SIGHT AND LIFE · SIGHT AND LIFE Magazine Issue N o3/2009 Elderly woman in Micronesia Micronutrient Status, Immune Response and Infectious Disease in Elderly of Less Developed Countries

SIGHT AND LIFEMagazine Issue No 3/2009

Elderly woman in Micronesia

Micronutrient Status, Immune Response and Infectious Disease in Elderly ofLess Developed Countries

The world’s population, especially in less developed countries, is expected to continueexpanding. This growth is occurring together with a demographic transition due toincreases in lifespan, and decreases in mortality and fertility. As a result, the number ofpeople aged above 60 years in less developed countries is expected to increase from thecurrent 8% to 20% in 2050, with the group aged above 80 years growing almost five-fold. Read more on page 6

Guest Editorial: Alfred Sommer

Micronutrient Status andImmune Response inthe Elderly

Helicobacter pylori Infection andMalnutrition

Genetic Variation in �-CaroteneCleavage

Provitamin A CarotenoidRetention in Orange Sweet Potato

The Honduras Children’sMicronutrient and Deworming Project

African Forum 2009

Micronutrient Forum SatelliteSession Highlights

A Day in the Life of Werner Schultink

Micronutrient Deficiencies and Affluence

IRC Border Eye Program/A2Z Child Blindness Program

SIGHT AND LIFE MagazineReader Survey

News

Letters to the Editor

Publications

ContentsSIGHT AND LIFE

Correspondents

William S. Blaner Martin BloemGeorge BrittonIan Darnton-HillOmar DaryFrances R. DavidsonJohn W. Erdman JrPhilip Harvey

Richard F. HurrellRolf D.W. KlemmDonald S. McLarenRegina Moench-PfannerChristine Northrop-ClewesNoel W. SolomonsFlorentino S. SolonAlfred Sommer

David I. ThurnhamAndrew TomkinsEmorn WasantwisutKeith P. West JrYu XiaodongChittaranjan S.YajnikMichael B. Zimmermann

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Contents

Guest Editorial 4

Micronutrient Status, Immune Response and Infectious Disease in Elderly of LessDeveloped Countries 6

No Association Between Helicobacter pyloriInfection, Anemia and Growth Impairmentin Children 16

Can the �-Carotene low ResponderPhenotype be Caused by GeneticPolymorphisms in the �-Carotene15,15’-Monoxygenase Gene? 22

Provitamin A Carotenoid Retention inOrange Sweet Potato 27

The Honduras Children’s Micronutrientand Deworming Project 34

Micronutrient Status, ImmuneResponse and Infectious Disease inElderly of Less Developed CountriesAdequate nutritional status is essential for efficientimmune function, especially for health and diseaseprevention in the elderly. 6

Lack of Association BetweenHelicobacter pylori Infection, Anemiaand Growth Impairment in ChildrenSeveral studies have shown controversial resultsabout the association between H. pylori infectionand iron deficiency or anemia in children andyoung people. 16

NewsPreventing�Micronutrient�Deficiencies

in�Woman�and�Young�Children:�

Latest�Findings 71

Helen Keller International Received António Champalimaud Vision Award 73

Natural Science Day Zurich 73

Expert Panel Convened to AdvanceUnified Advocacy on Global Problem of Hidden Hunger 74

Letters to the Editor 75

Publications 77

Magazine Issue 3/2009Contents

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Micronutrient Forum Satellite Session HighlightsIn order to ensure that the larger micronutrient community has access to what was shared during the satellite sessions of the Forum,SIGHT AND LIFE has compiled a summary. 43

Africa Forum 2009: Sharing Integrated Solutions to HIV and Food and Nutrition Insecurity 38

Micronutrient Forum Satellite SessionHighlights 43

A Day in the Life of Werner Schultink 53

Micronutrient Deficiencies and Affluence 56

IRC Border Eye Program 63

SIGHT AND LIFE MagazineReader Survey 68

Micronutrient Deficiencies and AffluenceThe epidemic of overeating in North America and the United Kingdom together with a sedentarylifestyle has led to a growing prevalence of obesity,diabetes and metabolic syndrome in children. 56

SIGHT AND LIFE Editorial

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Why Doesn’t Nutrition Get More Respect?

The title of this guest editorial more or less conveysthe topic of several panel discussions at the recentInternational Congress of Nutrition in Bangkok. Inactual fact, some populations already give “nutrition”more attention (and respect) than perhaps it deserves!The average American is almost pathologicallyobsessed by news reports of the latest (and often con-tradictory) “dietary health experts, discoveries and rec-ommendations.”

But many leaders within the nutrition communityare rightly concerned that global nutrition policy andprograms, particularly those aimed at poor, nutritional-ly deficient populations, receive little attention andsupport from political leaders and major funding agen-cies, particularly when compared with the recentexplosion of interest and investments in “globalhealth.” This discrepancy should not be surprising, andovercoming it will prove challenging.

Swine flu, SARS and HIV are seen as urgentthreats; investing in their control in poorer countrieshelps to reduce their risk of spread to wealthy coun-tries. In contrast, malnutrition is largely invisible, andposes no risk to wealthier nations.

Present calls to invest more in “nutrition” also missa subtle distinction. The current interest in “globalhealth” is not actually about “health” at all. Bono,Clinton, Gordon Brown and other public leaders haverallied around specific diseases; particularly diseasesfor which there are focused interventions: treatment ofAIDS, bednets for malaria, DOTS for TB, and polioeradication (as difficult as that may be proving).“Malnutrition” is not a specific entity; it thereforelacks the immediacy and tactile nature of specific(largely infectious) diseases.

Our nomenclature reinforces the problem. Thenon-emotive term, “malnutrition,” is hard enough toexplain; we compound the problem when we speak ofissues like “the double burden of malnutrition.”“Double burden” may be a clever, short-hand rallyingcry for the nutrition and public health cognoscenti,but just try explaining it to a science writer or a politi-cian.

We also fail tosend clear messages,be cause we needless-ly bicker over themeaning of “scientif-ic” data. One exuber-ant debate at the Micronutrient Forum in Beijing earli-er this year pitted the conclusions of two tightly con-trolled trials of newborn vitamin A dosing in similarpopulations, both with high baseline infant mortalityand serious vitamin A deficiency, against a “meta-analysis” that combined these two trials with ones inwhich populations were not particularly vitamin Adeficient, had considerably lower infant mortality, orfailed to administer vitamin A within the first few daysof birth. “Context” is usually everything; for this meta-analysis, originally commissioned by WHO, it appar-ently counted for little. No one would expect penicillinto prevent coronary artery disease; why would oneexpect vitamin A to be effective in non-deficient pop-ulations with relatively low mortality rates; unless ofcourse one were postulating an entirely differentmechanism of action?

Context and consistency was well illustrated byanother event that took place at the Forum: the presen-tation of the long awaited results of the well-executedvitamin A maternal mortality trial in Ghana. To manypeople’s surprise (and disappointment) vitamin A sup-plementation of pregnant women provided no apparentreduction in their mortality. This stands in strikingcontrast with an earlier trial in Nepal, where maternalmortality among women randomized to vitamin A (oran equivalent amount of �-carotene) was only 60 per-cent that of women in the placebo arm. Some viewedthis as contradictory. Yet, had the Ghana trial pro-duced the same outcome as the Nepal trial, there wouldhave been real cause for concern. The baseline vitaminA status of the women in Nepal was extremely poor,and their maternal mortality ratios were very high. Incontrast, the vitamin A status of the Ghanaian womenwas, in comparison, quite good, and their maternalmortality less than half that of the Nepalese women.The results of the two trials could not have been moreconsistent! A similar, as yet unpublished trial inBangladesh, yielded the same results as the Ghanatrial, and like Ghana, its participants had less than halfthe risk of death, and considerably better baseline vita-

Guest Editorial

SIGHT AND LIFE Magazine 2009;3:4–5

Magazine Issue 3/2009Editorial

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min A status, than those in Nepal. A “context-free”meta-analysis might conclude that two trials were pos-itive, one was negative, and therefore, on average,there is no potential survival benefit from providingpregnant women with supplemental vitamin A. That,indeed, is what several speakers proposed. A morethoughtful conclusion, of course, is that there maywell be a substantial benefit, but only among popula-tions in which women are seriously vitamin A defi-cient and at high risk of maternal mortality. Not sur-prisingly, one of the major complaints I received frompolicy-makers following the Beijing meeting was theirconfusion about the programmatic implications ofthese claimed contradictions!

“Diet” of course is “destiny.” The common person(and Minister of Health) is looking to us for guidanceabout their diet. Nutritionists stand on firm, clearground when recommending foods that prevent theclassic nutritional deficiencies (beri-beri, xeroph-thalmia, scurvy). But what do we commonly recom-mend to populations suffering from growing rates ofobesity, chronic diseases, and other scourges of plen-ty: “eat a balanced diet.” But what, precisely, IS a“balanced diet”? I don’t mean “philosophically”; Imean its specific content and preparation. Has humankind ever consumed a “balanced diet”? How would weknow? Even Michael Pollan’s admonition, “eat food,preferably plants, in small amounts” is more specific(if far from specific enough).

The US Department of Agriculture revised itsfamous “food pyramid” several years ago to furtheremphasize the value of grains and the dangers of meat(fat) consumption. Few people paid any attention tothe previous version; even fewer (in this age of fastfoods) pay much attention to this revised version. Anifty new, simplified scheme meant to facilitatehealth-conscious purchasing in the supermarket(“Smart Choice”), would, as one wag put it, award itsseal of approval to “sawdust if it was supplementedwith vitamins.” That outburst came in response to thebestowal of this “seal of approval” on sweetenedbreakfast cereals. Criteria for receipt of this seal weredeveloped by a panel of highly regarded nutritionists.

As long as we continue to speak in generalities,conflate our recommendations, or popularize unsub-stantiated speculation, the world will never take whatwe say as seriously as it takes a prescription for peni-cillin or statins. Perhaps it never will. People thinkthey “understand” food; they know they don’t under-stand molecular biology.

The new Global Action Plan for Scaling up onNutrition (“GAP”) initiative is a thoughtful attempt todefine a nutrition agenda that the world will under-stand and support. It has already generated vigorousand helpful debate within the nutrition community; adebate that has begun to clarify the challenges and cre-ate much needed consensus and coordination. Its greatchallenge will be fashioning message(s) that politi-cians and political leaders can grasp and will findcompelling and that put forward strategies that realis-tically address local capacity and engagement.

On a personal note, after three decades of service onthe IVACG/Micronutrient Forum Steering Com -mittee, including nearly two decades as its Chair, it isnow time (perhaps long past time!) for me to stepdown. The Micronutrient Forum (and IVACG beforeit) provides a collegial, efficient and productive venuefor researchers, policy-makers and program leaders toshare information and insights. It has also strength-ened support for, and attention to, evidence arisingfrom field-based observational data and trials on rep-resentative populations; evidence that often ran count-er to established orthodoxy. This important evolutionhas added greater credibility to both our science and toour recommendations.

Alfred Sommer, MD, MHS

Johns Hopkins Bloomberg School of Public Health,Center for Human Nutrition, 615 North Wolfe Street,Baltimore, Maryland 21205, USAEmail: [email protected]

SIGHT AND LIFE Micronutrients and Immune Response in the Elderly

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Introduction

The world’s population, especiallyin less developed countries, isexpected to continue expanding.This growth is occurring togetherwith a demographic transition dueto increases in lifespan, anddecreases in mortality and fertility.As a result, the number of peopleaged above 60 years in less devel-oped countries is expected toincrease from the current 8% to20% in 2050, with the group agedabove 80 years growing almostfive-fold.1 When using countrymedian age as an indicator of age-

ing, the 2006 Revision of the UNWorld Population Prospects showsthat the overall world populationwill age (Figure 1) and that thisshift will occur mainly in develop-ing countries. But, even thoughlife span has increased, quality oflife has not improved for this agegroup,2 leading to unhealthy ageingand increased morbidity. As elo-quently expressed in the 1995 Stateof World Health: “For most of thepeople in the world today, everystep in life, from infancy to old age,is taken under the twin shadows ofpoverty and inequity, and under thedouble burden of suffering and dis-

ease. For many, the prospect of alonger life may seem more like apunishment than a prize.” A pri-mordial objective is not only toincrease lifespan but to achievesuccessful ageing, which is definedas minimizing the time between theonset of illness and death.3

The elderly in the less developedworld play an important role insociety and in their country’s econ-omy.4 However, they are vulnera-ble to malnutrition and suffer frominfectious diseases. Additionally,many elderly people from lessdeveloped countries have experi-enced an increase in chronic dis-eases as a consequence of the dou-ble burden of malnutrition.5,6 Theincrease of infectious and non-communicable disease within thisexpanding population has translat-ed into poor quality of life and anincreased burden on the healthcaresystems of their countries.

Subclinical levels of micronutri-ents have been associated withimpaired immune function in peo-ple above 60 years of age,7 and ithas been found that micronutrientsupplementation and improved

Micronutrient Status, ImmuneResponse and Infectious Disease inElderly of Less Developed Countries

Maria C Dao, Simin Nikbin MeydaniNutrition Immunology Laboratory, JM USDA Human NutritionResearch Center on Aging at Tufts University, Boston, USA

Correspondence: Simin Nikbin Meydani, JM USDA HNRCA, 711 Washington Street, Boston, MA 02111, USAEmail: [email protected]


Figure 1: Demographic transition towards an older population(United Nations, Population Division, 1999)

Magazine Issue 3/2009Micronutrients and Immune Response in the Elderly

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nutrition can enhance immunefunction.8,9 It is important, how -ever, that more information isobtained on regional micronutrientstatus and the benefits a nutritionintervention might have. Such stud-ies on elderly populations in thedeveloping world are limited.Often, data obtained from devel-oped countries is applied to less

developed countries, or is extrapo-lated from younger age groupswithin the same country. Manyaspects of populations in developedcountries are not applicable togroups in less developed countries.Also, changes in health, physiolo-gy, and immune function duringageing make younger groups aninappropriate model for an oldergroup.

In this review, we will describeage-associated changes in immuneresponse, summarize the impact ofmicronutrients on immune status inthe elderly, assess the currentmicronutrient status of the elderlyin less developed countries and itsrelation to their immune response,and review current interventions todetermine what they teach us forimproving the health outcomes ofthis growing population, as well asthe obstacles we need to overcome.

Ageing and immunity

Both innate and acquired immunityweaken with age even in “healthy”elderly people.10 Age-relatedchanges detrimental to the immunesystem include thymic involution,poor response to vaccinations,impaired response to evolvingpathogens and newly encounteredantigens, increased vulnerability toinfection, increased autoimmunity,and inflammation.11-13

The most widely studied cells ofinnate immunity with respect toageing are macrophages. Some, butnot all studies have shown thatmacrophage chemotaxis, phagocy-tosis, cytokine production, andbone marrow population are com-promised with age.14 Macrophagesare part of the defense barrier in theskin; they detect pathogens anddefend the body against bacteria.14

Because skin is affected with age-ing, its efficiency as a protectivebarrier declines and, along with it,macrophage function is altered.This change leads to increased col-onization of bacteria and yeast onthe skin and on mucosal surfaces.14

Wound repair is also affected withageing, partly due to delayedmacrophage infiltration and func-tion. This causes delayed symptommanifestation and diagnosis ofinfection, which exacerbates dis-ease.14 Therefore, in general,macrophage ability to fight infec-tion is impaired and there is dereg-ulation of the molecules they pro-duce. For example, production ofprostaglandin E2, an inflammatorymolecule that has been shown tosuppress T cell function in agedindividuals15 as well as contribut-ing to several chronic diseasesassociated with aging, such as car-diovascular and inflammatory dis-eases, increases with age.16,17

Many aspects related to changesin other innate immune system

cells, such as neutrophils, eosin -ophils, mast cells, and NK cells,remain undiscovered or controver-sial. However, it is known that neu-trophil phagocytosis and superox-ide (O2

.-) and hydrogen peroxide(H2O2) production is impaired, andmast cell number seems to decreasein the skin.18 Also, eosinophil func-tion becomes impaired, leading toincreased responses to allergens,which partly explains the exacerba-tion of asthma with older age.18

Dendritic cell (DC) functiondecreases with age19 and chemo-taxis may be compromised18 but itis not clear whether the number ofDCs decreases.11

The adaptive immune system,whose main players are T and Bcells, is widely modified with age-ing. Even though peripheral B cellnumber and secreted immunoglob-ulin levels stay constant with age,there is impaired naïve B cell pro-duction,11 less affinity from anti-bodies to antigen, and more auto -antibodies produced.20 Thesechanges may reduce the response tonewly encountered antigens.19

It has been established that T celldecline is the main cause ofimmune senescence.3,19 There is areduced number of naïve T cellsand an expansion of memory T cells.11 This imbalance results, inpart, from thymic involution andthe expansion of memory T cells asa result of persistent or latentpathogens.13 The imbalance leadsto a decreased response to newantigens, such as new strains ofinfluenza.11 Additionally, CD4 T helper cell number and functiondeclines, and CD8 cytotoxic effec-tor T lymphocytes (CTLs) havereduced intensity in their responseagainst influenza vaccine and lessinterferon-gamma (IFN�) produc-tion during viral infections.19

Influenza is the fifth cause of deathin people older than 50 years.19

Elderly farmer in Bangladesh


8

This age group is a target for vaccination campaigns,but influenza virus vaccines have only 30–40% effica-cy in the elderly.11,13

In addition to age-associated immunologicalchanges, which predispose the elderly to a higher inci-dence of infectious diseases, a recent report by Gay etal21 showed that passage of an avirulent coxsackie B3virus (COXB3-0), which normally does not causemorbidity and mortality in young mice, through an oldhost resulted in several mutations in the virus thatincreased its virulence, transforming it into a morbidi-ty- and mortality-causing virus for the young mice.These results indicate that, in addition to immunologi-cal changes, increased viral virulence in the aged hostcould contribute to their higher susceptibility to infec-tion. Given that Beck et al22 have shown that micronu-trient deficiencies, such as those of selenium and vita-min E, also increase viral virulence, and there is a highprevalence of nutritional deficiencies in less developedcountries and an increasing number of older people inthese countries, these findings could have significantpublic health implications worldwide, and emphasizethe need to address nutritional deficiencies in the eld-erly populations of less developed countries.

