Combining a variety of approaches
Several approaches exist to prevent vitamin A deficiency, each with its own strengths and limitations, but which can be highly effective if applied in complementary ways. These include vitamin A supplements (commonly administered in capsule form), fortification of food and gardening or other methods to improve diets.
Vitamin A can be boosted through homestead gardening or adapting food preservation or preparation methods that can enhance retention. And fortifying food with vitamin A has become increasingly feasible as fortifiable foods penetrate the markets of the poor in a number of countries. These food-based approaches combine increased vitamin A supply with nutrition education that promotes the consumption of vitamin A-rich foods by young children and women.
Periodic supplementation that provides high-dose vitamin A capsules -- both to children from 6 months to 5 years and beyond, and to mothers as soon after childbirth as possible -- has proved to be a very valuable intervention, offering immediate help to children who are at risk of vitamin A deficiency in situations where food-based options are limited. Experts estimate that periodic high-dose supplements for young children have the potential of eliminating 90 per cent of blindness and other ocular consequences of vitamin A deficiency and about 23 per cent of mortality in early childhood wherever the deficiency is common.
Successes in supplementation
It is a major global achievement that by mid-1997, some 30 years after the first vitamin A supplementation programmes began in India, the policy of providing children with periodic high-dose supplements has been adopted in all but 3 of the 38 countries where clinical vitamin A deficiency still existed, and in all but 13 of the additional 40 countries with documented subclinical deficiency.
At least 35 countries also routinely provide vitamin A supplements with immunizations during 'national immunization days'. And many countries link vitamin A supplementation to regular immunization activities or to periodic deworming of children, as in India and Mauritania.
Overall, UNICEF estimates that more than half of all young children in countries where vitamin A deficiency is known to be common received high-dose vitamin A capsules in 1996, compared to about one third in 1994 (Fig. 10). This includes such large countries as Bangladesh, India, Nigeria and Viet Nam. Between 1993 and 1996, UNICEF purchased nearly a half-billion high-dose vitamin A capsules that were distributed in 136 countries, helping to bring or keep vitamin A deficiency under control. At roughly 2 cents per capsule and perhaps 20 to 25 cents per delivered dose, few other child health or nu trition interventions are as cost-effective in reducing mortality and disability throughout life as vitamin A supplements.
Breastmilk nearly always provides enough vitamin A to protect a child from severe deficiency, even if this means that the child's mother becomes deficient. However, both mothers and infants can be protected against deficiency if mothers receive a high dose of vitamin A soon after they give birth. Some 50 countries have adopted a policy of routine high-dose supplements for women soon after childbirth, which protects their children for about six months. New information on the impact of vitamin A deficiency on women's health makes post-partum supplementation an even greater priority (Panel 1).
Sugar fortification: A sweet success
Several countries have chosen another route to improved vitamin A status of their populations: fortifying the sugar supply.
Guatemala has led the developing world in fortifying sugar with vitamin A since the mid-1970s. Despite nearly a decade of civil disturbance and a lapse in fortification for several years in the early 1980s, an evaluation of 82 villages in 1990 concluded that sugar fortification had brought vitamin A deficiency under control among Gua te malan children.
Sugar is also being fortified in parts of Bolivia, Brazil, El Salvador, Honduras and the Philippines, and Zambia is planning to begin fortification in 1998, with other countries likely to follow or to find other staple foods to fortify with vitamin A. The Philippines, for example, has successfully tested and fortified a local, non-refrigerated margarine with vitamin A and is testing the impact of fortifying the wheat flour used in its national bread, pan de sal.
The success of fortification depends on a number of factors: Those at risk of the deficiency must consume the fortified food regularly and in great enough quantities to make a difference, the fortification must not alter the palatability of the product for consumers and it must not put the product out of their financial reach. If these conditions are met, this can be a very effective approach, as the Guate malan experience has shown. Supplementation may be an important complementary strategy for fortification if fortified foods do not reach all affected individuals.
Countries also need to ensure that sugar fortification programmes do not promote increased consumption of sugar but are aimed at informing consumers that whatever sugar they do consume should be fortified.
Improving diets to boost vitamin A
In many countries, vegetable gardening around the home and food preservation and preparation methods that enhance the vitamin content of the diet have been promoted as a means of improving vitamin A intake. In West Africa and Haiti, for instance, drying of mangoes has extended access to this important vitamin A source beyond the months of the mango season.
