Addressing Micronutrient Malnutrition in Urban Settings

Abstract

Access to nutritious foods for those living in poor urban settings is often more of a problem than the availability of these foods. This chapter describes a proven and effective strategy to impact food quality in urban settings through the implementation of national, mandatory food fortification programs. By leveraging what large sectors of the urban population already have access to and are already consuming on a regular basis, no new delivery mechanisms are needed, limited behavior change is required, and no additional responsibilities are placed on the healthcare system. Based on Project Healthy Children’s experience assisting governments to design and implement national fortification programs, this chapter describes micronutrient malnutrition, particularly in the context of urban settings, and the various interventions that exist to address it. The chapter proceeds to discuss why fortification is a well-suited strategy for urban populations touching on new design and implementation opportunities that exist around small-scale fortification. Broad steps necessary to design a program and critical components needed to successfully implement in urban settings are outlined. Finally, the chapter concludes with important lessons learned from past programs in East Africa.

Keywords

Food fortification Mandatory fortification Small-scale fortification Micronutrient malnutrition Micronutrient deficiency Iron deficiency Anemia Vitamin A deficiency Zinc deficiency Folate deficiency Neural tube defects Hidden hunger Food quality East Africa Malawi Zambia Rwanda Leadership 

References

  1. 1.
    World Health Organization (WHO) and United Nations Human Settlement Programme (UN-HABITAT) joint report: hidden cities: unmasking and overcoming health inequalities in urban settings. The WHO Center for Health Development, Kobe, and United Nation’s Human Settlements Programme (UN-HABITAT), 2010.Google Scholar
  2. 2.
    Crush J, Frayne B, McLachlan M. Rapid urbanization and the nutrition transition in Southern Africa. Urban food security series no. 7. Queen’s University and African Food Security and Urban Network (AFSUN): Kingston and Cape Town. 2011.Google Scholar
  3. 3.
    Dary O. Food fortification as a public health strategy and the contributions of A2Z. Sight Life Magazine. 2009;1:6–15.Google Scholar
  4. 4.
    Harvey P, Rambeloson Z, Dary O. The 2008 Uganda Food Consumption Survey: determining the dietary patterns of Ugandan women and children. A2Z: the USAID micronutrient and child blindness project. AED, Washington DC, 2010.Google Scholar
  5. 5.
    Allen L, de Benoist B, Dary O, Hurrel R, editors. Guidelines on food fortification with micronutrients. Geneva: World Health Organization; 2006.Google Scholar
  6. 6.
    Investing in the future: a united call to action on vitamin and mineral deficiencies, micronutrient initiative. FFI, GAIN, MI, USAID, World Bank, and UNICEF. 2009.Google Scholar
  7. 7.
    World Health Report. Geneva, World Health Organization, 2000.Google Scholar
  8. 8.
    World Health Organization (WHO) Global database on vitamin A deficiency. 2009.Google Scholar
  9. 9.
    Solomons NW. Sight and life luncheon forum on contributions of micronutrients to achieve the MDGs. Sight Life. 2011;25(3):76–80.Google Scholar
  10. 10.
    Center for Disease Control (CDC). IMMPACT Project. http://www.cdc.gov/immpact/micronutrients/index.html#Folate. Accessed 16 July 2012.
  11. 11.
    Dary O. The cost of food enrichment. Nutriview. 2010;1:2–4.Google Scholar
  12. 12.
    Rawe K, Jayasinghe D, Mason F, Davis A, Pizzini M, Garde M, Crosby L. A life free from hunger: tacking child malnutrition. Save the Children Fund. 2012.Google Scholar