Micronutrient status, ageing and immunity

Adequate nutritional status is essential for efficientimmune function. Investigating this relationship andits relevance to ageing is of great importance for thehealth of the elderly and for disease prevention.8 Manypostulate that improvements of nutritional status inelderly populations will enhance their immune sys-tem.8,20 In turn, this would lead to enhanced nutrition-al status by preventing the consequences of infectiousdisease, such as nutrient malabsorption, nutrient andenergy store loss, and reduced appetite.3 There is alarge body of evidence on the potential benefits thatmicronutrient enhancement can have for the ageingimmune system. However, much of this evidencecomes from the developed world and has yet to beextended to less developed countries.

There are several comprehensive reviews ofmicronutrient supplementation studies in the elder-ly.3,23 Single nutrient supplementation studies haveshown improvement in the immune response of the eld-erly. These nutrients include vitamin B6,24,25 vita -min C,26,27 vitamin E9,28,29 and zinc.30,31 Also, theremay be a role of vitamin D in age-related deregulationof the immune response in the elderly.32,33 However,more studies on this topic are needed. Additionally,there are studies supporting that certain micronutrients,

such as antioxidants, be given as a mixture so that theywork synergistically, and to prevent an imbalance thatmay lead to pro-oxidant production.34 However, suchevidence of supplementation in the elderly remainscontroversial. A systematic review by Stephen andAvenell35 showed that there was no significant effect ofmicronutrient mixture supplements in the elderly. But,subgroup analysis within that study showed that elder-ly individuals who were undernourished at baseline andconsumed supplements for six months experienced thegreatest benefit. A high proportion of elderly people indeveloped countries take multivitamins, which maybias the results of an intervention trial. Therefore, thelack of effect observed following micronutrient supple-mentation in developed countries might not be applica-ble to less developed countries.

A randomized controlled trial in which Girodon et al36 supplemented institutionalized elderly subjectswith zinc, selenium, and vitamins A, C, and E for twoyears showed significant improvement in antibodyproduction in response to influenza vaccine in groupsreceiving single supplements or combinations thereof.Also in this study, a correlation was observed betweenzinc and selenium supplementation and reduction ofrespiratory infections. This study suggests that elderlyvaccine response can be enhanced through micronutri-ent supplementation, which would not only prevent

Elderly man with boy in rural Kenya


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disease and malnutrition but alsoreduce the economic strain on thehealth care system by decreasingcosts associated with hospitaliza-tion.

The nutritional status and pres-ence of other diseases could influ-ence the impact of nutritional inter-vention on immune response andresistance to infection in the elder-ly. For example, Graat34 showedthat supplementing a group of eld-erly individuals from the Nether -lands replete with vitamin C and Ewith a 200 mg of vitamin E dailyhad no effect on infectious diseaseoutcomes. On the other hand, avitamin E trial by Meydani et al37

showed that supplementing nursinghome residents with 200 IU per dayof vitamin E reduced upper respira-tory tract infections, such as thecommon cold. Differences in dis-ease status, genetic background, aswell as study design and documen-tation of infection could haveattributed to the observed out-comes.38 Further analysis from thestudy by Meydani et al39 found thatlow serum zinc levels in this popu-lation correlated with higher inci-dence and duration of pneumonia.A recent study also showed thatgenetic variation in cytokine genescan influence the impact of vitaminE supplementation on cytokine pro-duction in the elderly.40

Finally, research on probioticsupplementation to prevent orreduce infection is being developedand offers potential for immunesystem enhancement. Probioticshelp maintain immunologic bal-ance in the mucosal sites of thebody and protect against patho -gens, and it has been suggested thatthey help restore impaired innateimmunity in the mucosal epithe-lia.41 Long-term daily supplemen-tation of 479 healthy adults (aged18–67 years) with vitamins andminerals, with or without probi-

otics, did not show a difference inthe incidence of common colds;however, shorter duration of colds,decreased severity of symptoms,and enhanced T cell responses wereobserved.42 Another study showedthat elderly people supplementedwith probiotic supplements hadhigher antibody titers after influen-za vaccination than those given aplacebo, indicating the potential ofprobiotics in enhancing response tovaccines in the elderly.43 Since the‘indigenous microbiota’ populationin the intestinal mucosa changeswith age,41 probiotic supplementa-tion together with micronutrientsupplementation may have a posi-tive impact on elderly immunity. Insummary, the studies describedabove, conducted in developedcountries, indicate that micronutri-ent and other dietary interventionscould be of benefit to the elderly ofless developed countries in provid-ing protection against infection andother immune/inflammation-relat-ed diseases,11 minimizing the num-ber of years in a person’s life dur-ing which he or she will suffer fromrecurring disease (Figure 2), andallowing healthy ageing.

Micronutrient status, immuneresponse and infectious diseases in elderly from lessdeveloped countries

The most prevalent and targetedcauses of malnutrition worldwideare protein energy malnutrition andvitamin A, iodine, iron, and zincdeficiency. Data on micronutrientstatus in less developed countriesis abundant for vulnerable groups,particularly children and pregnantwomen, but scarce for the elderly.The reasons for elderly popula-tions’ vulnerability to malnutritionin less developed countries includepoor diet, food insecurity, lack ofpublic health measures, and lowallocation of government funds tothe health care system,44 resulting

in a higher incidence of diseases.In many less developed nations,consumption of foods from animalorigin is very low due to inaccessi-bility and/or religious practices,limiting micronutrient consump-tion. This scenario also translatesinto low protein consumption,which has been shown to impairthe immune system in the elder-ly.45 In addition, many regionshave high consumption of phy-tates, further lowering the absorp-tion of minerals in a group thatalready has limited access to nutri-ents. All these factors lead to high-er incidence of communicable dis-eases and, due to the nutritiontransition and consumption offood of low nutritional quality, toobesity and chronic disease aswell.6

In order to target appropriatemicronutrient interventions anddevelop effective public healthmeasures, more detailed nutritionaldata is needed from less developednations. Nutritional status, eventhough generally impaired in poorelderly populations, differs greatlybetween regions. The recommend-ed micronutrient dosages to be usedin supplementation in less devel-oped countries, listed elsewhere,46

divide individuals into three agegroups: 1–3 years, 4–13 years, and> 14 years. The elderly are groupedtogether with adults, but due totheir impaired nutrient absorptionand intake, not to mention diseasestatus, they may require differentdoses for certain nutrients.

Table 1 summarizes studies thathave reported micronutrient statusin less developed country elderlypopulations and the relationshipsbetween micronutrients, immuneresponse and infection. From thislimited data, it is clear that micro -nutrient deficiencies vary greatlyfrom region to region, even withinthe same country. Even though


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vitamins C and E play an importantrole in immune function and theprevention of chronic diseases dueto their antioxidant properties, verylittle data has been acquired fromelderly populations in less devel-oped countries on these micronu-trients. Hamer et al5 reported that92.4% of elderly Ecuadorians weredeficient in vitamin C and that lowplasma vitamin C and zinc levelscorrelated with immune cells’impaired ability to produce IFN�.A little more is known about Bvitamins, which are important inthe development of chronic dis-ease, anemia, and cognitionimpairment, and are involved in awide array of cellular functions,including immune response.Vitamin B12 deficiency is commonin the elderly both in developedand less developed countries. Inthe less developed world, however,there is a higher prevalence and itstarts earlier in life5,47 because oflow dietary intake and other envi-ronmental factors. Helicobacterpylori infection has been identifiedas one of the causes of poor vita-min B12 absorption. There is evi-dence that probiotic supplementa-tion can help displace harmful bac-teria and repopulate harmless orbeneficial intestinal flora. Parasitic

infections are common in lessdeveloped countries among bothchildren and the elderly. Hamer etal found that most elderlyEcuadorians in their study had par-asites.5 In addition, as shown inTable 1, other B vitamin deficien-cies are also prevalent. For exam-ple, riboflavin deficiency has beenfound in several countries in thepast few decades.

Iron deficiency anemia (IDA)affects about one quarter of theworld’s population.48 The causesfor this deficiency in the elderlyinclude low iron intake, high levelsof dietary phytates and low animalfood consumption, as well asatrophic gastritis, intestinal atro-phies, and, in some instances,Helicobacter pylori infection.49

National data on elderly anemiaprevalence is missing from manycountries. According to Deitchleret al50 only three out of 12 coun-tries studied – Indonesia, Laos, andthe Philippines – have recordedanemia prevalence in the elderlyand found it to be greater than30%. Hamer et al5 found that 39%of the elderly Ecuadorians in theirstudy had serum iron below thereference range. Furthermore, theyfound that iron status correlated

with immune cell ability to pro-duce interleukin-2 (IL-2).

Several organizations and gov-ernments estimate micronutrientstatus in specific regions, but directmeasurements are scarce. Forexample, McLean et al48 gatheredglobal and regional data from theWHO Vitamin and MineralNutrition Information System for1993–2005 and determined anemiaprevalence in different vulnerablegroups based either on actual dataor estimations. Data on the elderlywere unavailable in almost everycountry, so only global estimationswere made. It was determined that24%, or 163 million, of elderlypopulations worldwide were suf-fering from IDA, with the highestproportion in low-income coun-tries.

Zinc deficiency is prevalent inthe elderly of both developed andless developed countries. Hamer etal5 reported that close to 50% ofelderly Ecuadorians had low serumzinc level and low serum zinc levels correlated with low IL-2 and INF� levels. Interestingly,Meydani et al39 reported that 30%of nursing home residents in USAalso had low serum zinc levels,

Figure 2: Hypothetical effect of micronutrient status assessment and nutritional interventions among theelderly in developing countries (adapted�from�Dr�Jose�Ordovas,�JM-USDA�HNRC�at�Tufts�University)

Healthstatus

Infections,Inflammation

Improved nutritional status andsuccessful ageing

No intervention

Onset of vicious cyclebetween malnutrition andimpaired immune response

Age


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which were associated with higherincidence of pneumonia. Resultsfrom the study by Hamer et al indi-cated that elderly Ecuadorians hada much higher prevalence ofmicronutrient deficiencies com-pared to those living in USA, andthat corresponded with their lowerimmune response compared to theirUS counterparts. For example, zincdeficiency was found to be two tothree times higher (depending onwhether the elderly individualswere living independently or nurs-ing home residents) in elderlyEcuadorians compared to those inUSA, and their delayed type hyper-sensitivity response (a measure ofcell-mediated immunity) was halfthat of their US counterparts.Hamer et al also showed that elder-ly Ecuadorians have a higher inci-dence of infectious disease thantheir US counterparts, and that asignificant correlation exists be -tween micronutrient deficiency andinfection in these elderly people.While several factors, includingsanitation, could contribute to thehigher incidence of infection in eld-erly Ecuadorians compared to theirUS counterparts, these data point tomicronutrient deficiencies as animportant contributor.

Summary and conclusions

In summary, the elderly populationis increasing worldwide and is suf-fering from the double burden ofdisease, i.e. both chronic and in -fectious diseases. As such, theyface significantly more healthproblems compared to other agegroups. Many factors contribute tohigher susceptibility of infection inthe elderly (Figure 3), chiefamong which are age-related im -muno logical changes. In addition,recent data suggest that the envi-ronment of elderly hosts mightincrease viral virulence, and mor-bidity and mortality from suchcauses. The limited data available

suggest that the elderly in lessdeveloped countries suffer from a high prevalence of several micro -nutrient deficiencies. Further more,these reports indicate that theprevalence and type of micronutri-ent deficiencies differ by region,and are correlated with lowimmune response and high inci-dence of infection. Micro nutrientsare needed for immune responseand their deficiency not onlyimpairs the immune response, butcould also increase viral virulenceby causing mutations in the virus.

Thus, the combined impact ofimmunological defects, increasedviral virulence in the aged, and thepresence of micronutrient deficien-cies in the aged not only puts theelderly of less developed countriesat high risk of infection, morbidityand mortality from them, but couldpose a public health problem for all age groups by contributing to the spread of more virulent viralspecies. Therefore, there is anurgent need to address the nutri-tional problems of the elderly in

less developed countries so thateffective intervention strategiescan be devised. Region-specificstudies to determine micronutrientstatus are needed so that cost-effective supplementation strate-gies can be proposed. For thosecountries in which specific defi-ciencies have already been de -scribed, studies are needed to de mon strate the efficacy of specif-ic micronutrient supplementationregimes to improve immune re -sponse and decrease infectious dis-eases.

Even though much data remainto be gathered with respect tomicronutrient status in the elderlyfrom less developed countries,especially as it pertains to immuneresponse, some initiatives havebeen taken to improve elderlyhealth and quality of life. Inresponse to the demographic transi-tion and the economic strain of eld-erly disease, Chile’s governmentdeveloped a program to distribute amicronutrient mix fortified withvitamins and minerals to low-

Figure 3: Holistic view of factors that influence the immune system

Age

Enviroment

MacronutrientsMicronutrients

Genetics,Epigenetics,

SNPs*

ImmuneResponse

*Single Nucleotide Polymorphism


12

Table 1: Studies on micronutrient status in less developed countries

Central Guatemala

Boisvert et al51 50+ 433 Cross-sectional study. Dietary assessment and riboflavin status.

Location Reference Age(years)

Samplesize

Study description

Bangkok,Thailand

Prayurahong et al52

NA (elderly)

147 Cross-sectional study. Hematological data.

Zimbabwe Allain et al53 65+ 278 Cross-sectional study. Hemoglobin, folate and B12 levels in rural and urban elderly.

Chile Olivares et al54 60+ 274 Cross-sectional study. Anthropo metric measurements and biochemical measuresof iron, copper, folate, vitamins B12 and A and C-reactive protein (CRP), and e rythrocyte sedimentation rate (ESR).

Chile Bunout et al55 70+ 98 Randomized controlled trial; lasted 18 months. Micronutrient supplement with or without exercise.

Chile Hirsch et al56 70+ 108 Prospective study. Six months after folic acid fortification started determinedeffect on folic acid and B12 status and plasma homocysteine

Chile Bunout et al57 70+ 60 Randomized controlled trial. Micronutrient (vitamin E, B12, folate), probiotic andprotein supplementation, and placebo.

Cape Town,South Africa

Charlton et al58 68.9

(SD = 5.7)

148 Cross-sectional study. 24-hr recall and anthropological measurements.

Beirut,Lebanon

Sibai et al59 65+ 200 Cross-sectional study. Questionnaires, anthropometric measurements, hematolog-ical and biochemical analyses period.

Cape Town,South Africa

Charlton et al60 72.7

(SD = 8.3)

285 Cross-sectional study. 24-hr recall, plasma micronutrient levels, anthropo-metric measurements.

Taiwan Cheng et al61 65+ 2373 Cros-sectional study (Elderly NAHSIT). Plasma retinol and tocopherol measurements.

Taiwan Wang andShaw62

65+ 2354 Cross-sectional study (Elderly NAHSIT). Plasma iron measurements.

Taiwan Yang et al64 65+ 2379 Cross-sectional study (Elderly NAHSIT). Biochemical measurements ofthiamin and riboflavin.

Quito,Ecuador

Sempertegui et al6

74.3

(SD = 6.9)

145 Cross-sectional study. Nutritional assessment through 24-hr recall,DTH, biochemichal and anthropometric measurements.

Quito,Ecuador

Hamer et al5 74.4

(SD = 6.4)

352 Cross-sectional study. CRONOS Questionnaires, anthopometric, blood micronu-trient and immuno assays.

Taiwan Wang et al63 65+ 1911§

2225§§

Cross-sectional study (Elderly NAHSIT). 24-hr recall and biochemicalmeasurements of magnesium.

§For dietary intake; §§for plasma Mg levels; DTH = delayed type hypersensitivity; RI = respiratory infection; NA = not available;


13

Riboflavin deficiency prevalence was 50–76%. Levels correlated with milk intake. Smallintervention trial revealed strong correlation between riboflavin status and dietary intake.

Study did not look at immune response.

Micronutrient Status Findings Immune response

15% of subjects had anemia, 21% were folic acid deficient, and 7% were B12insufficient.


Anemia seen in 23% of subjects, 30% had low folate level, and 13% had low serumB12 level. Folate was lower in urban subjects and B12 was lower in rural subjects.


5% men and 4% women were anemic. Abnormal serum retinol was seen in 14% of menand 16% of women. Folate deficiency was 50% in men and 33% in women. B12 defi-ciency seen in 51% of men and 31% of women. Almost no iron and copper deficiency.

10% subjects had inflammation (high ESRand CRP values, and high white blood cellcount). They had higher prevalence of ane-mia (22% men and 32% women).

Compliance with supplement was 48%. Supplemented, and supplemented + exer-cise maintained weight, lean mass, bone mineral density, serum cholesterol, and hadgreater muscle strength.


Folic acid increased, plasma homocysteine peroid decreased, and B12 stayed the same.Authors recommend elderly B12 supplementation.


Micronutrient status was not reported in this study. Response to influenza and pneumococcal vaccination. Theyobserved enhanced NK cell activity. There was no change inIL-2 production. Subjects on supplement reported less infec-tions, measured during scheduled hospital visits.

About one third had energy intake < 67% RDA. Low intakes of calcium, vitamin D,zinc, and B6. Low fruit and vegetable consumption. Over half of women and 18% menwere obese.


Deficiencies in zinc, magnesium, �-tocopherol, and vitamin A, D and B6 wereobserved in both institutionalized and free-living elderly. Also, they were anemic andhad low albumin levels.


Micronutrient levels (thiamin, riboflavin, niacin, vitamin B6, folate, pantothenate,biotin, vitamin C, calcium, iron, magnesium, phosphorus, zinc, copper, and selenium)were inversely related to added sugar intake. Sugar has a nutrient-diluting effect.


Low prevalence of plasma retinol or �-tocopherol deficiency. Study did not look at immune response.

Low prevalence of iron deficiency or iron deficiency anemia in men and women.Some subjects had elevated iron stores.


17% men and 14% women were thiamin deficient. 6.6% men and 4% women were riboflavin deficient. A large proportion (> 11% for thiamin and > 20% forriboflavin) were marginally deficient for both vitamins.