In Bangladesh, home gardens of fruits and vegetables have been adopted by families of low socio-economic status in one fifth of the country in recent years, the result of systematic introduction of village nurseries, the availability of low-cost seeds, and reliable extension services. This work has been supported by the NGO Helen Keller International. Initial evaluations suggest that this programme has curbed the incidence of night-blindness, especially in families that grow and consume a variety of vegetables. This is one of relatively few such projects where careful evaluations have made it possible to assess the impact of activities on vitamin A status.
There is evidence that eating a variety of foods rich in carotene -- the precursor form of vitamin A found in fruits and vegetables -- coupled with some vitamin A from animal sources -- can alleviate moderate to severe vitamin A deficiency in children and women.
The absence of more evidence that gardening projects improve vitamin A status may be because of the low avail ability of some carotenoids in plant foods for the body, the lack of complementary fats and animal foods in the diet, or inadequate evaluation methods. In addition, it is not clear which vegetables or fruits are most effective in improving vitamin A status. This question is an important research challenge.
Promoting increased consumption of vitamin A through animal foods may be possible in some countries. A recent project in Central Java (Indonesia), supported by Helen Keller International, the Micronutrient Initiative and UNICEF, promoted the consumption of eggs, which are affordable, to reduce vitamin A deficiency. As a result, egg consumption increased and vitamin A status improved significantly among young children in this project (Panel 16). Helen Keller International also successfully promoted increased consumption of vitamin A-rich liver by children in Niger, where animal products are relatively accessible in some regions.
Responding to anaemia
Iron deficiency anaemia is probably the most prevalent nutritional problem in the world. Over half the women in developing countries and a large per centage of young children suffer from it,9 and progress in reducing its prevalence and impact has been slower than might be hoped. As with vitamin A, several approaches have been pursued.
The consequences of anaemia for pregnant women and their newborn children are often disastrous. The condition puts women at higher risk of death because of the greater likelihood of haemorrhage in childbirth and other factors, and their newborns face a high risk of poor growth and development. Many countries have adopted policies to ensure that women who seek prenatal care have access to daily iron supplements to help them meet the very high needs of pregnancy and childbirth. UNICEF is a major supplier of iron/folate tablets. A total of 2.7 billion were provided to 122 countries from 1993 to 1996.
Photo: Vitamin A supplementation reduces the severity of illness and the risk of death in children in areas where the vitamin is deficient, resulting in dramatic increases in child survival. In Mali, a girl holds a mango, a good source of vitamin A.
However, since many pregnant women enter pregnancy already anaemic -- and it is difficult to resolve pre-existing anaemia during pregnancy -- more attention is being paid in some countries to improving the iron and folate status of girls and young women before their first pregnancy. There is evidence from small-scale trials that in cases where it is difficult to reach young women with daily iron/folate supplements, ensuring weekly or twice-weekly supplementation may still be effective in building iron stores.10 In Malaysia, weekly supplementation over several months resolved the anaemia in over 80 per cent of adolescent girls in a com munity where anaemia was highly prevalent. Similar results have been reported from other countries.
Fortification of foods with iron is also an effective means of addressing anaemia. Wheat flour and flour products are the most common vehicles for iron fortification in places where they are widely consumed and centrally processed, particularly in Latin America and the Middle East (Panel 17).
In 1993, Venezuela began fortifying all wheat and maize flour with iron and B vitamins. A 1996 evaluation showed large reductions in the prevalence of anaemia in children and adolescents following the fortification, even though during this period the country was suffering from a general economic decline.11
At a meeting in 1996, countries of the Middle East and North Africa made a joint commitment to fortifying wheat flour with iron as a principal strategy for anaemia reduction in the region, where wheat is a staple.
Anaemia is made worse by some illnesses, particularly hookworm infection. Malaria is also a major cause of anaemia, although this is not directly related to iron losses. In several countries, deworming of schoolchil dren has been shown to reduce the prevalence and severity of anaemia.12 Preventing malaria and improving its curative treatment, which are priorities of UNICEF and WHO for 1998 and beyond, will undoubtedly go a long way to reducing anaemia in children and adults alike.
Improving basic health services
The nutritional well-being of children around the world has benefited greatly from the enormous achievements since 1990 in improving children's access to basic health services, both curative and preventive.