  13. 13.
    Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/iodine/. Accessed 11 June 2012.
  14. 14.
    Rowe LA, Dodson DM. A knowledge-to-action approach to food fortification: guiding principles for the design of fortification programs as a means of effectively addressing micronutrient malnutrition. Health. 2012;4(10):904–9.CrossRefGoogle Scholar
  15. 15.
    EFA Global Monitoring Report 2005. http://unesdoc.unesco.org/images/0013/001373/137333e.pdf. Accessed 12 July 2012.
  16. 16.
    Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  17. 17.
    Badham J, Kraemer K. The link between nutrition, disease, and prosperity: preventing non-communicable diseases among women and children by tackling malnutrition. Sight Life. 2011;25(2):32–6.Google Scholar
  18. 18.
    Barker DJP. In utero programming of chronic disease. Clin Sci. 1998;95:115–28.CrossRefPubMedGoogle Scholar
  19. 19.
    Victoria CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371:340–57.CrossRefGoogle Scholar
  20. 20.
    Deshmukh US, Lubree HG, Yajnik CS. Intrauterine programming of non-communicable diseases: role of maternal micronutrients. Sight Life Magazine. 2011;25(2):16–22.Google Scholar
  21. 21.
    Leon D. Cites, urbanization and health. Int J Epidemiol. 2008;37:4–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Garcia OP, Long KZ, Rosado JL. Impact of micronutrient deficiencies on obesity. Nutr Rev. 2009;67(10):559–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Hales CN, Barker DJP. Type 2 (non-insulin dependent) diabetes mellitus: the thrifty phenotype hypothesis. In: Deshmukh US, Lubree HG, Yajnik CS, editors. Intrauterine programming of non-communicable diseases: role of maternal micronutrients. Sight and Life Magazine. 2011;25(2):16–22.Google Scholar
  24. 24.
    The World Bank. Repositioning nutrition as central to development: a strategy for large-scale action. 2006.Google Scholar
  25. 25.
    Horton S. The economics of nutritional interventions. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa: Humana Press; 1999.Google Scholar
  26. 26.
    World Health Organization. Poverty and Health. http://www.who.int/hdp/poverty/en/. Accessed 1 Aug 2012.
  27. 27.
    Horton S, Begin F, Greig A, Lakshman A. Copenhagen Consensus best practices paper on micronutrient supplements for child survival (vitamin A and zinc) 2008. In: Investing in the future: a united call to action on vitamin and mineral deficiencies. FFI, GAIN, MI, USAID, World Bank, UNICEF. 2009.Google Scholar
  28. 28.
    Global Alliance for Improved Nutrition. Investment in food fortification yields high returns. http://www.gainhealth.org/programs/gain-national-food-fortification-program. Accessed 1 Aug 2012.
  29. 29.
    Codex Alimentarius. General principles for the addition of essential nutrients to foods. http://www.fao.org/docrep/w2840e/w2840e03.htm.
  30. 30.
    Kim SS. Developing a national food fortification program in the dominican republic. In: Pinstrup-Anderson P, Cheng F, editors. Case studies in food policy for developing countries. Ithaca: Cornell University Press; 2009. p. 57–68.Google Scholar
  31. 31.
    Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/vitamins/vitaminA/. Accessed 18 July 2012.
  32. 32.
    Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/iodine. Accessed 18 July 2012.
  33. 33.
    West KP. Interactions between nutrition and infection in the developing world. Johns Hopkins Bloomberg School of Public Health. 2007. http://ocw.jhsph.edu/courses/EpiInfectiousDisease/PDFs/EID_lec10_West.pdf. Accessed 1 August 2012.
  34. 34.
    Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. In: Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  35. 35.