50% of subjects had low plasma B12, Zn, and Fe. About 30% had low B6, and 19%were low in folate and vitamin D.

Low DTH response. In previous 6months, 54% and 21% had at least oneepisode of RI or diarrhoea, respectively.

Deficiencies for vitamins C, D, B6, zinc and folate. Plasma vitamin C associated with INF� production. Zinc associated with INF� andIL-2 production. Micronutrient deficiency, poor immune response and burden of RI-like pneumonia and common cold, associated with history of recent infection.

Dietary magnesium intake was about 70% of RDA, and 8–9% had low plasma magne-sium levels. Magnesium levels and diabetes inversely related.


PEM = Protein Energy Malnutrition; CRONOS = Cross Cultural Research on the Nutrition of Older Subjects


14

income elderly individuals.64 Itwould be interesting to determinewhether this program has led to dis-ease prevention and improvementof Chilean low-income elderlynutritional status and quality of life.

In conclusion, there is an urgentneed to acquire more data on thenutritional status of the elderly inless developed countries and imple-menting specific interventions.Generation of this information willimprove elderly nutritional status ina cost-effective manner, which inturn could result in the reduction ofinfectious and chronic diseases,improve health status and quality oflife in this age group, and achieve significant savings tohealth care resources in these coun-tries. Further more, improving thenutritional status of the elderly inless developed countries couldreduce the global burden of infec-tious disease.

Acknowldgement

The author’s work was supportedby USDA contract number 581950-7-707, National Institute ofAging grant numbers R01AG009140, and R01-AG13975, Officeof Dietary Supplement, and aStanley N Gershoff Scholarship.

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27. Wintergerst ES, Maggini S, HornigDH. Immune-enhancing role of vita-min C and zinc and effect on clinicalconditions. Ann Nutr Metab 2006;50:85–94.

28. Meydani SN, Barklund MP, Liu S, etal. Vitamin E supplementation en -hances cell-mediated immunity inhealthy elderly subjects. Am J ClinNutr. 1990;52:557–63.

29. Pallast EG, Schouten EG, de WaartFG, et al. Effect of 50- and 100-mgvitamin E supplements on cellularimmune function in noninstitutional-ized elderly persons. Am J Clin Nutr.1999;69:1273–81.

30. Prasad AS, Beck FW, Bao B, et al.Zinc supplementation decreases inci-dence of infections in the elderly:effect of zinc on generation of cyto -kines and oxidative stress. Am J ClinNutr. 2007;85:837–44.


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31. Putics A, Vödrös D, Malavolta M,Mocchegiani E, Csermely P, Söti C.Zinc supplementation boosts thestress response in the elderly: Hsp70status is linked to zinc availability inperipheral lymphocytes. Experi mentalgerontology 2008;43:452–461.

32. Cannell JJ, Vieth R, Umhau JC, et al.Epidemic influenza and vitamin D.Epidemiol Infect. 2006;134: 1129–40.

33. Mariani E, Ravaglia G, Forti P, et al.Vitamin D, thyroid hormones andmuscle mass influence natural killer(NK) innate immunity in healthynonagenarians and centenarians. ClinExp Immunol 1999;116:19–27.

34. Graat JM, Schouten EG, Kok FJ.Effect of daily vitamin E and multivi-tamin-mineral supplementation onacute respiratory tract infections inelderly persons: a randomized con-trolled trial. JAMA 2002;288:715–721.

35. Stephen AI, Avenell A. A systematicreview of multivitamin and multi-mineral supplementation for infec-tion. J Hum Nutr Diet 2006;19:179–190.

36. Girodon F, Galan P, Monget AL, etal. Impact of trace elements and vita-min supplementation on immunityand infections in institutionalizedelderly patients: a randomized con-trolled trial. MIN. VIT. AOX. geri-atric network. Arch Intern Med1999;159:748–54.

37. Meydani SN, Leka LS, Fine BC, etal. Vitamin E and respiratory tractinfections in elderly nursing homeresidents: a randomized controlledtrial. JAMA 2004;292:828–36.

38. Hamer DH, Meydani SN. Vitamin Eand Respiratory Tract Infections inElderly Persons—Reply. JAMA2004;292:2834.

39. Meydani SN, Barnett JB, Dallal GE,et al. Serum zinc and pneumonia innursing home elderly. Am J ClinNutr 2007;86:1167–73.

40. Belisle SE, Leka LS, Delgado-ListaJ, Jacques PF, Ordovas JM, MeydaniSN. Polymorphisms at cytokinegenes may determine the effect ofvitamin E on cytokine production inthe elderly. J Nutr 2009;139:1855–60.

41. Dominguez-Bello MG, Blaser MJ.Do you have a probiotic in yourfuture? Microbes Infect 2008;10:1072–1076.

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43. Boge T, Rémigy M, Vaudaine S, etal. A probiotic fermented dairy drinkimproves antibody response toinfluenza vaccination in the elderlyin two randomised controlled trials.Vaccine 2009;27:5677–84.

44. Bermudez, OI, Dwyer J. Identifyingelders at risk of malnutrition: a uni-versal challenge. SCN News 1999;15–17.

45. Lesourd B. Protein undernutrition asthe major cause of decreased immunefunction in the elderly: clinical andfunctional implications. Nutr Rev1995;53:S86-91; discussion S92–84.

46. Bienz D, Cori H, Hornig D. Ade -quate dosing of micronutrients fordifferent age groups in the life cycle.Food Nutr Bull 2003;24:S7–15.

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48. McLean E, Cogswell M, Egli I,Wojdyla D, de Benoist B. Worldwideprevalence of anaemia, WHOVitamin and Mineral Nutrition Infor -mation System, 1993-2005. PublicHealth Nutr 2009;12:444–454.

49. Zimmermann MB, Hurrell RF.Nutritional iron deficiency. Lancet2007;370:511–520.

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51. Boisvert WA, Castaneda C, MendozaI, et al. Prevalence of riboflavin defi-ciency among Guatemalan elderlypeople and its relationship to milkintake. Am J Clin Nutr 1993;58:85–90.

52. Prayurahong B, Tungtrongchitr R,Chanjanaksijskul S, et al. VitaminB12, folic acid and haematologicalstatus in elderly Thais. J Med AssocThai 1993;76:71–78.

53. Allain TJ, Gomo Z, Wilson AO, et al.Anaemia, macrocytosis, vitamin B12and folate levels in elderly Zimbab -weans. Centr Afr J Med 1997;43:325–328.

54. Olivares M, Hertrampf E, CapurroMT, et al. Prevalence of anemia inelderly subjects living at home: roleof micronutrient deficiency and in -flammation. Eur J Clin Nutr 2000;54:834–839.

55. Bunout D, Barrera G, de la Maza P,et al. The impact of nutritional sup-plementation and resistance trainingon the health functioning of free-liv-ing Chilean elders: results of 18months of follow-up. J Nutr 2001;131:2441S–2446S.

56. Hirsch S, de la Maza P, Barrera G, etal. The Chilean flour folic acid forti-fication program reduces serumhomocysteine levels and masks vita-min B12-deficiency in elderly peo-ple. J Nutr 2002;132:289–291.

57. Charlton KE, Bourne LT, Steyn K, etal. Poor nutritional status in olderblack South Africans. Asia Pac J ClinNutr 2001;10:31–38.

58. Sibai AM, Zard C, Adra N, et al.Variations in nutritional status ofelderloy men and women accordingto place of residence. Gerontology2003;49:215–224.

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SIGHT AND LIFE Helicobacter pylori Infection and Malnutrition

16

Introduction

Helicobacter pylori infection is themajor etiologic factor in the devel-opment of chronic gastritis andpeptic ulcer disease.1 It is the mostcommon chronic bacterial infectionin humans and its prevalence tendsto be higher in developing coun-tries than in developed ones.2

Epidemiological studies conductedin Argentina showed a 40% infec-tion prevalence in symptomaticchildren3 and 15.7% prevalence inthe asymptomatic population4 –results similar to those reported indeveloped countries.5 On the otherhand, it is well known thatmicronutrient deficiencies affectbillions of people in developing

countries and iron deficiencyremains one of the most severe andimportant nutritional problems inthe world today.6 According to the2007 National Nutritional andHealth Survey by the ArgentineMinistry of Health, the prevalenceof anemia evaluated in infants aged6–24 months and children aged 2–5years was 34.9% and 10.6%,respectively.7

Several epidemiological studiesand some intervention studies haveshown controversial results aboutthe association between H. pyloriinfection and iron deficiency (ID)or iron deficiency anemia (IDA) inchildren and youth.8,9 The Maa -stricht III Consensus Report on themanagement of H. pylori infec-tion10 recommended that H. pyloriinfection should be sought for and

No Association Between Helicobacterpylori Infection, Anemia and GrowthImpairment in Children

Mariana A Janjetic1, Cinthia G Goldman1, Andrés D Barrado1,Horacio E Torti1, Julián A Fuda1, Emiliano I Meseri1, Eduardo A Cueto Rua2, Norma E Balcarce2, Marcela B Zubillaga1, José R Boccio1

1Physics Department, School of Pharmacy and Biochemistry,University of Buenos Aires, Argentina; 2Gastroenterology Unit, Children's Hospital “Superiora Sor MaríaLudovica”, La Plata, Argentina

Correspondence: Mariana A Janjetic, Physics Department, School ofPharmacy and Biochemistry, University of Buenos Aires, Junin 956(1113), Buenos Aires, ArgentinaEmail: [email protected]


Helicobacter pylori

Magazine Issue 3/2009Helicobacter pylori Infection and Malnutrition

17

treated in children and adolescents with refractoryIDA. Nevertheless, the American College of Gastro -enterology Guide lines11 established that further prop-erly designed trials would be needed to assess whetherH. pylori eradication offers benefit to patients withunexplained IDA.

Various studies have related H. pylori infection togrowth impairment in children and youth.12-14 Onesuch study hypothesizes that this infection is the initia-tor of a vicious cycle of events ultimately resulting inmalnutrition and growth impairment in children in par-ticular from developing countries.14 Argentina, likeother countries in Latin America, today faces an epi-demiological nutrition transition; on one hand, obesityis increasing dramatically and, on the other, hiddenhunger and infection continue to be public health con-cerns.7, 15 Hence, it is important to ascertain whetherH. pylori infection is associated with anemia andgrowth impairment in children.

Study

To evaluate the relationship between iron status andgrowth anthropometric indicators in children withupper gastrointestinal symptoms, the authors conduct-ed a cross-sectional study among 395 children (aged4–16 years) who were referred to the GastroenterologyUnit of the Children's Hospital ‘Superiora Sor MariaLudovica’, La Plata, Argentina, for evaluation ofupper gastrointestinal signs and symptoms. The studywas approved by the Committee of Ethics of the hos-pital and the parents signed a written consent formaccording to the Helsinki declaration. Subjects takingantibiotics or acid suppressants during the previousmonth of the study as well as iron supplements duringthe previous three months were excluded from thestudy.

An epidemiological questionnaire was administeredto the parents or guardians of the participant children,which focused on ethnicity, socio-demographic fac-tors, mothers and head of household’s educationallevel, and household water and sanitation facilities.Unsatisfied basic needs (UBN) were defined accordingto the guidelines of the Argentine Bureau of Statisticsand Census (Instituto Nacional de Estadísticas yCensos).16

Children were instructed to fast for at least six hoursbefore the 13C-Urea Breath Test (13C-UBT) was per-formed. Two samples of exhaled air were taken priorto the ingestion of the labeled solution to determinebasal 13C/12C ratios. Then, 150 mL of milk containing50 mg of 13C-urea (Cambridge Isotope LaboratoriesInc., Massachusetts, USA) were taken by each patient.Breath samples were collected in hermetically sealedcontainers (Labco Ltd, Bucking hamshire, UK) 30 and45 minutes after the ingestion of the labeled solution.Each sample of exhaled air was measured in a massspectrometer coupled to a gas chromatographer(FinniganMAT GmbH, Thermo Quest Corp., Bremen,Germany). A change of > 3.5‰ in the delta over base-line (DOB) value was considered positive.17

Venous blood samples were obtained during themorning to assess iron status, which was evaluated bydetermination of hemoglobin, serum ferritin (SF), andserum transferrin receptor (sTfR) concentrations.Hemoglobin was measured by an electronic counterthrough the cyanmethemoglobin method. Serum fer-ritin was determined by an immuno-radiometric assay(Diagnostic Systems Laboratories, Texas, USA) andsTfR by means of an enzyme immunoassay (TF-94Ramco Laboratories, Texas, USA). Serum sampleswere kept at -70 °C until assay. Anemia was definedwith hemoglobin values < 115 g/L for children under12 years, and < 120 g/L for children over that age. SFcut off was 12 µg/L for children below 5 years and 15µg/L for children over 5 years. Serum sTfR concentra-tions were measured as an additional marker of func-tional iron deficiency, with a normal range of 2.9–8.5mg/L. ID was defined when SF concentration waslower than the cut off value and IDA when both ID andanemia were present.18

Height was recorded using a stadiometer (Stanley,Morangis, France) and weight was measured by aportable mechanical scale (CAM, Buenos Aires,Argentina). Height and weight were expressed (as z-scores) relative to the CDC-2000 age and sex appropri-ate standards. Underweight and stunting were definedwhen weight-for-age (WAZ) and height-for-age (HAZ)

Helicobacter pylori

z-scores were below minus 2 standard deviations fromthe median of the reference population. Overweightand obesity were defined according to the body massindex (BMI) centiles > 85 and > 95, respectively.19

Percentiles and z-scores were calculated using EpiInfo,version 3.2 software (Atlanta, Georgia, USA).

The Fisher Exact test and Chi squared were used toanalyze dependency between H. pylori positivity andother categorical variables. Student’s t test was usedwhen it was proven that variances were homogeneous;if not, the non-parametric Mann-Whitney test wasapplied. A binary logistic regression was performed toestimate the impact of H. pylori status alone and adjust-ed for confounders as predictive variables for anemia,ID, stunting, underweight, overweight and obesity.Statistical analyses were performed using Epi Info 3.2

(Atlanta, Georgia, USA) and SPSS 11.5 software(Chicago, Illinois, USA).

Results

A total of 96 children (24.3%) with a mean age of 9.9years, were H. pylori positive. No significant differ-ences were found between age (P = 0.38) and sex (P =0.56) and H. pylori positivity. H. pylori infection wasassociated to low socioeconomic status, poor sanitaryconditions, a high number of siblings and family mem-bers, ethnicity, and low educational level of the par-ents. These results are consistent with epidemiologicaldata previously described by our group in the samepopulation3 and others.20 No significant differenceswere found for any of the biochemical markers evalu-ated for iron status between H. pylori positive and neg-

Table 2: Effect of H. pylori infection on the presence of anemia, iron deficiency, and anthropometricindicators

OR crude OR Adjusted(95% CI) P (95% CI) P

Anemia 1.54 1.11(0.73–3.24) 0.26 (0.49–2.50)a 0.81

Iron deficiency 1.35 1.45(0.67–2.70) 0.39 (0.69–3.04)b 0.32

Stunting 1.35 1.25(0.51–3.59) 0.55 (0.46–3.39)c 0.65

Underweight 1.50 1.28(0.63–3.60) 0.36 (0.47–3.46)d 0.63

Overweight and obesity 1.57 1.75(0.46–5.33) 0.47 (0.5–6.13)e 0.38

a Adjusted for source of water and type of flooring

b Adjusted for type of toilet, mother’s educational level, ethnic group and overcrowded

c Adjusted for age

d Adjusted for anemia and head of household’s educational level

e Adjusted for overcrowding and UBN

SIGHT AND LIFE

18

Table 1: Iron biochemical markers in H. pylori positive and negative patients

H. pylori (+) H. pylori (-)Mean ± SD Mean ± SD P-value

Hemoglobin (g/L) 126 ± 11 127 ± 11 0.42Serum ferritin (µg/L) 30.9 (16.3–58.6)* 35.3 (17.8–70.1)* 0.10Soluble transferrin receptor (mg/L) 4.2 ± 1.6 4.4 ± 1.6 0.38

*Geometric mean (� 1 SD)

Helicobacter pylori Infection and Malnutrition

Magazine Issue 3/2009

19


ative patients (Table 1). Pre -valence of anemia was 12.0% (95%CI, 7.2–22.6%) for the H. pyloripositive group and 8.9% (95% CI,6.0–13.6%) for the H. pylori nega-tive group. ID was found in 14.3%(95% CI, 7.8–23.2%) and 11.0%(95% CI, 7.6–15.2%) of the H.pylori positive and negativepatients, respectively. A low rate ofIDA was observed in the studiedpopulation, with a prevalence of2.4% (95% CI, 1.1–4.8%).

A binary logistic regression wasperformed to estimate the impact ofH. pylori status alone and adjustedfor confounders as a predictivevariable for anemia, ID, stunting,underweight, overweight and obe-sity. The results showed that therewas no association between H. pylori infection, iron status and anthropometric indicators(Table 2).

The prevalence of stunting foundwas 5.0% and 6.2% for H. pylorinegative and positive patients.Underweight was determined in5.7% and 8.3% of the H. pylori neg-ative and positive patients. In addi-tion, obesity and overweight wasfound in 15.3% and 20.0% of theinfected and non-infected patients.In the present study, no significantdifferences were found betweenanthropometric indicators and H.pylori status (Figure 1).