The success of child immunization programmes has been a major boost to child health. Immunization also protects vitamin A levels, which plum met during acute measles infections. So, the spectacular achievement of over 90 per cent immunization coverage in 89 countries and over 80 per cent in another 40 countries by 1996 -- including a 79 per cent global measles immunization rate13 -- means that for millions of children, vitamin A levels undisturbed by measles episodes will continue to help protect them from illness.
Programmes to improve hygiene and sanitation are also likely to be of crucial importance almost everywhere there is malnutrition in impoverished communities. Improved water supplies or support to food production may also be very critical, depending on local circumstances. Analyses in several countries have found that the strongest predicting factors for malnutrition are lack of safe water, inade quate sanitation and high fertility rates.
Each year over 1 million more children are saved from death through the use of oral rehydration therapy (ORT).14 ORT promotion includes sup port for continued feeding during and after diarrhoea as well as the use of oral rehydration salts (ORS) to prevent and treat dehydration. Continued progress is needed in diarrhoea prevention, treatment, nutritional management and cure to ensure that growth lost during diarrhoea episodes is rapidly caught up, but the achievements so far have been of great nutritional benefit to millions of children. Similarly, the gains already achieved in access to safe water and sanitation facilities have translated into nutritional benefits around the world. Millions more children than before have been able to avoid plunging deeper into the spiral of infection and poor dietary intake because so many illness episodes are prevented or readily cured.
Photo: Diarrhoea, often in conjunction with malnutrition, claims the lives of 2.2 million children each year. Increased use of ORT as well as improvements in hygiene and sanitation are helping stem the toll. In Syria, a woman gives her baby oral rehydration solution.
An especially important advance in the health world has been the revitalization of basic health services through such measures as the Bamako Initiative, the set of policy measures launched by African governments in 1987 in response to the rapid deterioration of public health systems in Africa in the 1970s and 1980s. Now op er ating in other regions, the Bamako Initiative measures have meant that health centres in remote areas -- virtually abandoned in the 1980s for lack of basic drugs and supplies -- are again thriving and serving the communities whose active involvement in their management has helped resuscitate them. The results have been striking. In addition to ensuring access to basic curative services, the initiative has sustained increased coverage of immunization and other preventive activities. In Guinea, for example, pre natal care coverage went from less than 5 per cent before the initiative to almost 80 per cent in the mid-1990s.
With WHO and other partners, UNICEF is committed to accelerated action in malaria control, including the promotion of insecticide-treated bednets and support for improved drug use in malaria treatment. A combined programme for prevention of both iron deficiency anaemia -- through iron supplementation, fortification and dietary improvement -- and parasite-induced anaemia -- through malaria control and deworming -- is one emerging approach for effectively addressing these age-old problems.
Programmes featuring improved education and information
The programmes described above in Niger and Tanzania included important education, information and communication components. In some cases, this included reinforcing classroom education, as in Niger, where literacy and other non-formal instruction to women in participating villages only served to highlight the need to improve formal education for their children, especially their daughters. One donor agency involved in supporting community-based programmes in Niger, in fact, encouraged the inclusion of formal education for girls as part of the activities meant to improve nutrition.
School-based programmes in cases such as this, as well as non-formal programmes for youth and adults, such as literacy and parent education courses, are a useful complement and sometimes a principal vehicle for other activities promoting better nutrition. It is easy and usually very appropriate to ensure that curricula used in these programmes include strong nutrition components.
Photo: Community-based growth monitoring is a central component of the triple A approach. A child's growth chart is updated during a growth monitoring session in Mauritania. 67
Schools, teachers and education programmes can serve as mobilizers of community participation in many ways, such as through village education committees and parent-teacher associations. These can also serve as a resource for nutrition and help organize relevant community-based assessment, analysis and action as well as promote good practices and share information concerning nutrition.
In the Lao People's Democratic Republic, for example, early childhood development volunteers in the community and parents are mobilized through participatory processes to develop, among other skills, better nutrition practices, both traditional and modern. The essential role of teachers and schoolchildren in promoting the use of iodized salt and even testing its quality in Indonesia was mentioned earlier. In this case, messages about salt iodization and its importance have even been formally incorporated into teacher training courses across the country.
Figure 10. Progress in Vitamin A Supplementation Programmes
In the 78 countries where vitamin A deficiency is a recognized public health problem, supplementation programmes are on the rise.Countries where policies to supplement post--partum mothers are in place
young children routinely recieve vitamin A supplements
more than 50% of young children routinely recieve vitamin A supplements
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