    Sommer A, West KP. Infectious morbidity. In: Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  36. 36.
    Arroyave G, Dary O. Manual for sugar fortification with Vitamin A, Parts 1, 2, and 3. In: Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  37. 37.
    Smith RS, Goodman DS, Zaklama MS, Gabr MK, El Maraghy S, Patwardhan VN. Serum vitamin A, retinol-binding protein, and prealbumin concentrations in protein-calorie malnutrition I. In: Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  38. 38.
    Smith RF, Suskind R, Thanangkul O, Leitzmann C, Goodman DS, Olson RE. Plasma vitamin A, retinol-binding protein and prealbumin concentrations in protein-calorie malnutrition III. In: Howson CP, Kennedy ET, Horwitz A, editors. Prevention of micronutrient deficiencies: tools for policymakers and public health workers. Institute of medicine. Washington, DC: National Academy Press; 1998. p. 17–8.Google Scholar
  39. 39.
    Nestel P, Bouis HE, Meenakshi JV, Pfeiffer W. Biofortification of staple food crops. J Nutr. 2006;136:1064–7.PubMedGoogle Scholar
  40. 40.
    Ministerio de Salud Publica de Nicaragua. Sistema Integrado de Vigilancia de Intervenciones Nutricionales (SIVIN). Informe de Progreso 2003–2005. 2008.Google Scholar
  41. 41.
    Martinez C, Mena I, Boy E, Dary O. Evaluation of nutritional blindness in Guatemala and its association with sugar fortification and vitamin A supplementation: Retrospective study of hospital cases from 1980 to 2000. Guatemala City: PAHO/Institute of Nutrition of Central America and Panama; 2005.Google Scholar
  42. 42.
    Personal communication with Omar Dary. July 13, 2012.Google Scholar
  43. 43.
    Lotfi M, Manar MGV, Merx RJHM, Naber-van den Heuvel P. Micronutrient fortification of foods: developing a program. J Food Technol Africa. 1999;4:2–4.Google Scholar
  44. 44.
    Toolkit for developing a national flour fortification monitoring and surveillance system: a purposive and convenience sampling approach. Smarter Futures. March 12, 2011.Google Scholar
  45. 45.
    Frankenberg E, Thomas D, Beegle K. The real costs of Indonesia’s economic crisis: preliminary findings from the Indonesia family life survey. In: Adams P. Fortification remains wise investment in midst of global economic woes. Flour Fortification Initiative. White Paper. http://www.sph.emory.edu/wheatflour/economicbenefit.php. Accessed 23 July 2012.
  46. 46.
    Micronutrient initiative. An impact study on small-scale fortification project in Lalitpur District: Feb 2009–April 2011.Google Scholar
  47. 47.
    Project Healthy Children (PHC), Imagine Lalitpur, and Micronutrient Initiative (MI) preliminary data from Nepal small-scale fortification pilot project. July 2012. Unpublished.Google Scholar
  48. 48.
    Horton S. The economics of food fortification. J Nutr. 2006;136:1068–71.PubMedGoogle Scholar
  49. 49.
  50. 50.
    Meenakshi JV et al. How cost effective is biofortification in combating micronutrient malnutrition? An ex-ante assessment. In: Investing in the future: a united call to action on vitamin and mineral deficiencies, micronutrient initiative. FFI, GAIN, MI, USAID, World Bank, and UNICEF. 2009.Google Scholar
  51. 51.
    Adams P. Fortification remains wise investment in midst of global economic woes. Flour fortification initiative. White Paper. http://www.sph.emory.edu/wheatflour/economicbenefit.php. Accessed 23 July 2012.
  52. 52.
    Mora J, Dary O, Chinchilla D, Arroyave G. Vitamin A Sugar Fortification in Central America: Experience and Lessons Learned. Washington, DC: The USAID Micronutrient Program (MOST)/ US Agency for International Development (USAID)/Instituto de Nutricion de Centro America y Panama (INCAP) / Pan American Health Organization (PAHO). 2009.Google Scholar