Discussion

Although the relationship betweenH. pylori infection and ID or IDAhas been studied by several groupsover the last two decades, a uni-form and clear conclusion has stillnot been reached. A number ofcross-sectional studies performedin children and youth described anassociation between H. pyloriinfection and IDA,21-23 althoughother reports demonstrated a lackof association between H. pylori

either with IDA24 or with ane-mia.25,26 One variable that shouldbe taken into account for the com-parison of the results of differentstudies is the methodology appliedfor the diagnosis of H. pylori in -fection, as it was shown byDiGirolamo et al.27 According tothese authors, who evaluated theassociation between H. pyloriinfection and IDA in children fromAlaska, IDA was associated withpositive H. pylori serology results,whereas no association was estab-lished with positive 13C-UBT orfecal antigen test values. Thesefindings contrast with those foundin a cross-sectional study conduct-ed in the same population, in whichpositive 13C-UBT results wereassociated with IDA.22

Relatively few intervention stud-ies have sought to establish a cause-and-effect relationship be tween H. pylori, ID and anemia.28-30 Oneof the largest and most recent ran-domized controlled trials per-formed in 200 Bangla deshi chil-dren concluded that H. pylori infec-tion is neither a cause of IDA/IDnor a reason for the treatment fail-

ure of iron supplementation inyoung children.31 Moreover, astudy which evaluated iron absorp-tion by the use of stable isotopessupported these findings: ironabsorption did not differ betweenH. pylori infected children withanemia and anemic controls, evenafter H. pylori eradication.32

Our study revealed that H. pyloriinfection was not associated withID or anemia although lower serumferritin levels were observed in H.pylori positive patients. Our results,along with others from a coordinat-ed series of cross sectional studiesin Latin American countries,reported the lack of associationbetween H. pylori and anemia,which argues against the causativerole of this bacterium in the devel-opment of anemia in LatinAmerica.33

Some cross-sectional and pro -spective studies have shown anassociation between growth delayand H. pylori infection in chil-dren,23,34,35 although other studiessuggested that H. pylori infectionseemed to affect growth as a result

Figure 1: Effect of Helicobacter pylori infection on anthropometricindicatorsHAZ: height-for-age; WAZ: weight-for-age; BMI: body mass index

-0.3

0.4

0.3

0.2

0.1

0

-0.1

-0.2

H. pylori (-)H. pylori (+)

HAZ WAZ BMI

P = 0.09P = 0.54 P = 0.07z-sc

ore

of a concomitant presence of IDAor low socioeconomic status.12,36 Acohort study performed in 347infants showed a significant andnontransient effect of H. pyloriinfection on height and weight.37 Incontrast, another study suggestedthat H. pylori colonization in earlyinfancy would predispose thedevelopment of malnutrition andgrowth faltering, although theeffect did not persist into laterchildhood.13

Our results showed that H.pylori infected children tend tohave lower WAZ, HAZ, BMI,although these differences were notstatistically significant. Similarly,cross-sectional studies by LeandroLiberato et al38 and Chimonas etal39 also reported a lack of associa-tion between H. pylori infectionand growth – results that were cor-roborated after an interventionalstudy.39 Given the important role insocioeconomic status on anthropo-metric development, it should betaken into account its evaluation toascertain the reported discrepan-cies.

In conclusion, the relationshipbetween H. pylori infection, ane-mia and growth impairment is stillcontroversial. Additional prospec-tive controlled studies need to beconducted to clarify this importantissue.

Acknowledgement This work was supported by theARCAL LIV-6042 and ARCALLIV-6054 Projects of the Inter -national Atomic Energy Agency(IAEA), Vienna, Austria; the PICT14243 Project of the NationalAgency of Scientific and Tech -nological Research, Argen tina; andthe UBACyT B007 Project of theUniversity of Buenos Aires,Buenos Aires, Argentina.

References

1. NIH Consensus Conference. Helico -bacter pylori in peptic ulcer disease.NIH Consensus Develop ment Panelon Helico bacter pylori in PepticUlcer Disease. JAMA 1994;272:65–9.

2. Perez-Perez GI, Rothenbacher D,Brenner H. Epidemiology of Helico -bacter pylori infection. Helico bacter2004;9 Suppl 1:1–6.

3. Goldman C, Barrado A, Janjetic M,et al. Factors associated with H.pylori epidemiology in symptomaticchildren in Buenos Aires, Argentina.World J Gastroenterol 2006;12:5384–8.

4. Olmos JA, Rios H, Higa R.Prevalence of Helico bacter pyloriinfection in Argentina: results of anationwide epidemiologic study.Argentinean Hp EpidemiologicStudy Group. J Clin Gastroenterol2000;31:33–7.

5. Chong SK, Lou Q, Zollinger TW, etal. The seroprevalence of Helico -bacter pylori in a referral populationof children in the United States. AmJ Gastroenterol 2003; 98: 2162–8.

6. Strang B. Investing in the future: Aunited call to action on vitamin andmineral deficiencies. Ottawa: Micro -nutirent Initiave, USAID, GAIN,Canadian International Develop mentAgency (CIDA), 2009.

7. Ministerio de Salud de la RepúblicaArgentina. Encuesta Nacional deNutrición y Salud. Documento deResultados 2007. Available at:http://www.msal.gov.ar/htm/site/enny s / p d f / d o c u m e n t o _ r e s u l t a -dos_2007.pdf. (accessed June 20,2009).

8. Muhsen K, Cohen D. Helico bacterpylori infection and iron stores: asystematic review and meta-analysis.Helicobacter 2008;13:323-40.

9. DuBois S, Kearney DJ. Iron-defi-ciency anemia and Helico bacterpylori infection: a review of the evi-dence. Am J Gastroenterol 2005;100(2):453–9.

10. Malfertheiner P, Megraud F,O'Morain C, et al. Current conceptsin the management of Helico bacterpylori infection: the Maastricht IIIConsensus Report. Gut 2007; 56:772–81.

11. Chey WD, Wong BC. AmericanCollege of Gastroenterology guide-line on the management of Helico -bacter pylori infection. Am J Gastro -enterol 2007;102:1808-25.

12. Choe YH, Kim SK, Hong YC.Helico bacter pylori infection withiron deficiency anaemia and subnor-mal growth at puberty. Arch DisChild 2000;82:136–40.

13. Thomas JE, Dale A, Bunn JE, et al.Early Helico bacter pylori colonisa-tion: the association with growth fal-tering in The Gambia. Arch DisChild 2004;89:1149–54.

14. Windle HJ, Kelleher D, Crabtree JE.Childhood Helico bacter pylori infec-tion and growth impairment in devel-oping countries: a vicious cycle?Pediatrics 2007;119:e754–9.

15. Rivera JA, Barquera S, Gonzalez-Cossio T, et al. Nutrition transition inMexico and in other Latin Americancountries. Nutr Rev 2004;62(7 Pt2):S149–57.

16. Instituto Nacional de Estadísticas yCensos de Argentina. Available at:http://www.indec.gov.ar/censo2001s2/ampliada_index.asp?mode=01.(accessed June 15, 2009).

17. Gisbert JP, Pajares JM. Review arti-cle: C-urea breath test in the diagno-sis of Helico bacter pylori infection -- a critical review. Aliment Phar -macol Ther 2004;20:1001–17.

18. WHO.UNICEF.UNU. Iron deficien-cy anaemia: assessment, preventionand control. A guide for programmemanagers. Geneva: World HealthOrganization, 2001. [WHO/NHD/01.3].

19. Kuczmarski RJ, Ogden CL,Grummer-Strawn LM, et al. CDCgrowth charts: United States. AdvData 200;314:1–27.

20. Bruce MG, Maaroos HI. Epi -demiology of Helico bacter pyloriinfection. Helicobacter 2008;13Suppl 1:1–6.

21. Choe YH, Kim SK, Hong YC. Therelationship between Helico bacterpylori infection and iron deficiency:seroprevalence study in 937 pubes-cent children. Arch Dis Child2003;88:178.

22. Baggett HC, Parkinson AJ, Muth PT,et al. Endemic iron deficiency associ-ated with Helico bacter pylori infec-tion among school-aged children inAlaska. Pediatrics 2006;117:e396–404.

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21


23. Suoglu OD, Gokce S, Saglam AT, etal. Association of Helico bacterpylori infection with gastroduodenaldisease, epidemiologic factors andiron-deficiency anemia in Turkishchildren undergoing endoscopy, andimpact on growth. Pediatr Int2007;49:858–63.

24. Choi JW. Does Helico bacter pylori-infection relate to iron deficiencyanaemia in prepubescent childrenunder 12 years of age? Acta Paediatr2003;92:970–2.

25. Baysoy G, Ertem D, Ademoglu E, etal. Gastric histopathology, iron statusand iron deficiency anemia in chil-dren with Helico bacter pylori infec-tion. J Pediatr Gastroenterol Nutr2004;38:146–51.

26. Haghi-Ashtiani MT, MonajemzadehM, Motamed F, et al. Anemia in chil-dren with and without Helico bacterpylori infection. Arch Med Res2008;39:536–40.

27. DiGirolamo AM, Perry GS, GoldBD, et al. Helico bacter pylori, ane-mia, and iron deficiency: relation-ships explored among Alaska nativechildren. Pediatr Infect Dis J2007;26:927–34.

28. Mahalanabis D, Islam MA, Shaikh S,et al. Haematological response toiron supplementation is reduced inchildren with asymptomatic Helico -

bacter pylori infection. Br J Nutr2005;94:969–75.

29. Kurekci AE, Atay AA, Sarici SU, etal. Is there a relationship betweenchildhood Helico bacter pylori infec-tion and iron deficiency anemia? JTrop Pediatr 2005;51:166–9.

30. Choe YH, Kim SK, Son BK, et al.Randomized placebo-controlled trialof Helico bacter pylori eradication foriron-deficiency anemia in preadoles-cent children and adolescents.Helicobacter 1999;4:135–9.

31. Sarker SA, Mahmud H, Davidsson L,et al. Causal relationship of Helico -bacter pylori with iron-deficiencyanemia or failure of iron supplemen-tation in children. Gastro enterology2008;135:1534–42.

32. Sarker SA, Davidsson L, Mahmud H,et al. Helico bacter pylori infection,iron absorption, and gastric acidsecretion in Bangladeshi children.Am J Clin Nutr 2004;80:149–53.

33. Santos IS, Boccio J, Davidsson L, etal. Helico bacter pylori is not associ-ated with anaemia in Latin America:results from Argentina, Brazil,Bolivia, Cuba, Mexico and Vene -zuela. Public Health Nutr 2009:1–9.

34. Perri F, Pastore M, Leandro G, et al.Helico bacter pylori infection andgrowth delay in older children. ArchDis Child 1997;77:46–9.

35. Richter T, Richter T, List S, et al.Five- to 7-year-old children withHelico bacter pylori infection aresmaller than Helicobacter-negativechildren: a cross-sectional popula-tion-based study of 3,315 children. JPediatr Gastroenterol Nutr 2001;33:472–5.

36. Soylu OB, Ozturk Y. Helico bacterpylori infection: effect on malnutri-tion and growth failure in dyspepticchildren. Eur J Pediatr 2008;167:557–62.

37. Mera RM, Correa P, Fontham EE, etal. Effects of a new Helico bacterpylori infection on height and weightin Colombian children. Ann Epi -demiol 2006;16:347–51.

38. Leandro Liberato SV, HernandezGalindo M, Torroba Alvarez L, et al.[Helico bacter pylori infection in thechild population in Spain: preva-lence, related factors and influenceon growth]. An Pediatr (Barc)2005;63:489–94.

39. Chimonas MA, Baggett HC,Parkinson AJ, et al. AsymptomaticHelico bacter pylori infection andiron deficiency are not associatedwith decreased growth among AlaskaNative children aged 7-11 years.Helicobacter 2006;11:159–67.

DSM Nutritional Products Ltd.P.O. Box 2676, CH-4002 BaselSwitzerland

DSM – the Life Sciences and Materials Sciences CompanyRoyal DSM N.V. creates innovative products and services in Life Sciencesand Materials Sciences that contribute to the quality of life. DSM’s productsand services are used globally in a wide range of markets and applications,supporting a healthier, more sustainable and more enjoyable way of life. Endmarkets include human and animal nutrition and health, personal care, phar-

maceuticals, automotive, coatings and paint, electrical and electronics, lifeprotection and housing. DSM has annual net sales of over EUR 9 billion andemploys some 23,500 people worldwide. The company is headquartered inthe Netherlands, with locations on five continents. DSM is listed on EuronextAmsterdam. More information: www.dsm.com

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Introduction

Vitamin A deficiency isa serious public healthproblem in less devel-oped areas of the worldwhere the populationearns a low income andconsumes diets low invitamin A. Chronic in -take of foods low invitamin A and �-caro -tene forming an unbal-anced diet with littlevariety, which leads tomicronutrient deficien-

cies, is common in manypopulations. The most vul-

nerable groups affected are preg-nant or lactating women and pre-school children, with an estimated250 million at risk of developingvitamin A deficiency disorders(VADD).1

Deficiency in these groupsoccurs largely due to increases inphysiological requirements, togeth-er with a low dietary intake of vita-min A.2 Provitamin A carotenoids,

SIGHT AND LIFE

22

Can the �-Carotene Low ResponderPhenotype be Caused by GeneticPolymorphisms in the �-Carotene15,15’-Monoxygenase Gene?

Georg LietzHuman Nutrition Research Centre, Newcastle upon Tyne, UK

Correspondence: Georg Lietz, Human Nutrition Research Centre,School of Agriculture, Food and Rural Development, AgricultureBuilding, Newcastle University, Kings Road, Newcastle upon Tyne,NE1 7RU, UKEmail: [email protected]

Genetic Variation in �-Carotene Cleavage

particularly �-carotene, are a major source of vitamin A for the world’spopulation. Vitamin A from animal sources are usually expensive andrarely relied upon to meet daily requirements in developing countries. Ithas been noted that Asia and Africa, where the most serious problems ofVADD occur, place the greatest reliance on provitamin A sources withapproximately 80% of dietary vitamin A derived from carotene-richplants.3

However, the average intake of pre-formed retinol is low even in theUK, with average intakes of 673 µg (median 363 µg) for men and 472 µg(median 277 µg) for women.4 This intake includes the consumption ofdietary supplements, mostly comprising of multivitamins, cod and halibutliver oil, which are consumed by 34% of women and 18% of men.4 Thepercentage of men and women with intakes of pre-formed retinol belowthe recommended nutrient intake (RNI) or the lower recommended nutri-ent intake (LRNI) are 81% and 43%, respectively (Figure 1), indicatingthat, for a majority of the UK population, vitamin A requirements are notmet by dietary intake of pre-formed retinol.

In calculating the retinol equivalence (RE) of total vitamin A from foodsources (provitamin A sources plus preformed vitamin A), severalassumptions are made for the degree of bioavailability and bioconversion(Figure 2). The bioavailability of retinol derived from foods of animalorigin is assumed to be 100%, hence, 1 RE is equal to 1 µg of all-transretinol. Before 1995, it was assumed that 6 µg of dietary �-carotene wouldprovide 1 µg of RE and that 12 µg of all other provitamin carotenoids mustbe ingested to yield 1 µg RE. Since then, however, several studies havesuggested that dietary �-carotene may not be effective in improving vita-min A status. de Pee et al called for a re-examination of the conversionfactors for fruits and vegetables when daily portions of green leafy veg-


Magazine Issue 3/2009Genetic Variation in �-Carotene Cleavage

23

etables were found not to be effective in improvingvitamin A status.5 Since it was reported that 12 µg of�-carotene from fruits provided 1 µg RE and 26 µg of�-carotene from green leafy vegetables provided 1 µgRE,6 the International Vitamin A Consultative Group(IVACG) as well as the Institute of Medicine (IOM)adopted new conversion factors for �-carotene in fruitsand vegetables, with 12 µg �-carotene and 24 µg otherprovitamin A carotenoids providing 1 µg retinol activ-ity equivalent (RAE) in a mixed diet. This raises thequestion of whether the current recommendation of2–4 mg �-carotene per day in industrialized countriescould close the gap between the low intake of pre-formed vitamin A and the recommended intake(Figure 3).

The low responder phenotype

The amount of newly absorbed �-carotene and con-verted retinol present in the blood after supplementa-tion with �-carotene can be measured in the lipopro-tein-rich chylomicron fraction and is highly variablebetween healthy individuals.7–9 In a number of studies,poor absorbers of �-carotene, shown to have very little�-carotene in the blood after supplementation, havebeen classified as low responders.8,10 However, inthese same studies, poor absorbers of �-carotene alsohave a low retinol palmitate/�-carotene ratio, which isa measure of conversion efficiency, indicating that notonly are they poor absorbers but also poor convertersof �-carotene. Up to 45% of volunteers have been clas-sified as poor converters.8,10,11 These individuals havea capacity to form only 9% vitamin A from �-carotenecompared to those who are classified as normal con-

verters.11 Genetic variability in �-carotene metabolismmay provide an explanation for the molecular basis ofthe poor converter phenotype within the population.The enzyme responsible for �-carotene conversioninto retinol is �-carotene 15,15’-monoxygenase(BCMO1), and approximately 95% of retinoids arisingfrom �-carotene are produced by this pathway invivo.12 BCMO1 is a soluble cytosolic enzyme thatshows the highest activity in intestinal mucosa, specif-ically in jejunal enterocytes.13 Elevated levels ofBCMO1 mRNA are also found in the liver, lung, andkidney, and lower levels in the brain, prostate, ovary,colon, and skeletal muscle, which suggests the impor-

Figure 1: Proportion of females in the UK withpreformed vitamin A intakes below therecommended nutrient intake (600 µg)and lower recommended nutrientintake (250 µg). Data extracted from Henderson et al4

0

100

80

60

40

20

< 250 µg < 600 µg

Cum

ulat

ive

% p

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atio

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Preformed vitamin A intake

Figure 2: Bioefficacy of provitamin A conversion with new conversion factors. Adapted from West et al20

Consumed Absorbed Bioconverted

Dietary supplemental Retinolvitamin A (1 µg)

Supplemental�-carotene in oil (2 µg)

�-Carotene Retinol (1 µg)Dietary �-carotene(12 µg)

Dietary �-carotene or �-Carotene or�-cryptoxanthin (24 µg) �-cryptoxanthin

Bioefficacy

SIGHT AND LIFE Genetic Variation in �-Carotene Cleavage

24

tance of local vitamin A synthe-sis.14 In deed, studies in a knockoutmouse model for BCMO1 haveprovided further evidence for thefundamental role of this enzyme inproducing local vitamin A fromdietary �-caro tene.15

Genetic variations in the �-carotene cleavage enzyme

It was recently shown that theT170M missense mutation in the�-carotene 15,15’-monoxygenasegene (BCMO1) causes a dramaticde crease in the enzyme activity invitro, and is associated with hyper-carotenemia and hypovitaminosisA in a heterozygote carrier.16 How -ever, given its very low frequency,this mutation cannot explain thehigh frequency of the low convert-er phenotype observed in humans.Our group screened the total openreading frame of the BCMO1 cod-ing region that leads to the identifi-cation of two common non-synony-mous single nucleotide polymor-phisms (R267S; rs12934922 andA379V; rs7501331) with variantallele frequencies of 42% and 24%,respectively. These frequencies are

close to those observed for the lowresponder phenotype.

