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Pediatric Micronutrient Deficiencies, Epidemiology and prevention I. Introduction, principles and iron deficiency Drora Fraser. Drora Fraser. Director of the S. Daniel Abraham International Center for Health and Nutrition, Ben-Gurion University of the Negev (BGU), Beer-Sheva, Israel.

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Pediatric Micronutrient Deficiencies, Epidemiology and prevention I.Introduction, principles and iron deficiencyDrora Fraser
drora fraser
Drora Fraser
  • Director of the S. Daniel Abraham International Center for Health and Nutrition, Ben-Gurion University of the Negev (BGU), Beer-Sheva, Israel.
  • Member of the Epidemiology and Health Services Evaluation Department, Faculty of Health Sciences, BGU.
course objectives
Course Objectives:
  • To familiarize the students with the extent of the problems of micronutrient deficiencies worldwide
  • To understand the implications of those problems
  • Using the models of micronutrient interventions studied, learn the possible methods available and judge their applicability to their own specific situation
the hidden hunger
The “hidden hunger”

“Millions of people suffer and may die from lack of minute traces of nutrients. Methods of prevention are cheap and simple. Their universal application could yield health and economic benefits comparable to those achieved by the smallpox eradication”.

Dr. V. Ramalingaswami, Chair, LTNDP task force on health research and development, End hidden hunger conference, Montreal, Canada, October 1991.

the status in the world
The status in the world
  • Deficiencies of iron, Vitamin A and iodine are highly prevalent
  • 1/3 of the human race is affected and is at increased risk of death, disease or disability
  • Deficiencies disproportionately affect vulnerable groups
  • Deficiencies damage human capital and national economic development
nutritional status in populations
Nutritional status in populations

Nutritional status flux of populations

Severe micronutrient malnutrition

Nutrient overload

which micronutrients are involved
Which micronutrients are involved?

Group A Group B

Iron Zinc

Vitamin A Folate

Iodine Vitamin - B12

+ others


There are options for effective interventions:

  • Supplementation
  • Food fortification
  • Dietary diversification
  • Public health measures: such as parasite and diarrheal disease control, improve sanitation and hygiene
When planning an intervention:
  • Incorporate knowledge of factors such as: location and clustering, severity, prevalence and multiple causes of deficiencies
  • Take account of the level of country development and ability to implement and sustain the intervention
  • Set in place continuous monitoring and feed back mechanisms
  • Incorporate flexibility to be able to respond to monitored changes
  • The method of choice when treatment is needed i.e. to address the problem of severe micronutrient deficiency
  • Can be used as a preventive measure by targeting groups at high risk
  • Has been shown to be a cost-effective approach
  • Most efforts to control Vit A and iron deficiencies used this method
food fortification
Food fortification
  • Is not appropriate for therapeutic measures (except for iodized salt)
  • Requires active participation of the food industry
  • Requires intervention by governmental agencies for regulating levels of fortification and foods to be fortified
  • Requires ongoing monitoring
dietary diversification
Dietary diversification
  • Introduce to the diet nutrient rich foods
  • Change dietary habits
  • Encourage people to grow new foods
  • Increase market availability of specific foods
iron deficiency consequences
Iron deficiency - consequences
  • Impaired physical growth
  • Compromised cognitive development
  • Impaired learning capacity
  • Reduced muscle function
  • Decreased physical activity and lower work productivity
  • Lowered immunity
  • Increased risk of infectious disease
iron deficiency definitions
Iron deficiency - definitions

Age/gender Hemoglobin< hematocrit<

g/l mmol/l l/l

child 6M-5Y 110 6.83 0.33

5-11Y 115 7.13 0.34

12-14Y 120 7.45 0.36

women 120 7.45 0.36

pregnancy 110 6.83 0.33

men 130 8.07 0.39

iron deficiency public health
Iron deficiency & public health

Iron deficiency prevalence in a population is 2 to 2.5 times the rates of anemia.

Category of public Prevalence of

health importance anemia in risk gp.

High >20%

Moderate 12.0 -19.9%

Low 5.0 - 11.9%

short term prevention of ida
Short term prevention of IDA*

In infancy

  • Avoid gestational ID**
  • Try to prevent premature delivery and low birth weight
  • Increase birth spacing
  • Delay pregnancy beyond teens
  • Delay ligation of umbilical cord (by 30-60 seconds)
anemia in negev jewish children beer sheva dimona 1985 1993
Anemia (%) in Negev Jewish children: Beer-Sheva & Dimona 1985 & 1993












Naggan L, Levy A, Shoham-Vardi I, 1994

hb distribution in jewish children attending mch clinics for routine vaccinations 1999
Hb distribution in Jewish children attending MCH* clinics for routine vaccinations 1999


n=127 n=65

short term prevention of ida1
Short term prevention of IDA

In children and adolescents

  • Give preventive iron supplementation
  • Institute parasite and malaria control where needed
  • Periodic de-worming, where needed
  • General vitamin and mineral fortification of school meal programs
sustainable approaches to elimination of micronutrient deficiency e g iron
Sustainable approaches to elimination of micronutrient deficiency e.g. iron

Iron fortification of foods, foods in the target group:

  • Foods consumed regularly
  • Consumed in sufficient quantities
  • Consumed in stable amounts
  • Centrally processed foods
  • Foods that are easy to fortify
food fortification e g iron
Food fortification e.g. iron

To be considered:

Chemical composition





community studies thailand
Community studies: Thailand
  • Fish sauce fortified with NaFeEDTA to 0.5-1 mg iron/ml. Average per capita consumption 10-15 ml/day. Should provide 0.4 mg absorbable iron.
  • Trial was in 2 villages
  • In the trial village, anemia rates were reduced.
community studies india
Community studies: India
  • 7,000 persons used iron fortified salt
  • 7,000 persons used regular salt
  • Several locations Rural I anemia rates:
    • 98%-53% young children
    • 23%-9% in older children
    • 77%-32% in adults
  • Rural II: all ages anemia >90%
  • Urban: Women 30%, men <7%
community studies venezuela
Community studies: Venezuela
  • Increased in anemia seen between 1989-90 and 1992
  • Prevalence measured in 7, 11 and 15 year old children
  • Iron deficiency increased from 13.5% to 30.5%
  • Anemia increased from 3.6% to 19.0%.
  • February 1993, started fortification of maize flour and white wheat flour with ferrous fumarate
cost effectiveness of iron fortification
Cost effectiveness of iron fortification

Fortification Place Cost(1) Protect(2)

Salt A 0.12 0.12

Flour B 0.16 --

Sugar C 0.12 0.12

Sugar D 1.00 1.00

Tablets E 3.2-5.3 3.2-5.3

conclusions iron deficiency
Conclusions - iron deficiency
  • Iron deficiency is common worldwide
  • It’s consequences are far reaching
  • Effective measures are available
  • Supplementation has been successfully used in various populations
  • Fortification has been successfully implemented in various locations using different foods
  • The programs were cost effective