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Targeting specific nutritional deficiencies

In assessing nutrition problems and implementing programmes to attack them, it is not possible to separate protein-energy malnutrition from vitamin and mineral deficiencies. In te grated community-based programmes that have achieved reductions in overall malnutrition have usually done so by addressing both micronutrient and protein-energy deficiencies. But among the kinds of malnutrition identified at the 1990 World Summit for Children, progress has been more rapid in reducing some deficiencies than others.

Grains of salt: Reducing iodine deficiency disorders

The reduction in iodine deficiency, the world's leading cause of prevent able mental retardation, is a global success story by any standard. This achievement, which began to show significant results beginning in 1992, involved a coordinated international effort to change diets in a subtle but important way -- an approach that has had an impact on probably more people worldwide than any previous nutrition initiative.

Photo: Rapid gains in salt iodization worldwide demonstrate the effectiveness of public- and private-sector cooperation in combating nutritional deficiencies. In Bolivia, a man seals a packet of iodized salt.

A diet deficient in iodine exerts its saddest and most significant effect on the developing embryo, starting at around 12 weeks after conception. In adequate iodine results in insufficient thyroid hormone, which in turn leads to a failure of normal growth of the brain and nervous system. The result is all too often a child born with a lifetime disability.

The practice of using iodized salt as a safe, cheap and effective way to combat iodine deficiency disorders (IDD) had a long track record by 1992. It was introduced in Swit zer land in 1922, in the United States in 1924, and in the Andean countries of South America in the 1950s and 1960s.

Among the goals adopted at the World Summit for Children, the virtual elimination of IDD was regarded by UNICEF as one of the most ac hievable. Universal salt iodization -- all salt destined for both human and animal consumption -- was the ob vious strategy to advance the attack on IDD.

Getting the job done, a continuing effort, is a process that uses the 'triple A' approach -- assessment, analysis and action -- on a global scale.

In some countries, the problem of iodine deficiency was known, but rigorous assessments -- using such indicators as goitre prevalence and urinary iodine excretion -- were needed to convince policy makers and salt producers of the need for action. The next step was to analyse these results, along with the workings of com mercial salt networks and the organization of the salt industry. Using advocacy and attention to legal detail, it was also necessary to pass appropriate legislation to ensure correct levels of salt iodization, and to protect io dized salt producers by eliminating non-iodized salt from the market.

Actually getting iodine into salt supplies was another matter. The task was addressed in ways that ranged from relatively easy adaptations by resource-rich major industrial salt producers that supply whole countries, to providing support for small producers to enable them to iodize salt without loss of income. Quality control and evaluation of the impact of salt iodization remain continuing challenges. Thanks to support from many quarters, all of these steps have been realized in a short time in an extraordinary number of countries. UNICEF estimates that nearly 60 per cent of all edible salt in the world is now iodized, and among countries in the world with recognized IDD problems, all but seven have passed appropriate legislation to ensure universal iodization.

Of the countries that had IDD problems in 1990, 26 now iodize over 90 per cent of their edible salt or import that proportion if they are not salt producers. Another 14 countries iodize between 75 per cent and 90 per cent of their salt. As late as 1994, 48 countries with established IDD problems had no programmes at all. Of these, 14 now iodize more than half their salt (Fig. 9).

At the level of children and their families, these results, though still incomplete, are improving lives by the thousands. It is estimated that up until 1990, about 40 million children were born each year at some risk of mental impairment due to iodine deficiency in their mothers' diets. By 1997, that figure was probably closer to 28 million3 -- still too many, but representing a clear and rapid decrease.

The number of children born each year with cretinism is difficult to estimate, but in 1990 it was on the order of 120,000. It is probably about half that now.

It is impossible to measure the impact of IDD on miscarriages, which are rarely well reported in health statistics, but the improvements are surely noticeable by affected women and their families. In highly iodine-deficient areas, infant mortality was long known to be elevated, but recent research now indicates that increasing the iodine intake of young infants to adequate levels may improve their survival to a far greater degree than previously expected, probably through improvements in their immune systems.

The gains in salt iodization came about largely because of the work of an alliance of responsive and knowledgeable partners. WHO, in collaboration with UNICEF and the In ter national Council for the Control of Iodine Deficiency Disorders (ICCIDD), not only helped raise awareness of the importance of IDD but also worked to ensure scientific consensus and information on standards for: levels of salt iodization, the safety of iodized salt in pregnancy, and indicators for monitoring and evaluation. UNICEF, WHO and ICCIDD also provided technical and financial support for many steps of the process.

Kiwanis International, a global ser vice organization, provides funding support and continues to educate its grass-roots membership about IDD (Panel 15).

The Government of Canada was a major player in all stages of this work, supporting UNICEF programmes in many countries and supporting the Ottawa-based Micronutrient Ini tia tive, which in turn has extended technical support and funding to field programmes, including the development of monitoring guidelines. In 1995, UNICEF estimated that over 7 million children were born free of the mental impairments of IDD largely because of the Canadian contribution.