More important, however, wasthe observation that carriers of boththe 379V and 267S+379V variantalleles had a reduced ability to con-vert �-carotene by 32% and 69%,respectively, and consequentlyhigher fasting �-carotene concen-trations (Figure 4).17 Further evi-dence of the interaction of geneticvariability with the low responder

phenoytype comes from the analy-sis of a recent genome-wide associ-ation study that indicated a stronglink between fasting �-caroteneconcentrations and polymorphismsin the vicinity of the BCMO1gene.18 However, it is yet unclearwhether the identified SNPs(Single Nucleotide Polymorphism)in the vicinity of BCMO1 influencethe ability to cleave �-carotene.Although the authors have indicat-ed that their identified genetic vari-

Figure 3: Median total vitamin A intake as retinol (activity) equiv-alents in UK women depending on the provitamin A con-version factor of 1:6 or 1:12, respectively.Data extracted from Henderson et al4

0

1000

750

500

250

Conversion 1:6 Conversion 1:12In

take

of t

otal

vita

min

A

RNI

b-Carotene intakeRetinol intake

}Gap to be filledby b-carotene

Figure 4: Effect of BCMO1 genotype on (A) �-carotene conversion and (B) fasting �-carotene con-centrations. Concen trations displayed as mean ± SEM. Data from Leung et al17

*Significantly different from wild type (WT) at P < 0.05; ** significantly different from wild type (WT) at P < 0.01 (One way ANOVA); WT = AA for R267S and CC for A379V; A379V = at least one T allele;R267S+A379V = at least one T allele in both R267S and A379V

0

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0.6

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WT A379V

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ol p

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ene

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ol/L

] 600

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B

100

*

**

* *

Magazine Issue 3/2009Genetic Variation in �-Carotene Cleavage

25

ants had no significant effect on plasma retinol con-centrations, this is not an indication of whether theseSNPs will influence �-carotene conversion efficiencysince plasma retinol concentrations are maintainedeven if liver retinol concentrations are low.18,19 Moreresearch will be needed to identify the mechanistic roleof these genetic variants on vitamin A metabolism.

Variations in polymorphism frequenciesbetween ethnic groups

Interestingly, the variant allele frequencies of the func-tional polymorphisms identified in our study, R267Sand A379V, were similar in Americans with Europeanancestry but lower in Han Chinese and Japanese popu-lations (Figure 5). More importantly, the 379V vari-ant allele was not found in the Yoruba Nigerian popu-lation.17 Although the current HapMap database indi-cates that large differences in frequencies between eth-nic groups occurs for the 379V and 267S+379V vari-ant alleles, we have, to date, no data on populationgroups for which vitamin A deficiency is a recognizedpublic health problem.

Conclusions

It is clear that more research is needed to shed somelight on this important nutrient-gene interaction inthose populations for which vitamin A deficiency is aserious public health problem. Genetic variabilityshould be taken into account in future recommenda-tions for vitamin A supplementation. It is possible thatpopulations with a high frequency of the 379V variantallele may benefit from supplementation with pre-formed vitamin A rather than increased intake of plantprovitamin A sources to combat vitamin A deficiency.However, more research is needed before such recom-mendations can be made.

References

1. Underwood BA. Vitamin A deficiency disorders: interna-tional efforts to control a preventable “pox”. J Nutr2004;134:231S–236S.

2. Miller M, Humphrey J, Johnson E, et al. Why do childrenbecome vitamin A deficient? J Nutr 2002;132:2867S–2880S.

3. Olson JA. Needs and sources of carotenoids and vitamin A.Nutrition Reviews 1994;52:67–73.

4. Henderson L, Irving K, Gregory J, et al. The National Diet& Nutrition Survey: adults aged 19 to 64 years. Vitaminand mineral intake and urinary analytes. London: HMSO,2000.

5. de Pee S, West CE, Muhilal, et al. Lack of improvement invitamin A with increased consumption of dark green leafyvegetables. Lancet 1995;346:75–81.

6. de Pee S, Bloem MW, Gorstein J, et al. Reappraisal of therole of vegetables in the vitamin A status of mothers inCentral Java, Indonesia. Am J Clin Nutr 1998;68:1068–1074.

Figure 5: Allele frequencies of A379V andR267S + A379V variants in 3 differentethnic groups according to HapMap(www.hapMap.org). A379V = at least one T allele; R267S+A379V =at least one T allele in both R267S and A379V

0

50

40

30

20

10

% P

opul

atio

n

A379V allele frequency

0

40

30

20

10

% P

opul

atio

n

R267S+A379V allele frequency

US European (n=87)Han Chinese (n=44)Japanese (n=43)

Dried apricots

7. Borel P, Grolier P, Mekki N, et al. Low and high respondersto pharmacological doses of beta-carotene: proportion inthe population, mechanisms involved and consequences onbeta-carotene metabolism. J Lipid Res 1998;39:2250-2260.

8. Hickenbottom SJ, Follett JR, Lin Y, et al. Variability inconversion of beta-carotene to vitamin A in men as meas-ured by using a double-tracer study design. Am J Clin Nutr2002;75:900-7.

9. Edwards AJ, You CS, Swanson JE, Parker RS. A novelextrinsic reference method for assessing the vitamin Avalue of plant foods. Am J Clin Nutr 2001;74:348-55.

10. Lin Y, Dueker SR, Burri BJ, et al. Variability of the conver-sion of beta-carotene to vitamin A in women measuredby using a double-tracer study design. Am J Clin Nutr

2000;71:1545-54.11. Wang Z, Yin S, Zhao X, et al. Beta-

Carotene-vitamin A equivalence inChinese adults assessed by an isotopedilution technique. Br J Nutr2004;91:121-31.

12. Barua AB, Olson JA. Beta-carotene is converted primarilyto retinoids in rats in vivo. J Nutr 2000;130:1996-2001.

13. During A, Nagao A, Hoshino C, Terao J. Assay of beta-carotene 15,15'-dioxygenase activity by reverse-phasehigh-pressure liquid chromatography. Anal Biochem 1996;241:199-205.

14. Lindqvist A, Andersson S. Cell type-specific expression ofbeta-carotene 15,15'-mono-oxygenase in human tissues. JHistochem Cytochem 2004;52:491-9.

15. Hessel S, Eichinger A, Isken A, et al. CMO1 deficiencyabolishes vitamin A production from beta-carotene andalters lipid metabolism in mice. J Biol Chem2007;282:33553-61.

16. Lindqvist A, Sharvill J, Sharvill DE, Andersson S. Loss-of-function mutation in carotenoid 15,15'-monooxygenaseidentified in a patient with hypercarotenemia and hypovita-minosis A. J Nutr 2007;137:2346-50.

17. Leung WC, Hessel S, Meplan C, et al. Two common singlenucleotide polymorphisms in the gene encoding beta-carotene 15,15'-monoxygenase alter beta-carotene metabo-lism in female volunteers. Faseb J 2009;23:1041-53.

18. Ferrucci L, Perry JR, Matteini A, et al. Common variationin the beta-carotene 15,15'-monooxygenase 1 gene affectscirculating levels of carotenoids: a genome-wide associa-

tion study. Am J Hum Genet 2009;84:123-33.19. Gerster H. Vitamin A - Functions, dietary

requirements and safety in humans. Int JVitam Nutr Res 1997;67:71-90.

20.West CE, Eilander A, van Lieshout M.Consequences of revised estimates ofcarotenoid bioefficacy for dietary control ofvitamin A deficiency in developing countries. JNutr 2002;132:2920S-2926S.

SIGHT AND LIFE Genetic Variation in �-Carotene Cleavage

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Vegetable market

Magazine Issue 3/2009Provitamin A Retention in OSP

27

Introduction

Orange sweet potato (OSP) rich in provitamin A(PVA) is part of an international biofortification effortby HarvestPlus, the International Potato Center (CIP),and others to reduce vitamin A and other micronutri-ent deficiencies through staple food crops withenhanced micronutrient content. Sweet potato consti-tutes the 8th most important food crop in the worldwith > 107 million MT produced per annum.1

Consumption is high across a wide range of easternand central Africa’s agro-ecological regions, from 116 kg/capita/year in Burundi to 16 kg/capita/year in

Kenya.1 It has been suggested by CIP that production(and by extension consumption) may be underestimat-ed due to the challenges of tracking multiple annualharvests on small non-contiguous plots with littleyield destined for international markets.2 Because ofits nutrient content and many excellent agronomicalcharacteristics such as high productivity, droughtresistance and ability to grow in marginal soils, theimportance of OSP as a food-security staple shouldcontinue to increase.

HarvestPlus’s goal is to breed sufficient levels ofmicronutrients into crops to have a measurable impacton human nutritional and health status without sacri-ficing their agronomic qualities, such as yield and dis-ease resistance. Development of biofortified cropsincludes research on post harvest nutrient retention,dietary intake and consumer acceptability, bioavail-ability (or bioconversion to retinol in the case of PVA-rich foods), efficacy, large scale dissemination of thebiofortified crop, and effectiveness in specific targetcountry contexts. For OSP, the potential for success isclear, as recently demonstrated in Mozambique whereregular OSP consumption had a significant positiveeffect on serum retinol concentrations among childrentaking part in a 2 year integrated agriculture-nutritionintervention versus controls (P < 0.01).3

The purpose of this review is to update informationon the impact of common cooking methods on PVAconcentration in OSP as reflected by the percent

Provitamin A Carotenoid Retentionin Orange Sweet PotatoA Review of the Literature

Erick Boy, Alexander MiloffHarvestPlus, Ottawa, Canada

Correspondence: Alexander Miloff, HarvestPlus, 180 Elgin St. Suite 1000, Ottawa On K2P 2K3, CanadaEmail: [email protected]


Demonstration of processed products made withsweet potatoes at the National Potato ResearchCenter, Kenya

retention of �-carotene and the isomerisation oftrans-�-carotene to its less potent cis-configuration.This paper represents a summarized version of ourfindings and includes average retention figures forseveral processing techniques. It differs from pastreviews4,5 in that we have attempted to go beyondindividual descriptions of published studies andaggregate results into meaningful comparisons bycooking method.

Methods

A review of available retention literature was per-formed using Pubmed, Google Scholar and Agricola.Search terms in English included: 1. [Provitamin A orCarotenoid] and [Retention] and [Sweet potato]; 2.[Provitamin A or Carotenoid] and [Boiling or Dryingor Flour or Roasting or Steaming or Frying or Micro -waving] and [Sweet Potato]. Addi tionally, a numberof respected experts and authors of recent retentionpublications were contacted for cross-checking theresults of the literature review, locating specific arti-cles and providing unpublished data. Reten tion datawere extracted from reports and studies into a masterMS Excel file by cultivar, cooking process, cookingtime, trans-�-carotene or total-carotenoid content(µg/g), cis-�-carotene content (% of total �-carotene),dry matter content (%), retention (%) and country ofcultivation. MS Exel was used for statistical analysis.Studies were excluded from data analysis if methodof calculating retention was not clarified6-9 or out-liers10 were evident, indicating possible analyticalerrors.

Results

Studies were balanced between those that attempt toemulate traditional cooking techniques with those thatuse standardized food technology laboratory methods.No true community studies of roots processed by tar-get populations were available and most studies useddifferent protocols even within each processingmethod.

Seven different processing techniques wereexplored for retention of PVA carotenoids (boiling,steaming, frying, roasting, micro waving, baking, anddrying). Table 1 displays a listing of each by author,percent retention (average/range), whether trans-�-carotene (BC) or all-carotenoid (AC) retention wasmeasured, the duration of processing (min/hrs), thetype of retention calculation used (true, apparent, dryweight basis)11, whether more than one cultivar wasincluded in the analysis and finally, if and why a

study was excluded from analysis. Average retentionvalues by processing technique are un weighted arith-metic means of all BC and AC data points from stud-ies included in the review.

Boiling was the most commonly studied cookingprocess (11 of 20 retention publications). It is alsoamong the most common and affordable sweet potatocooking techniques in developing countries, as it doesnot require additional ingredients.12 Boiling wasfound to have one of the highest retentions on average(84%, Range: 50–130%) of any processing technique(Figure 1).13-20 Among three studies that recorded theisomerisation effect, the average cis-isomer contentfollowing boiling was 9% of BC14,15 and 12% oftrans-�-carotene16 (average 11%). This compares toan average of 1.5% in fresh roots (Figure 2).14-16

SIGHT AND LIFE Provitamin A Retention in OSP

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Figure 1: Average retention (%) and No studies ( ) by OSP processing technique

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Table 1: Carotenoid retention in orange sweet potato by processing technique

Time Ave (%) Min (%) Max (%) Carotenoid Retention Cultivars Exlusion(BC or AC) calculation criteria

(True, DWB*or Apparent)

Boiled MinsAlmedia-Muradian13 10 90 82 94 BC True YesBengtsson14 20 77 70 81 BC DWB Yesvan Jaarsveld16 20, 30 82 70 92 BC True NoKidmose15 15,22,27,39 93 50 130 BC True YesKimura17 20 86 101 103 BC True YesKosambo6 30,45,60 75 39 100 BC NA Yes CalculationNascimento18 20 88 NA NA BC True NoReddy7 10 32 21 43 BC NA NA CalculationSungpuag8 15 57 NA NA BC NA No CalculationTadria19 30 80 75 85 AC True YesWu20 10,20,30,40,50 85 68 99 BC True NoAverage (or Mode) 20 85Steamed MinsBengtsson14 30 77 69 81 BC DWB YesReddy7 10 36 NA NA BC NA NA CalculationTadria19 50 82,5 70 90 AC True YesWu20 10,20,30,40,50 71 48 94,81 BC True NoAverage (or Median) 30 77Fried MinsBengtsson14 10 80 76 80,4 BC DWB YesKidmose23 1, 3 87 81 95 BC True NoNascimento18 12 68 NA NA BC True NoReddy7 10 46 NA NA BC NA NA CalculationWu20 1 64 NA NA BC True NoAverage 1.0–12.0 79**Baked/Roasted MinsChandler24 80 69 NA NA BC DWB NoKidmose15 30-90 74 40 110 BC True YesAverage 30–90 73Microwaved MinsChandler24 7 77 NA NA BC DWB NoWu20 15 64 34 92 BC True NoAverage 7,15 67Sun Dried HrsBechoff25 8 66 NA NA BC Apparent NoBechoff26 26 80 54 98 AC Apparent YesBengtsson14 6--10 84 NA NA BC DWB NoTadria19 30 40 25 70 AC True YesKosambo10 NA 18 12 23 BC Apparent Yes OutlierAverage 6–30 59Shade Dried HrsBechoff26 39 97 92 101 AC Apparent YesKidmose15 5 79 NA NA BC Apparent NoAverage 5,39 91Solar Dried HrsBechoff 25 8,5 77 NA NA BC Apparent NoBechoff 26 30 79 56 98 AC Apparent YesBengtsson14 6–10 91 NA NA BC DWB NoMdziniso27 11 –14 90 73 106 BC DWB NoAverage 6–30 82Oven-dried HrsBechoff 25 2,7.5 84 NA NA BC Apparent NoBengtsson14 10 88 NA NA BC DWB NoHagenimana9 12 70 NA NA AC NA Yes CalculationNascimento28 NA 96 NA NA BC True NoKosambo10 4 36 6 56 BC Apparent Yes OutlierWu20 5,11 62 59 65 BC True NoAverage 2–12 87**** DWB: Dry Weight Basis**This average retention for frying excludes Wu20 which, unlike other authors, fried pre-boiled mashed sweet potato***This average retention for frying excludes Wu20 which, unlike other authors, steamed sweet potato prior to dryingNA: not available; BC: trans-�-carotene; AC: all-carotenoid

Notwithstanding the variability of boiling method-ologies used, there was a moderate inverse correlation(r = 0.50) between cooking time and carotenoid reten-tion and a significant coefficient of determination (R2

= 0.25; P < 0.0001; N = 38).13-20 This association isbest exemplified by Wu et al20 in which five portionsof sweet potato were boiled one by one for 10, 20, 30,40 and 50 min. A corresponding drop in retention wasfound at each time period demonstrating a strong andsignificant negative correlation despite a small samplesize (R2 = 0.97; P < 0.001; N = 5).

It has been assumed that boiling whole sweet pota-to reduces BC loss compared to cut and/or peeledfractions due to surface area reduction and the peel’sprotective effect;5 however, data in this review wereinsufficient to validate this assumption. Past researchhas suggested that retention may be mediated by cul-tivar BC content (and intracellular location)21 and/orcultivar dry matter content of the raw root.22

However, neither relationship had a strong correla-tion, (R2 = 0.06; P = 0.12 and R2 = 0.0014; P < 0.0001)respectively.14,15

The effect of full versus partial immersion of rootsin water and the use of a lid were addressed in onestudy.16 Half-immersed sweet potato boiled with lidon for 20 min had 9% less retention than those boiledfully immersed in water over the same time. Steamhas greater heat energy transfer than boiling waterwhich may have played a part in this result. Althoughsweet potatoes cooked fully immersed in capped potswere boiled for 10 min longer than a sample with thelid off, both samples had comparable retention levels,indicating a closed cooking vessel may improveretention slightly.

