF.
The guideline on zinc supplementation for children is currently developing by WHO and all relevant information can be found here.


This spreadsheet application is used for planning, calculating and monitoring the nutritional value of food aid. There are three main components of the tool: the food and nutrient database and calculator both aid in selection of products and the calculation of nutrient content of the food aid ration; the on-site distribution monitoring sheet assists with collecting and analysing distribution monitoring data.



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Related tools, guidelines & resources

Related links

Electronic Library of Evidence for Nutrition Actions - Nutrients

WHO Publications Library for Micronutrients

Micronutrient Initiative (MI)

Hellen Keller International (HKI)

Global Alliance for Improved Nutrition (GAIN)

Zinc Task Force

The Micronutrients Database of VMNIS (WHO) contains information on anemia, vitamin A deficiency, and iodine deficiency in populations around the world.

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