Partly because of Canada's early and unambiguous support to combating IDD, other donors and governments in affected countries were drawn into the battle. The approximately $20 million invested by the Government of Canada catalysed other investors. Total investment by public- and private- sector partners in this effort since 1986 is now estimated to exceed $1 billion.4

In country after country, advocacy for salt iodization legislation has brought together teachers, consumer groups, women's groups and health professionals. Primary schoolchildren by the millions are armed with test kits that enable them to check whether the salt in their homes is iodized -- and to get a valuable chemistry lesson in the process. In Indonesia, for example, the enormous challenge of salt iodization in a country of almost 14 thousand islands, with highly decentralized salt production, is being overcome by a coalition that includes millions of the country's schoolchildren and teachers.

The elimination of IDD as a public health problem is, of course, not complete, and momentum must not be lost. But the effort has already had results beyond these tangible benefits in the lives of individuals.

The fight against IDD has brought to the attention of policy makers and communities the importance of good nutrition in ensuring the physical and mental development of children and populations. It has opened the door to accelerated work on other nutrient deficiencies with public health significance. It has demonstrated the value of public- and private-sector partnerships in pursuit of a well-defined goal in favour of children.

The success of the drive for universal iodization of salt shows that the diets of children, women and families worldwide can be changed in small but very beneficial ways in just a few years as a result of concerted global, national and local action. It is imperative that this experience be built upon in attacking some of the other nutritional deficiencies that can begin impairing the development of a child even before birth.

Although the value of vitamin A for protecting children against blindness has been known for decades, vitamin A's amazing ability to strengthen resistance to infection and reduce the chances of children dying has only recently won general acceptance by the scientific and medical establishment.

Following a dramatic report from Indonesia in 1986 of a 34 per cent reduction in pre-school child mortality with vitamin A,5 seven additional large studies were carried out over the next seven years. Most of these studies, involving more than 160,000 African and Asian children, reported large and significant reductions in mortality when children were given additional vitamin A through supplements or fortified food products. When these results were combined statistically in 1993, it was firmly established that vitamin A supplementation could reduce child mortality by about 23 per cent where there is a risk of deficiency.6 These conclusions, strengthened further by evidence that the vitamin has an even greater life-saving effect on children with measles, brought widespread acceptance that measures to prevent vitamin A deficiency could have an enormous impact on child survival.

Adequate vitamin A status does little to prevent children from being infected but has a major effect on reducing the severity of illness, especially persistent diarrhoea, dysentery, measles and malaria (Panel 18). Vita min A's power to reduce the severity of illness was clearly evident in Ghana, where periodic distribution of the vitamin led to a reduction in local clinic attendance by 12 per cent and hospital admissions by 38 per cent.7 Vitamin A can thus have a double-barrelled effect: It not only reduces the severity of illness and saves lives but also may ease the demand on often overworked health workers and facilities.

The effect of the discovery of vitamin A as a child survival tool led to renewed global interest in updating knowledge about the extent and public health significance of vitamin A and other micronutrient deficiencies. Numerous surveys of clinical and sub clinical vitamin A deficiency have led to an estimate that in 1990 there were over 100 million young children in the world at risk from the deficiency because of inadequate diets, although today the immediate risk for many of these children has been diminished by effective interventions, including regular vitamin A supplements.

Some countries still lack good assessments, but vitamin A deficiency, its underlying causes and its consequences for health and survival are much better understood now than ever before.

The age-old condition of maternal night-blindness has finally come to be recognized as a major public health problem. Long ignored by both afflicted women and the medical establishment, maternal night-blindness is now recognized to be widespread, with an estimated 1 million to 2 million pregnant women affected at any given time in South Asia alone. Women describe how they are able to see adequately during the day but after sunset are unable to move about and carry out their household chores. They consider it a common problem of pregnancy that goes away once the child is born. But recent work in Nepal shows that women with night-blindness during pregnancy are six times more likely to have been night blind in a previous pregnancy8 and that the condition is a marker for a constellation of risk factors, including dietary vitamin A inadequacy and deficiency; iron deficiency anaemia; protein-energy malnutrition; increased morbidity during pregnancy; and mortality up to two years after diagnosis (Panel 1).

Figure 9. Iodine deficiency disorders and salt iodization

Iodine deficiency disorders (IDD) were still a major public health problem in many of parts of the world in 1990. Today, programmes to produce or import iodized salt are in place in most developing countries.

Global Prevelence of IDD (circa 1990)

Percentage of Households Consuming Iodized Salt (1992--1996)

Source: IDD data from UNICEF 'Report on Progress Towards Universla Salt Iodization', 1994. Salt iodization data compilled by Unicef, 1997. Note: The boundries shown on this map do not imply official endorsement or acceptance by UNICEF. Dotted line represents approximately the line of control in Jammu and Kashmir agreed upon by India and Pakistan.

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