Steaming is also a very popular way of preparingsweet potato in some countries.12 Average retentionwas 77% (Range: 48–95%) over three studies14,19,20

and cis-isomers were recorded at 6.4% of BC after 30min of steaming in one publication14. In one studywith peeled and cubed sweet potato, the impact ofsteaming time on retention was comparable to boilinguntil 30 min at which point the contents of the steamedcubed roots had 17% less BC and continued to dropthereafter (Figure 3).20

As discussed previously, in comparison with boil-ing the higher heat energy of steam may be a factor inreducing retention. On the other hand, in two studies,whole steamed roots wrapped in banana leaves,which may have dampened heat transfer to the rootparenchyma, had retention levels roughly comparable

to boiled samples despite having been steamed for 10and 20 min longer.14,19 Regarding cultivar selection,the Kakamega varieties (e.g., SPK004/1 and 6)appear to be superior to their parent variety by asmuch as 20% during boiling and steaming.14,19

Frying was found to be a relatively non-destructiveprocess for BC content over the short times needed tofully cook OSP, with an average of 79% retention(Range: 67–95%).14,18,20,23 In two studies cis-isomerswere on average 7% of BC.14,23. Although BC reten-tion did not decrease with short frying times of cubedsamples (1 vs. 3 min), cis-trans isomerisation didincrease significantly (from 2.4 to 15% of BC) (P <0.05).23 According to the authors, the preparationmethod for frying (cubes vs. shreds) resulted in a non-significant difference in retention, with shreds retain-ing 14% more BC than cubes (P > 0.05). This resultmay be due to greater cell-wall destruction enablingimproved extraction of carotenoids24. A similar phe-nomenon may have occurred in Wu’s study20 inwhich pre-cooked (boiled mashed) sweet potato friedfor 1 min was found to increase in BC content by6%.20 Only when sweet potato was fried for 12 minwere lower retention results found (68%).18

Roasting whole sweet potato on a grill was foundto be less damaging to BC contents than baking in anoven with 74% (Range: 40–110%)15,24 and 69%retention, respectively. Duration of roasting and freshroot BC content had a non-significant inverse corre-lation and no correlation with BC retention (R2 = 0.39; P = 0.53 and R2 = 0.004; P = 0.33),respectively.15 Isomerization was highest using thesecooking techniques, with 12 and 30% of BC found incis form, respectively. These levels were mildly cor-related with cooking time (R2 = 0.08; P < 0.001).15,24


30

Figure 3: �-Carotene retention (%) during boil-ing and steaming of sweet potato

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Microwaving is associated withlower average BC retention valuesamong the conventional cookingtechniques examined (67%;Range: 34–92%).20,24 The propor-tion of cis-isomers was also highin sweet potato cooked with thistechnique (17% of BC).24 Lengthof cooking explained a large pro-portion of the variance in retention(R2 = 0.76; P < 0.05).20,24 Themicrowave power (watts) used ineach of the studies also affectedretention. Energy-per-unit-timeused in Chandler & Schwartz24

was 10-times as high as in Wu20

but the sweet potato received 1/10 the energy-per-unit-weight.Never theless, despite a 3-minshorter duration of microwaveheating, Chandler’s & Schwartz'sstudy24 still resulted in 15% lowerretention. This would suggest thathigh power microwave heating ismore damaging to BC levels. Themolecular mechanism for thisoccurrence was not elucidated inthe publications.

Drying is an important tech-nique for ensuring access to PVAfoods during times of scarcity andis a necessary procedure for sweetpotato flour production. Retentionof BC associated with direct sun

drying ranged from 54 to 92%with an average of 59%.14,19,25,26

Among all drying processes cis-isomerization was minimal atapproximately 6% of BC.14,15,25

Humidity and drying time playedan important role in producing awide range of retention results. In Bechoff et al26, for example, 15 hours of direct sun in “dry”weather resulted in 92% AC reten-tion and “wet/rainy” conditions(46 hours) resulted in just 54% re -ten tion. In the study there was asignificant correlation betweenlosses and drying time (R = 0.727; P < 0.01). Similarly, hot dry condi-tions (30 –52 °C) in Bengtsson etal14 over 6–10 hours yielded a BCretention of 91.1%. Good weatherdoes not always ensure very highretention, however. A recent studyby Bechoff et al25 found that over8 hours in warm (29 °C), dry (39%moisture) and windy weather con-ditions BC retention was lower(66%).

Shade drying retained higherlevels of the nutrient than otherdrying techniques (91% averageretention).15,26 Under “dry” condi-tions, average AC retention was97% and in some cases similar tofresh sample levels (-1%)26.

Despite the benefits of shade dry-ing it was suggested that a greaterlikelihood of fermentation waspossible than with sun drying.26

Four studies reported on a vari-ety of solar dryers used to processOSP in both wet and dry weatherconditions. Retention averaged82% with a range of between a 56and 106%.14,25,26,27 Hot and dryconditions resulted in retentionsabove 90%,14,25,26 with dryingoccurring 2.6-times as quickly asin “wet/rainy” conditions usingtunnel or tent dryers.25 Dryer types(tunnel vs. tent) in Bechoff et al26

did not have different retentionsnor was solar drying significantlydifferent than sun drying.

One of the benefits of solar dry-ers is the capability of increasedload density over sun/shade drying.In Mdziniso et al27, the highest BCretention levels in a solar dryer(106%) were found using a wide (5 mm) slice and thin load (430 g/m2) and the lowest retentionlevels (73%) were found with nar-row (3 mm) slice and thick load (715 g/m2). Machine crimping ofslices was effective at reducing AC losses in the sun (but not solar dryer) versus flat chips (P < 0.05).25 This was understoodto be due to maintenance of betterstructural integrity with 20% moresurface area in crimped than flatslices following drying.

Four studies were included onthe effect of oven drying.14,20,25,28

One was not used in calculationsdue to a pre-baking steamingstep.20 Oven dried sweet potatoretained on average 87% BC con-tent (Range 79–96%). Bengtsson etal14 found that sun-drying (84%)was not statistically different thansolar (91%) or oven drying (88%)at 57 °C in regards to BC retention(P > 0.05). Although in Bechoff etal25, forced-air drying at 24–45 °C

Ugandan woman steams orange sweet potato

ap pear ed to have better retention(88%) than solar (77%), this differ-ence was not significant (P > 0.05).Nascimento et al28 used a higherdrying temperature (70 °C) as ameans of inactivating oxidativeenzymes. The high retention result(96%) indicates that this techniquemay be effective.

Even while retention in somecases was not significantlyimproved in oven drying overother drying methods, this processdid result in quicker drying of highdensity loads. In Bechoff et al25,for example, the forced air dryertook 2 hours to dry 8 kg/m2 whilethe solar dryer technique, evenunder favourable conditions, took8 hours to dry at 3.5 kg/m2 packingdensity.

Conclusions

OSP contain high levels of BC,with root contents ranging from1,800 µg to 16,000 µg/100 g29

fresh weight to as much as 31,000 µg/100g dry weight in new

Kaka mega varients.14 The majori-ty of BC in sweet potato is in theform of trans-�-carotene whichexhibits the highest PVA activityamong carotenoids.29

Even after traditional and mod-ern cooking methods, OSP contin-ues to be an excellent source ofPVA carotenoids. Limitations ofthis study include lack of pooledstatistical analysis. However, themost common preparation meth-ods, boiling and steaming, bothyielded retention levels in excessof 75%. This surpasses the con-servative assumption of 50% madeby nutritionists and plant breederswhen initial BC target levels wereestablished for HarvestPlus OSPcultivars. Using this estimate,daily consumption of 100 g of

OSP retaining 50% of original BCcontents and observing a 12:1 bio-conversion rate will provide achild 4–6 years of age withapproximately 50% of the estimat-ed average requirement for thisvitamin (~126.5 µg RE).

Except in a few cases, such asbaking and microwaving, cis-iso-mer levels were minimal. Frying,which is often thought to be moredamaging in regards to BC reten-tion5, also yielded retention above75%. Current estimates indicate thata significant proportion of BC isretained through baking and roast-ing of OSP (69 and 74%, respec-tively). However, more informationis needed to confirm this statement.As demonstrated for the methodsreviewed above, results in the fieldwill depend primarily on processingduration, average temperature (heatenergy transfer) used during cook-ing, integrity of the root (surfacearea of root pulp exposed) and culti-var selected.

Numerous drying techniques inboth dry and wet weather alsoyielded PVA retention resultsabove 50%. Depending on weath-er conditions, density of the loadand innovations such as crimpedslices and higher drying tempera-tures, much higher retentions canbe achieved. More data is neededon shade drying, roasting, bakingand the result of cis-isomerizationduring various processes to ensureestimates are correct. Future stud-ies should use true retention and astandardized (HPLC) carotenoidmeasurement protocol, such asthat suggested by HarvestPlus30,to ensure comparability of results.The results of this review indicatethat BC levels in OSP are notseverely impacted by the mostcommon food processing tech-niques. OSP should continue to bea strong food-based interventionfor prevention of vitamin A defi-ciency in women and children indeveloping countries.

References

1. FAOSTAT. Agricultural data. Rome,Italy: Food and Agriculture Or gani -zation of the United Nations. 2007.


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Harvesting of high �-carotene sweet potato


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Available from: http://faostat.fao.org/site/339/default.aspx. Accessed:August 2009.

2. CIP. Sweetpotato/ Sweetpotato Facts.La Molina, Peru: Intl. Potato Center.Available from: http:// www.cipota-to .o rg / swee tpo ta to / fac t s / fac t s .Accessed: August 2009.

3. Low JW, Arimond M, Osman N, et al.A food-based approach introducingorange-fleshed sweet potatoesincreased vitamin A intake and serumretinol concentrations in young chil-dren in rural Mozam bique. J Nutr2007; 137:1320–1327.

4. Wheatley C, Loechl C. A criticalreview of sweetpotato processingresearch conducted by CIP and part-ners in Sub-Saharan Africa. CIPReport, 2008.

5. Rodriguez-Amaya DB. Carotenoidsand food preparation: the retention ofprovitamin A carotenoids in prepared,processed, and stored foods. USAID-OMNI, Washington DC, 1997.

6. Kosambo LM, Carey EE, Misra AK etal. Influence of age, farming site, andboiling on pro-vitamin A content insweet potato (Ipomoea batatas (L.)Lam.) storage roots. J Food CompAnal 1998; 11:305−321.

7. Reddy V, Vijayaraghavan K, Bhas -karachary K et al. Carotene rich foods:The Indian experience. 1995. InEmpowering Vitamin A Foods. Eds. E.Wasantwisut and G. A. Attig. Bang -kok: Institute of Nutrition, 15–28.

8. Sungpuag P, Tangchitpianvit S,Chittchang U, et al. Retinol and betacarotene content of indigenous rawand home-prepared foods in NortheastThailand. Food Chemistry 1999;64:163–167.

9. Hagenimana V, Carey E, Gichuki ST,Oyunga MA, Imungi JK. Carotenoidcontents in fresh, dried and processedsweetpotato products. Ecol Food Nutr1999; 37: 455−473.

10. Kosambo LM. Effect of storage andprocessing on all trans-beta carotenecontent in fresh sweetpotato (Ipomoeabatatas (L.) Lam) roots and its prod-ucts. CIP Funded Research Project:Annual Report (July 2003 – June2004).

11. Murphy EW, Criner PE, Gray BC.Comparisons of methods for calculat-ing retentions of nutrients in cookedfoods. J Agric Food Chem 1975;23:1153–1157.

12. Woolfe JA. Sweet potato: an untappedfood resource. Cambridge UniversityPress, 1992

13. Almeida-Muradian LB, PenteadoMVC. Carotenoids and provitamin Avalue of some Brazilian sweet potatocultivars (ipomea batatas lam.) Rev.Farm Bioquim. Univ. S. Paulo 1992;28:145–154.

14. Bengtsson A, Namutebib A,Almingera ML et al. Effects of varioustraditional processing methods on theall-trans-b-carotene content oforange-fleshed sweet potato. J FoodComp Anal 2008; 21:134–143.

15. Kidmose U, Christensen LP, Agili SMet al. Effect of home preparation prac-tices on the content of provitamin Acarotenoids in coloured sweet potatovarieties (Ipomoea batatas Lam.) fromKenya. Innovat Food Sci Emerg Tech2007;8:399–406.

16. van Jaarsveld PJ, Marais DW, HarmseE et al. Retention of �-carotene inboiled, mashed orange-fleshed sweetpotato. J Food Comp Anal 2006;19:321–329.

17. Kimura M, van Jaarsveld P. Eva -luation of beta-carotene content ofsweetpotato. Unpublished. Projectreport, August 2006.

18. Nascimento P, Kimura M, FernandesNS. Beta-carotene retention of boiledand fried sweetpotato and cassava. In:Proceedings of 13th World Congressof Food Science and Technology -IUFOST, Nantes, France, September2006.

19. Tadria S, Kaaya AN, Namutebi A.Provitamin A carotenoid retention inindigenous products from improvedorange-fleshed sweetpotato (Ipomea -batatasL.) varieties. Unpublished.Department of Food Science andTechnology, Makerere University,Uganda, 2008.

20. Wu X, Sun C, Zeng LYG et al. �-carotene content in sweet potatovarieties from China and the effect ofpreparation on �-carotene retention inthe Yanshu No. 5. Innovat Food SciEmerg Tech 2008;9:581–586.

21. Li S, Tayie FAK, Young MF, et al.Retention of provitamin A paro tenoidsin high carotene maize (Zea mays)during traditional African householdprocessing. J Agric Food Chem 2007;55:10744–10750.

22. Rees D, van Oirschot Q, Kapinga RE.Sweet Potato Post-Harvest Assess -ment. Experiences from East Africa.Chatman (UK): Natural ResourcesInstitute (NRI); Crop Post-HarvestProgramme (CPHP); Department forInternational Develop ment (DFID);International Potato Center (CIP);

Ministry of Agriculture Tanzania,2003.

23. Kidmose U, Yang RY, Thilsted SH etal. Content of carotenoids in common-ly consumed Asian vegetables and sta-bility and extractability during frying.Journal of Food Composition andAnalysis 2006; 19:562−571.

24. Chandler LA, Schwartz SJ. Iso -merization and losses of trans-�-carotene in sweet potatoes as affectedby processing treatments. Journal ofAgricultural and Food Chemistry1988; 36:129−133.

25. Bechoff A, Dufour D, Dhuique-MayerC et al. Effect of hot air, solar and sundrying treatments on provitamin Aretention in orange-fleshed sweetpota-to. Journal of Food Engineering 2009;92(2):164-171

26. Bechoff A, Westby A, Dufour D, et al.Effect of drying and storage on thecontent of provitamin a of orangefleshed sweet potato (Ipomoa batatas):Direct sun radiations do not have sig-nificant impact. In: ISTRC Con -ference, 8-12 Octobre 2007, Maputo,Mozambique. s.l.

27. Mdziniso P, Hinds MJ, Bellmer DD etal. Physical Quality and CaroteneContent of Solar-Dried Green Leafyand Yellow Succulent Vegetables.Plant Foods for Human Nutrition2006;61:13–21.

28. Nascimento P, Fernandes NS, MauroMA. Beta-carotene stability duringdrying and storage of cassava andsweet potato. In 2nd InternationalSymposium on Health Human Effectsof Fruits and Vegetables,FAVHEALTH 2007, Patil B (ed.)Houston, USA, 2009

29. Bovell-Benjamin AC. Sweet Potato:A review of its past, present and futurerole in human nutrition. Advances inFood and Nutrition Research 2007;52.

30. Rodriguez Amaya DB, Kimura M.HarvestPlus Handbook for Caro tenoidAnalysis. Copyright Harvest Plus c/oInternational Food Policy ResearchInstitute, Washington DC, USA, 2004

SIGHT AND LIFE Micronutrient and Deworming Project

34

Introduction

The Honduras Children’s Micronutrient and Dewor -ming Project was a 3-year (July 2006–June 2009) proj-ect jointly implemented by Vitamin Angels (VA) andCristo Salva. With the support of SIGHT AND LIFE,this campaign-style intervention sought to provideessential multiple micronutrient supplements(EMMNS) to children aged 2–14 years in selectedschools in the northwestern region of Honduras. Thechildren were given a daily supplement for an averageof 180 days per year, which is the number of schooldays in the academic year. In addition, the childrenwere given 400 mg of the deworming drug,Albendazole, twice a year. This project was designedas part of a larger HonduranMinistry of Health (MOH) ruralhealth program that brings preven-tive and therapeutic care to theregions served by this project.

Problem and need

Growth stunting among children isrecognized as an indicator ofchronic malnutrition. In 2006, theWorld Health Organization (WHO)reported that 29.9% of underfivechildren in Honduras werestunted.1 The 2006 HondurasDemo graphic and Health Surveyreported that one out of fourHonduran children under five yearsof age is chronically undernour-ished.2 In some rural communitiesin the west Honduras, chronic mal-

nutrition reached 88 percent.2 According to Honduras’Ministry of Health (MOH), the highest prevalence ofstunting and underweight in children occurred in therural west region as a whole.3

Parasitic infection contributes to malnutrition, par-ticularly among children entering school, who are themost vulnerable to soil transmitted helminthes (STHs).The Pan American Health Organization (PAHO)reported in 2006 mild parasitic infection rates of40.4% in the northwest region of Santa Barbara State– the highest rate of moderate infections among PAHOstudy locations.4 The net effect of these conditions isthat growth, development, and school performance aresignificantly affected. For the last several years, the

The Honduras Children’sMicronutrient and Deworming Project

Cami Allen, Clayton A Ajello Vitamin Angels, Santa Barbara, CA, USA

Correspondence: Cami Allen, Vitamin Angels, PO Box 4490, SantaBarbara, CA 93140, USAEmail: [email protected]

Children in Macuelizo, Honduras


Magazine Issue 3/2009Micronutrient and Deworming Project

35

MOH has worked to provide nutritional supplementsand anti-parasitics to vulnerable children. However,coverage rates have been inconsistent across regionsand communities due to limited funding for nutrition-al supplements and deworming agents.

Honduras Children’s Micronutrient andDeworming Project

To combat the significant levels of chronic malnutri-tion complicated by STH infections, the HonduranGovernment requested assistance to provide micronu-trient supplementation and deworming agents for theentire northwest region of Honduras, and identified atarget of 55,000 children at 88 schools in four districtsof northwestern Honduras (Macuelizo, Azacualpa,Nueva Frontera, and Quimistan). With support fromSIGHT AND LIFE, VA offered to sponsor theHonduras Children’s Micronutrient and DewormingProject. Under this project, VA partnered with localNGO, Cristo Salva, to design an intervention thatenabled teachers to deliver nutritional supplementseach school day and Albendazole once every sixmonths to eligible children.

The project further provided an additional supply ofnutritional supplements to the parents of school-goingchildren in order to reach their preschool-aged chil-dren. To reach eligible school-aged children who arenot enrolled in school (out-of-school children), an out-reach program supplied the supplements and anti-par-asitics to local intermediaries who distributed them tothe children. The project also arranged for adult fami-ly members to be educated, through the school system,in the preparation and use of local foods rich in vita-min A as well as in gardening, sanitation, and basichygiene.