  53. 53.
    Gottlieb J. Center for Global Development. Case Study #16: Prevention of Neural-Tube Defects in Chile. Available from: http://www.cgdev.org/doc/millions/MS_case_16.pdf. Accessed on June 22, 2012.
  54. 54.
    Hertramph E, Cortes F. Folic acid fortification of wheat flour: Chile. Nutr Rev. 2004;62(6):S44–8.CrossRefGoogle Scholar
  55. 55.
    Chen J, Zhao X, Zhang X, Yin S, Piao J, Huo J, Yu B, Qu N, Lu Q, Wang S, Chen C. Studies on the effectiveness of NaFeEDTA-fortified soy sauce in controlling iron deficiency: a population-based intervention trial. Food Nutr Bull. 2005;26:177–89.PubMedGoogle Scholar
  56. 56.
    Sayed A, Bourne D, Pattinson R, Nixon J, Henderson B. Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa. Birth Defects Res, Part A Clin Mol Terol. 2008;82:211–6.CrossRefGoogle Scholar
  57. 57.
    Assey VD, Peterson S, Kimboka S, Ngemera D, Mgoba C, Ruhiye DM, Ndoss GD, Greiner T, Tylleskar T. Tanzania national survey on iodine deficiency: impact after twelve years of salt iodization. BMC Public Health. 2009;9:319.CrossRefPubMedCentralPubMedGoogle Scholar
  58. 58.
    Ray JG, Meier C, Vermeulen MJ, Boss S, Wyatt PR, Cole DEC. Association of neural tube defects and folic acid food fortification in Canada. Lancet. 2002;360:2047–8.CrossRefPubMedGoogle Scholar
  59. 59.
    Serdula, Pena-Rosas, Maberly, Parvanta, Arbuto, Perrine, and Mei: Flour fortification with iron, vitamin B12, vitamin A, and zinc: Proceedings of the Second Technical Workshop on Wheat Flour Fortification, The United Nations University. 2010.Google Scholar
  60. 60.
    Fletcher RJ, Bell IP, Lambert JP. Public health aspects of food fortification: a question of balance. Proc Nutr Soc. 2004;63:605–14.CrossRefPubMedGoogle Scholar
  61. 61.
    Fortification Rapid Assessment Tool & Guidelines Micronutrient Initiative & PATH Canada, 2000.Google Scholar
  62. 62.
    Food and Agricultural Organization (FAO). Preventing micronutrient malnutrition: A guide to food-based approaches. http://www.fao.org/docrep/x0245e/x0245e02.htm#P220_21819. Accessed 11 July 2012.
  63. 63.
    Emory University School of Public Health. Flour Miller’s Tool Kit on Fortification. Presentation. March 2011.Google Scholar
  64. 64.
    Johnson Q, Mannar V, Ranum P. Fortification Handbook. Vitamin and mineral fortification of wheat flour and maize meal. The Micronutrient Initiative. June 2004.Google Scholar
  65. 65.
    ECSA Manual for Internal Monitoring of Fortified Maize Flour. First edition. 2007.Google Scholar
  66. 66.
    Dary O. Mass food fortification programs as public health nutrition interventions. In: Dary O. The importance and limitations of food fortification for the management of nutritional anemia. In: Kraemer K, Zimmerman MB (eds) Nutritional Anemia. 2007. Basel: Sight and Life. pp. 315–36.Google Scholar
  67. 67.
    Serlemitsos JA, Fusco H. Vitamin A Fortification of Sugar in Zambia 1998–2001. The USAID Micronutrient Program (MOST). 2001.Google Scholar
  68. 68.
    USAID Micronutrient Project (MOST)/UNICEF/CDC/The National Food and Nutrition Commission of Zambia. Report of the national survey to evaluate the impact of vitamin A interventions in Zambia. 2003.Google Scholar
  69. 69.
    Hurrel R, Ranum P, de Pee S, Biebinger R, Hulthen L, Johnson Q, Lynch S. Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr Bull. 2010;31:S7–S21.Google Scholar
  70. 70.
    Flour Fortification Initiative. Economic Benefits. http://www.sph.emory.edu/wheatflour/economicbenefit.php . Accessed on 23 July 2012.

Copyright information

© Springer New York 2015

Authors and Affiliations

  1. 1.Project Healthy ChildrenCambridgeUSA

Personalised recommendations