The project aimed to achieve at least 70% coverageof all children aged 2–14 years (i.e., all childrenenrolled in school) in the project’s geographical areasduring the school year with the nutritional supple-

ments, which were provided during school sessions.The project also set out to achieve at least 70% cover-age of all children aged 2–5 years living in the samehouseholds as the school-going children.

For planning purposes, all children were targeted toreceive, as appropriate, both a daily nutritional supple-ment throughout the school year and Albendazoletwice a year for three years. By achieving this level ofcoverage in the target population, the project soughtreduce the prevalences of parasitic infections, stunting,anemia, vitamin A deficiency, and chronic malnutri-tion, as well as reduce clinic visits and hospitalization,increase school attendance, decrease morbidity and/ormortality rates, and improve school performance.

Over the three years of the Honduras Children’sMicronutrient and Deworming Project, nearly 100% ofschool-going children (a total of 26,034 children aged2–14 years), attending 88 selected schools in the fourproject districts, were reached annually with bothnutritional supplements and deworming tablets. The

School child listening to a lesson on essentialvitamins and minerals

Table 1: Number of children served with a daily multiple micronutrient supplement and bi-annualdosing with a deworming agent

Year Number of micronutrient Number of deworming Number ofcapsules distributed tablets distributed children served

2006 (1/2 year) 4,000,000 30,000 35,0002007 8,982,800 30,000 55,0002008 10,393,600 110,000 55,0002009 (1/2 year) 4,411,400 NA 55,000Total 27,787,800 170,000 55,000/year

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project also reached approximately 75% of associated,eligible pre-school children aged 2–5 years (approxi-mately 29,000 children), living in the same householdsas the school-going children with the same regimen.

Key findings and lessons learned

The project design was effective in achieving the tar-gets. Based on the overall project design, VA andCristo Salva reached approximately 35,000 school-children in the four project districts during the first sixmonths of implementation. In the second six months,implementation was scaled up and the target of 55,000children (including both school-going and out-of-school children) was reached and continued to bereached from 2007 onward. Thus, all numerical targetswere met or exceeded by the pro ject intervention.

The results were validated by the

MOH. The project objectives wereto mitigate the effects of deficien-cies of essential micronutrients,eliminate parasites, and therebyimprove the absorption of micronu-trients. Observational and anecdot-al accounts from parents and teach-ers collected by both the MOH andCristo Salva, combined with MOHsurvey data, indicate that the chil-dren have shown improvements inhealth, growth, and attentiveness inclass.

The distribution mechanism and

effective monitoring served the

project well. Teachers and localintermediaries, also known as thelocal health prometeras, were able to successfullycarry out distributions to reach children as intended bythe program. Close contact was maintained with distri-bution agents by the Cristo Salva project coordinators,and monitoring of the distribution became routine. TheCristo Salva program director and staff regularly visit-ed the distribution locations and collected information,including photographs, records, and beneficiary lists.For those few schools discovered not to be completingtheir obligations fully, as evidenced from monitoring,feedback from the program director resulted inimprovements and helped this public-private partner-ship to surpass its targets.

Integrated relationships among different programsfacilitated success, but there is a need for continuity.The Honduras Children’s Micronutrient and

Deworming Project is integrated with a larger MOHprogram (largely designed, funded and implementedby Cristo Salva) that seeks to improve the long-termnutritional status of children in Macuelizo and sur-rounding regions. The strategy is contained in a two-phase approach. The first phase is to address the imme-diate crisis: chronic malnutrition. Essential nutritionalsupplements and anti-parasitics are deemed to be aneffective foundational strategy to achieve positive out-comes rapidly. The second phase is to enable policiesand programs that ensure sustainable means for a com-munity’s good health and micronutrient status.Tactically, this entails supporting nutrient-rich garden-ing among communities and schools; on-going educa-tion on available red, green, and orange leafy fruits andvegetables that supply vitamin A and other essentialnutrients; and education on hygiene, sanitation, water

and nutrition in schools and through community out-reach. Thus, the MOH and Cristo Salva have an over-all strategy to move from immediate interventions toabate the nutritional crisis to a longer-term set of poli-cies and programs to alleviate the underlying causes ofmalnutrition.

The district of Azacualpa has proven particularlysuccessful in realizing both short and longer-termobjectives within this strategic framework designed toeliminate malnutrition. In addition to compliance withmicronutrient supplement distribution under this proj-ect, the district schools have been at the forefront ofeducation on nutrition and good health. They haveplanted and maintained school gardens, including atilapia fish farm. Dental care has been instituted, andwater filters are being installed in all of the schools.

School children listening to a presentation on essential micronutrients

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Teachers in all areas are reporting a decrease in absen-teeism, and an increase in student activities. They citethe provision of nutritional supplements and anti-para-sitics as an important part of the increasing engage-ment with health and nutrition issues by both studentsand parents.

The overall MOH/Cristo Salva framework helped toframe the tactical implementation of this project whileassisting in the mobilization (especially by CristoSalva) of resources to achieve longer-term goals – as isdemonstrated to be occurring in Azacualpa District. Itis important to note, however, that the longer-termgoals will not be achieved according to the rapidschedule set at the start of the project. While the MOHis making significant progress, it also acknowledgesthat the tasks associated with the strategic plan it hasput in place are more costly than expected and willtake longer to achieve than expected. Consequently,there are reasons to continue to maintain this programfor another three-year period. This experience is in linewith WHO experience in other countries – while thereis general progress being made to bring about changeto nutritional status, supplementation programs remaineasy to implement, effective, and fulfill a significantrole in helping governments move to fulfill theirlonger-term objectives. Supplementation programs areincreasingly being viewed as an essential interventionto move governments toward better nutritional statusfor their populations, yet are required for longer-than-expected periods.

Conclusion and recommendation

Through steady execution of this project, undertakenin the context of a larger Honduran Government planto alleviate malnutrition, this project has met with con-siderable success in fulfilling the MOH’s objective(and the project objective) to quickly reach large num-bers of children through a locally designed supplemen-tation and deworming project to alleviate the immedi-ate problem of micronutrient deficiency. Anecdotalevidence suggests progress has been achieved amongthe target beneficiaries.

Unfortunately, the cost and effort anticipated by theHonduran MOH to alleviate malnutrition through atwo-stage effort (i.e., use of supplementation and de-worming programs in advance of longer-term inter-ventions to alleviate malnutrition) is proving to begreater than anticipated. The MOH is making progressin implementing its longer-term strategy to eliminatemalnutrition, but it believes that supplementation anddeworming efforts will need to be in place for several

more years until its longer term interventions takehold. This experience is not dissimilar to that found inother countries and there is a growing consensus thatsupplementation and deworming projects will need tocontinue for significantly longer periods than previ-ously anticipated. Consequently, there is a desire onthe part of the Honduran MOH to continue this suc-cessful project for another three-year period – anassessment with which VA agrees. VA intends to sup-port this project for another three years.

References

1. World Health Organization (WHO). World HealthStatistics 2008. Geneva: WHO, 2008. Internet:http://www.who.int/whosis/whostat/2008/en/index.html(accessed 1 October 2009).

2. Honduras Encuesta Nacional Demografia y Salud ENDE-SA 2005-2006.

3. Nestel P, Melara A, Rosado J, et al. Undernutrition amongHonduran children 12-71 months old. Rev Panam SaludPublica 1999; Oct;6:256-65.

4. Pan American Health Organization. Taller sobre el controlde las geo helmintiasis en los países de Centro -América,México y la República Dominicana, 2007. Copan Ruinas,Honduras: PAHO, 2007.

Mother and her infant in Macuelizo, Honduras

SIGHT AND LIFE Africa Forum 2009

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Africa Forum 2009: SharingIntegrated Solutions to HIV andFood and Nutrition Insecurity

Gwenelyn O'Donnell-BlakeProject Concern International, Washington, USA

Correspondence: Gwenelyn O'Donnell-Blake, Project ConcernInternational, National Press Building Suite 955, 529 14th St NW,Washington, DC 20045, USAEmail: [email protected]


These priorities formed the basis of three, interlinked and complemen-tary components of what subsequently became the Links for LifeInitiative:

1. Africa Forum 2009: Inter-country sharing to improve skills andknowledge in integrated programming and to facilitate the scaling-up of promising interventions;

2. Communities of Practice (CoPs): Promotion of field-based learningand knowledge generation on emerging practices in Malawi andEthiopia; and

3. Food and Nutrition Security and HIV/AIDS Advocacy (FANSHA):Advocacy to increase awareness and influence key policy decisionsand processes.

AF09 attendees actively participated as presenters, panelists, and facil-itators with high levels of commitment, and clearly yearned for learningon integrated HIV and FNLS. Over the course of the week, their enthusi-asm seemed to grow, despite being overwhelmed at times with so manyconcurrent sessions, group work sessions, and hands-on activities.According to evaluations, participants left AF09 strongly motivated to dothings differently, not only programmatically, but also in terms of howthey would organize planning meetings, trainings, workshops, and con-ferences, going forward.

Impact at individual, household, and community levels

On a daily basis throughout sub-Saharan Africa, AF09 practitioners arefaced with the fact that millions of people living with HIV (PLHIV) arebecoming ill and dying prematurely, not only from the lack of advancedmedicines but also because of health problems associated with poor nutri-tion, inadequate access to food, and preventable illnesses. While theregion is home to only 10% of the world’s population, it hosts 60% of theglobal population living with HIV. Simul taneously, the region is definedby chronic food insecurity and malnutrition, with an estimated 206 mil-lion people chronically hungry and malnourished (UNAIDS, 2007).1 In

The Africa Forum 2009 (AF09)was held on the shores ofMangochi, Malawi, on June21–26, 2009, on the theme ofSharing Integrated Solutions toHIV and Food and NutritionInsecurity. Attended by 170Africans from 18 sub-SaharanAfrican countries, the Forum was apractitioner-led, non-academicconference on the integration offood, nutrition, and livelihoodsecurity (FNLS) with HIV/AIDS.This is the second Africa Forum tobe held, after the inaugural AfricaForum in Zambia in 2006 on thetheme An Inte grat ed Response tothe Dual Epi demics of HIV/AIDSand Food In security. The Decla -ration produced during that confer-ence laid the foundation for AF09,outlining key priorities in the realmof integrated HIV and food andnutrition security programming forthe future, namely:

• Making the integration ofHIV/AIDS and FNLS a priority

• Increasing learning & informationsharing on integrated programs

• Decision-making about integratedprograms is guided by those mostaffected

Magazine Issue 3/2009Africa Forum 2009

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addition, the 2008 global food crisis has pushed evenmore Africans into chronic hunger, making the UnitedNations Millennium Development Goal to reduce thenumber of people worldwide suffering from hunger by50% increasingly remote. Food, nutrition and liveli-hood security are essential elements to successfullymitigate the impact of HIV/AIDS on individuals, fam-ilies, and communities. HIV and malnutrition are inex-tricably linked at each level and require integratedsolutions if impact is to be alleviated.

Impact at individual level

HIV and malnutrition have a synergistic relationship.HIV undermines food and nutrition security, just asmalnutrition thwarts efforts at HIV prevention andtreatment. Experience and research have shown thatactivities aimed at immune system strengthening andthe prevention of malnutrition in PLHIV can extendthe average asymptomatic period by four to six years.2

This is supported by evidence that micronutrientsupplements, providing the recommended dailyallowance of vitamins and minerals, slow the progres-sion of HIV.3 Prolonging the latent period not onlybrings valuable years of health to PLHIV and theirchildren, it can also delay the need for antiretroviraltherapy (ART) among those infected; reduce the costof treatment; and provide time for overburdened healthsystems to build the capacity needed to meet demand.When ART is needed, having access to food and goodnutrition helps ensure drug adherence. AF09 partici-pants shared anecdotal reports about each of these sit-uations. Individuals who start ART when malnour-ished suffer more severe side effects than those whoare sufficiently nourished. These side effects – whichinclude nausea, taste changes, diarrhea, vomiting andloss of appetite – threaten to decrease adherence todrug regimens, speeding the development of drug-resistant strains of HIV as individuals start and stoptreatment. One study asserts that PLHIV who startART when malnourished may be up to six times morelikely to die than their well-nourished counterparts.4 InMalawi, as ART scaled up, reports showed very highmortality rates with 71% of clients dying during thefirst three months with malnutrition as a major con-tributing factor.5

Impact at household level

AF09 practitioners also know all too well how HIValso undermines livelihood security. When PLHIVbecome sick, the impact of the disease reduces house-holds’ asset base and labor supply, promotes labor

reallocation from agricultural production to other areas(e.g., care and support), and decreases overall produc-tivity. The majority of countries in the sub-Saharanregion are agro-based economies, with agriculturecontributing upwards of 85% of the GDP; Malawiserves as a primary example. Traditional methods offarming are labor intensive and difficult for PLHIV tosustain. To survive, those infected with HIV and theirfamilies often turn to destructive coping mechanisms,involving high-risk behaviors and/or environmentaldegradation, such as using natural resources to pro-duce and sell charcoal.

At the household level, illness and the prematuredeath of parents have created a generation of orphanswho will grow up unsupervised and take on adultresponsibilities, such as caring for and feedingyounger siblings and ill family members. In theabsence of parental guidance, the agricultural and lifeskills ordinarily passed down from parent to child areno longer transferred, undermining the ability of theseyouths to pursue productive livelihoods.

Impact at the community level

At the community level, fewer adults are able to har-vest crops, earn income, and contribute to the well-being of the more vulnerable members of society, thusweakening the fabric of traditional community safety

Container garden

nets, which were once a staple feature of African soci-eties. The convergence and dual impact of HIV andfood insecurity has also decimated the capacity of gov-ernments to retain skilled staff and volunteers and, ulti-mately, to provide basic health care to its citizens at thecommunity level. This constrains the ability of healthcenters to roll out antiretroviral drugs as well as pro-vide programs on nutrition education and the rehabili-tation of malnourished individuals. Government offi-cials from the majority of countries represented atAF09 participated in order to learn from their peersaround the continent and support continued learning intheir own countries upon returning home.

Building capacities of adult learners

In order to build individual and organizational capaci-ty to implement and scale up quality integratedHIV/FNLS programs throughout sub-Saharan Africa,AF09 showcased models that would reduce high-riskbehaviors of people, extend the asymptomatic periodfor PLHIV, and help communities mitigate the overallimpact that food, nutrition, and livelihood insecuritycombined with HIV has on community well-being anddevelopment.

The AF09 program included plenary sessions,debates, skills building workshops, program site visits,cluster presentations, panel discussions, morning moti-vational speakers, country-specific CoP planning ses-sions, and opportunities for networking and relation-ship building. Even the main address was unique,

delivered as a ‘musical keynote’ by Oliver “Tuku”Mtukudzi, a best-selling African artist. Recordingsince the mid-1970s, Tuku has produced more than 40albums with undeniably contagious music and lyrics.Singing with his son, Sam, at AF09, Tuku featured hisoriginal songs that address the HIV epidemic with asense of realism, humor and optimism. The inspiringkeynote set the tone for the week.

Communities of practice

During the week, AF09 participants took part in inter-active learning methodologies and hands-on skillbuilding sessions to enhance their capacity to imple-ment integrated programming. To sustain learning onintegrated programming in specific country contextsafter the Forum, AF09 helped to facilitate the creationof country-based mechanisms to help practitioners –including government representatives – to scale uppromising practices in their own countries.

In 2007, in response to requests for assistance, andin an effort to be responsive to the AF06 Declarationto create inter-country learning, Project ConcernInternational (PCI) designed the Links for LifeCommunities of Practice (CoP) and sought fundingfrom sister organizations. Two CoPs, also known aslearning communities, were established in Ethiopiaand Malawi. Led by experienced facilitators hired byLinks for Life, CoP members from NGOs, governmentand academic institutions working in HIV and FNLSprogramming shared their programmatic experiencesand documented what they learned from being part ofthe CoP. The CoP learning and planning process wasa thread woven throughout AF09.

The Ethiopia and Malawi CoP coordinators and ahandful of CoP participants (i.e., 12 from Malawi and7 from Ethiopia) collaborated to develop and facilitatevarious sessions throughout the week. The purpose ofthese plenary and breakout sessions was to build thecapacity of participants in establishing a CoP – or sim-ilar mechanism – in their own countries to continueand sustain learning. The ‘A to Z’ of establishing andmaintaining CoPs, and the specifics of how they oper-ated in Ethiopia and Malawi were shared through a‘how-to’ guide, videos of the Malawi and EthiopiaCoP experiences, personal testimonies, plenary ses-sions, and skill-building seminars.

We are what we eat

AF09 strove to practice what it preached by ensuringthat all meals offered at the conference were highly


40

Learning first hand about the role of aquaculture

Magazine Issue 3/2009Africa Forum 2009

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nutritious. Specifically, the menuwas designed to reflect a diet foranyone wanting to eat the healthi-est foods available while protect-ing the environment. Toward thatend, with generous support fromGTZ/Malawi, a permaculture gar-den was established at the venue,known as Sun ’n’ Sand, and specif-ic technical assistance provided tovenue staff. A permaculture expertand long-time Malawi resident,June Walker, coached Sun ’n’Sand staff on how to establish andmaintain the garden, as well ashow to replicate it at their homes.Dubbed ‘We Are What We Eat,’the garden and correspondingAF09 menu were developed tocontribute to:

• Supporting the supply of organicfoods grown on-site for AF09participant consumption whilemaking the most out of local nat-ural resources;

• Ensuring the availability ofmicronutrient-dense food choices,such as herbal teas, fruits, vegeta-bles, spices, legumes, nuts, herbs,dairy, and other appropriatefoods, as listed in the guide, Foodfor People Living with HIV; and

• Facilitating food preparationmethods that conserve nutrients,

such as steaming, preparing rawfood, and baking, and avoidingovercooked and fried foods.

Lunch and tea break menus con-sisted of food produced in the per-maculture garden. During an AF09plenary session, June and her localMalawian counterparts – SamuelBaruti and Amos – described thesteps they took to prepare food for

AF09 participants. Starting withthe garden, they explained how thesoil in a permaculture garden doesnot require tilling, and that it can beprepared from seeds with compostmade from local manure. As stan-dard with permaculture gardens, alltypes of fertilizers and chemicals totreat plants were avoided, and natu-ral insect repellents were used.Seeds and seedlings were plantedin pumpkin shells to help nurturethem, using biodegradable toiletpaper rollers for support rather thanpolythene or other types of tubes.

Members from the communityinitially laughed at the permacul-ture gardeners, saying that the com-post heaps looked like “earth tomb-stones.” Later, however, the sameindividuals started to appreciateand admire the vegetables andfruits produced in the garden. Thehead chef at Sun ’n’ Sandexplained how he used producefrom the garden to prepare mealsfor AF09 participants each day. Healso talked about how important itis to eat different types of food for

Vegetable dish made by the staff of Sun n' Sand

Permaculture garden

good nutrition, and encouragedeveryone to visit the garden. Truly,this was a very unique and sustain-able part of AF09 that each partici-pant enjoyed. The garden will con-tinue to benefit not only the stafffrom the venue, but also local com-munity members who observed theprocess from the beginning andlearned how to replicate it if they sochoose.

In keeping with the spirit ofdemonstration and hands-on learn-ing, a ‘Taste and Touch’ sessionwas also organized to introducelocal dishes and nutritious foods forPLHIV from various African coun-tries. The session featured recipesfrom eight African countries(Ethiopia, Ghana, Kenya, Malawi,Rwanda, South Africa, Zambia,and Zimbabwe), and ranged fromnatural teas and biscuits to easy-to-ingest soya-sorghum-rich meals.Facilitators shared the recipes andpreparation methods during the ses-sion. Delegates also received arecipe booklet with all the recipesfrom the session.

Application of learning post-AF09

Since June, personal testimonieshave been shared by AF09 partici-pants about how they are applyingwhat they learned at the Forum. Forexample, a member of the MalawiDefense Force (MDF), Lt DavieJones Gondwe, attended AF09 onbehalf of the Umodzi HIV-positivesupport group that he and his bar-racks had been supporting. TheMalawian military had providedthe Umodzi Support Group withland at their barracks for gardensand a fish pond. The garden pro-duced sufficient quantities of veg-etables and fruits to strengthen thefood security of families in the net-work, along with the salaries ofthree civilian gardeners, and a per-son to maintain the fish pond.

There were structural problemswith the group’s first pond, howev-er, resulting in the loss of fish andwater.

Upon returning from AF09, LtGondwe used skills acquired atAF09 to provide aquaculture tech-nical assistance, including pondmaintenance, and the use ofimproved fish feed to reduce time-to-harvest from six to four months.He also worked with the UmodziSupport Group to expand theirproject to include a second fishpond. The construction of the pondhas been financed by contributionsfrom the network’s membership ofPLHIV, with the expectation thatthey would reap the benefits offuture fish harvests.

Lt Gondwe has been recognizedby the MDF for his efforts andappointed to be its national pro-gram coordinator for HIV/AIDS toshowcase the successes to otherbarracks around Malawi. Thus far,he has provided technical assis-tance on fish farming at three otherbarracks, and it is expected thataquaculture will be scaled up inother areas of the country over thecoming year.

This example is only one ofmany where AF09 participantshave taken their learning forwardfrom the event into their work anddaily lives. Indeed, at the nextAfrica Forum, there will be muchto share on the progress made inscaling up successful integratedprograms for individuals, house-holds, communities, and hopefullycountries as well.

References

1. AIDS epidemic update 2007, Fullreport, UNAIDS

2. Patient D, Orr N. Positive Health (4thEdition). Johannesburg: Juta Pub -lishing, 2005.

3. Fawzi WW, Msamanga GI, Spiegel -man D, et al. A Randomized Trial ofMultivitamin Supplements and HIVDisease Progression and Mo rtality. NEngl J Med 2004;351:23–32.

4. Paton NI, Sangeetha S, Earnest A,Bellamy R. The impact of malnutritionon survival and the CD4 countresponse in HIV-infected patients start-ing antiretroviral therapy. HIV Med.2006;7:323–30.

5. Regional Centre for Quality of HealthCare (RCQHC) and the Food andNutrition Technical Assistance(FANTA) Project. Nutrition, Food Se -curity and HIV: A Compendium ofPro mising Practices. Washington,D.C.: Academy for Educational De -velop ment (AED), 2008.


42

Quotes

“We’ve definitely moved forward. Whereas in Africa Forum 2006 wewere talking about the need for integration, now we are talking aboutkey issues that we find in integrated programs. In addition, in 2006 wewere all looking for ideas and advice. AF09 has shown an outstandinglevel of expertise in many areas – expert implementers, not directors oradvisors, but the implementers themselves! We are moving forward.”

– Africa Forum 2006 participant attending Africa Forum 2009

“I am grateful to be accorded an opportunity to share a story onbehalf of the women of Malawi – those that have no voice – and hopethat, one day, they can be afforded this opportunity to share their sto-ries.”

– AF09 participant

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Scaling Up Maternal, Infant, and YoungChild Nutrition Programming

More than 85 people participated in Scaling Up Maternal, Infant, andYoung Child Nutrition (MIYCN) Programming, a satellite session at theMicronutrient Forum in Beijing, China, on May 11, 2009. The meeting,sponsored by the Global Alliance for Improved Nutrition (GAIN); theUniversity of California, Davis; the United States Agency forInternational Development (USAID); and USAID’s Infant & YoungChild Nutrition (IYCN) Project, led by the Program for AppropriateTechnology in Health (PATH), brought together a wide range of confer-ence participants and members of the MIYCN Network, a group of indi-viduals working toward integrated programming for MIYCN.

The session emphasized the importance of an integrated approach foraddressing nutritional needs during the important life cycle windowfrom preconception through two years of age. Speakers representinggovernment, nongovernmental organizations, universities, and the pri-vate sector presented successful approaches to identify and address theproblem of malnutrition through the life cycle. Presenters discussed awide variety of integrated solutions that have achieved results inThailand, Bangladesh, Honduras, Malawi, and other countries.

During closing remarks, USAID’s Frances Davidson said thatalthough the consequences of malnutrition are overwhelming, it lackssupport and funding compared to other diseases such as HIV/AIDS andmalaria.

“Since malnutrition is not as easily identifiable as other diseases andconditions – despite the important role it plays in dealing with diseasesin the long term – it has been given less attention and fewer resources,”said Dr Davidson.

Dr Davidson said that the session’s emphasis on solutions to improvenutrition highlighted the intergenerational deficits of malnutrition thatcan be overcome. Participants agreed that addressing the problem will

Micronutrient Forum SatelliteSession Highlights

Editor’s note: In order to ensure that the larger micronutrient community has access to what was shared during the satellite sessions of the Forum, SIGHT AND LIFE has compiled a summaryof the available content and discussion.

require a long-term view by poli-cymakers, financial planners, andpoliticians, as well as the publichealth community.

The MIYCN Network will con-tinue to hold regular meetings todiscuss scale-up of MIYCN pro-gramming. Next steps includelooking at further documentationof delivering science in nutrition –translating knowledge into actionto ensure all children achieve theirpotential.

Visit the Infant & Young ChildNutrition Project website to down-load selected presentations: http://www.iycn.org.

Keynote address

Dr Kathryn Franko of theUniversity of Auckland gave thekeynote speech. She discussed therelationship between poor healthoutcomes in all individuals, in -cluding men, and malnutrition inwomen, infants, and young chil-dren. Malnutrition in pregnancyaffects the nutritional status of theunborn baby, often resulting inlow birth weight — which lateraffects health and nutrition well-being and productivity in earlychildhood, school-aged children,and in adults.


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How Thailand reduced nationalrates of malnutrition

Dr Pattanee Winichagoon ofMahidol University in Thailandpresented a case study aboutThailand’s successful efforts toreduce national rates of malnutri-tion. Strong leadership, advocacyefforts, mass media campaigns,and community-based approachescontributed to rapid and continuedimprovements in nutritional sta-tus. Figure 1, below, shows thedecrease in the prevalence of pro-tein-energy malnutrition in thecountry from 1989 to 2001.

Communicated by:Rae Galloway, Infant & YoungChild Nutrition (IYCN) ProjectEmail: [email protected]

Prevention of Anemiain Women ofReproductive Age(WRA) with WeeklyIron and Folic AcidSupplements (WIFS)

The satellite session on thePrevention of Anemia in Womenof Reproductive Age (WRA) withWeekly Iron and Folic AcidSupplements (WIFS), was spon-sored by the World HealthOrganization (WHO) and sharedthe conclusions of a WHO GlobalConsultation and program out-comes on this topic.

Juan Pablo Pena-Rosas, ofWHO, presented on his organiza-tion’s Position Statement onWIFS for WRA, specifically itsrole in promoting optimal mater-nal and child health. This was anoutcome of a WHO Global ExpertConsultation on WIFS forPreventing Anemia in WRA con-

vened in Manila, Philippines, in2007. Fernando Viteri, of Chil -dren’s Hospital Oakland Re searchInstitute (CHORI), de scribedstudies examining high iron intakeduring recovery from iron defi-ciency. Among his key pointswere that WIFS should be contin-uous rather than periodic and foodfortification programs should becomplemented with WIFS forWRA. Sheila Vir described casestudies on WIFS among adoles-cent girls in India, with specific

reference to a study in UttarPradesh (Table 1). Key pointswere that the WIFS reduced ane-mia prevalence significantly with-in 6 months and, hence, it is a cost-effective intervention for adoles-cent girls, whether in school, undersupervision or unsupervised.

Tommaso Cavalli-Sforza, pre-sented on WIFS in Cambodia, thePhilippines and Viet Nam, target-ing about 30,000 WRA per coun-try for 12 months with the aim ofbeing able to apply a commonprotocol. In all three countries,WIFS were well accepted andmost women were willing andable to purchase WIFS for anaffordable price and there weremajor improvements in knowl-edge and practices, in all coun-tries, including improved diets.Results differed in each countrywith the best outcomes in VietNam, where anemia decreased by50% or more, in both non-preg-nant and pregnant women whotook WIFS (p < 0.01), while irondeficiency anemia decreased from9% to 1% in non-pregnant women.

Figure 1: Prevalence of protein energy malnutrition among childrenaged 0–60 months in Thailand from 1989 to 2001

0

25

15

5

1989

20

10

1990 1991 1992 1993 1994 1995 1996 1997 1998 2000 2001

2119.3

1716.5

15.514.4

12.1

10.89.6

8.7 8.4 8.4

Source: Surveillance Report of Nutrition Status of UnderfiveChildren, Bureau of Health Promotion, MOPH 2001

Percent

Juan Pablo Pena-Rosas (WHO)


45

Bounthom Phengdy presentedon a WIFS program for WRA inthe Sekong Province of Lao PDR,which led to an overall significantreduction in the prevalence of ane-mia from 43% to 23%. Based onthis, WIFS are planned to beincluded as part of the essentialpackage for maternal and childcare under the Lao NationalNutrition Strategy and NationalPlan of Action on Nutrition.

Dr Vir and Dr Cavalli-Sforzaconcluded the session with a dis-

cussion on best practices for theimplementation of anemia preven-tion programs among WRA withWIFS, highlighting the need toensure political commitment, un -interrupted and accessible sup-plies of supplements, effectivedistribution, and appropriate com-munication.

In 2008, WHO adopted a newmethodology to systematicallydevelop evidence-based recom-mendations using systematicreviews and the ‘Grading of

Re commendations Assessment,Development and Evaluation’(GRADE) methodology to evalu-ate the quality of the evidence andthe strength of the recommenda-tions (Figure 2). The processrequires: 1) con stitution of a tech-nical guideline developmentgroup to assist WHO to refine thequestion/scope of the guideline, 2)systematic synthesis and assess-ment of the evidence, 3) formula-tion of recommendations, and 4)disseminating the guidelines. Thequality of the evidence is evaluat-

Figure 2: WHO’s methodology to systematically develop evidence-based recommendations

Table 1: Results from four case studies in adolescent girls in India

States Age Coverage Anemia Percent WIFS(years) prevelance change in Compliance

School Girls not (baseline) anaemia (%)girls going to relative to prevalence

school baseline (12 mo)Bihar 10–18 79,590 191,070 93.0 8.8 10–72Gujarat 12–19 65,000 9,536 74.7 21.5 89–94Madhya 10–18 25,000 87.8 7.8 > 90PradeshUttar 10–19 77,000 73,700 73,3 34.3 86–90Pradesh

• Scoping the document: reasons for choosing the topic, problemswith existing guidelines, variations and gaps

• Group composition (or consultations)• Conflict of interest

• Formulations of the questions and choice of the relevant outcomes• Evidence retrieval, evaluation and syntheses

(balance sheet, evidence table)• Benefit/risk profile: integrating evidence with values and prefer-

ences, equity and costs• Formulation of the recommendations

• Implementation and evaluation of impact• Research needs or areas of further research• Peer-review process and updating

Reporting standard and process

Standards for evidence:GRADE system

Reporting standard and process


46

ed using various criteria in four categories from verylow to high quality. The relative strength of a recom-mendation is assigned as ‘strong’ or ‘weak’ based onthe quality of evidence, balance between desirableand undesirable effects, values and preferences, andcosts (resource allocation).

The WHO’s position statement on WIFS for WRAcan be found at: http://www.who.int/nutrition. It isanticipated that the recommendations in this state-ment will remain valid until December 2010. WHOwill then be responsible for initiating a review fol-lowing their formal guideline development process.

The outcome of the process will feed into theWHO E-Library for Nutrition Programme Guidance:Recommendations, Evidence and Best Practices, amulti-partner project bringing together WHO depart-ments, programs, regional and country offices, andexternal partners, including UNICEF, WFP, FAO,CDC, GAIN, MI, and Cochrane. The collaborationwill be a long-term commitment to update recom-mendations, evidence and best practices to find inno-vative nutrition interventions to effectively addressthe Millennium Development Goals (MDGs).

Flour Fortification Ini tiative – Flour Forti ficationRecommendationsMary Sedula introduced the topic of flour fortifica-tion and highlighted that the major advantage of afortified product is that it can be delivered throughexisting systems, which mill 400 million tons ofwheat flour per year for human consumption. A 2004technical workshop on wheat flour fortification withiron and folic acid concluded that the addition of ironand folic acid to wheat flour is a feasible, affordable,

and effective strategy to reduce the prevalence ofimportant micronutrient deficiencies. This was fol-

lowed by a second technical workshop in 2008 onpractical recommendations for national applicationof the recommendations to give guidance on the for-tification of flour with zinc, iron, folic acid, vitaminsA and B12. Expert groups on each micronutrient pre-pared background documents and draft recommenda-tions, which were discussed and approved by WHO.The satellite meeting was an opportunity to summa-rize the outcomes of the workshop to a wider audi-ence.

Iron working group

Ralf Biebinger presented on the development of rec-ommendations for the iron fortification of wheatflour. The group evaluated to what extent the flourindustry is following the 2004 guidelines, and adjust-ed the guidelines based on recently published effica-cy studies and more realistic flour intake patterns.Currently, only 9 out of 78 programs are likely tohave significant positive effect on iron status at thenational level. Many countries do not specify ironcompounds and millers use poorly bioavailable H-reduced and atomized elemental iron powders.Some countries specify non-recommended iron pow-ders, have too low fortification levels, poor coverageor low flour consumption. Strategies are needed toencourage governments to modify legislation andmillers to follow guidelines.

Zinc working group

Ken Brown presented on current recommendationsand research needs relating to zinc fortification ofcereal flours, noting that little work has been done onthe efficacy of zinc. However, preliminary data fromChina, where zinc oxide was added to flour withEDTA iron or elemental iron, showed improvementsin serum zinc concentrations after three years. Zincfortification of cereal flour with zinc oxide or zincsulphate is a safe, effective and low cost method toincrease zinc intake, total absorbed zinc, and (inselected population groups) zinc status. Zinc fortifi-cation should be included in flour fortification pro-grammes in countries with an elevated risk of zincdeficiency if flour is consumed in sufficient amountsby target groups.

Vitamin A working group

Keith West presented for the vitamin A workinggroup, highlighting that wheat and maize flour cantechnically be fortified with vitamin A and that vita-min A is stable in flour without producing organolep-


47

tic changes. Experience with vita-min A fortification of wheat andmaize flour in developing coun-tries is increasing. Although vita-min A is most often used in thefortification of oils and fats, cur-rently 11 countries are fortifyingor propose to fortify wheat and/ormaize flour with this vitamin. Twopublished efficacy trials havereported the impact of vitamin Afortified wheat flour on vitamin Anutritional status but there are nopublished studies that have evalu-ated the effectiveness of this inter-vention on a national scale. Nu tri -tional surveys are needed to estab-lish the vitamin A intake andwheat flour intake of vulnerablegroups but it will be necessary toconsider high consumers in thecalculations.

Folic acid working group

Robert J Berry presented for thefolic acid (FA) working group,focusing on evidence based pro-grams for micronutrient healthand development. In the USA, afew products were voluntarily for-tified with FA before 1996, butafter that date, the number of vol-untarily fortified products in -creased. Mandatory fortification

of cereal grain products with FAwas introduced in 1998 with thepositive impact of reducing theprevalence of neural tube defects(NTDs); similar effects were seenin Chile, Canada and Costa Rica.The important recommendationsfor wheat flour fortification withFA are to improve monitoring ofNTDs and other potential healthoutcomes potentially associatedwith fortification; establish sup-port for countries preparing todevelop plans to fortify flour withFA; conduct a workshop to assesspossibilities for defining bloodfolate concentrations that estimatethe concentrations at which FApreventable NTDs rarely, if ever,would occur; and standardize themeasurement of blood folate con-centrations for different assays sothat concentrations can be com-pared easily.

Vitamin B12 working group

Dr Berry also presented forLindsay Allen for the discussionon vitamin B12 fortification offlour. The reasons to consider thefortification of flour with vitaminB12 include the low intake of ani-mal-source foods in many com-munities resulting in deficient and

marginal plasma B12 in 40–80%people of all ages. There is anincrease in depletion and deficien-cy associated with aging, even inwealthier countries, due to foodcobalamin malabsorption. Manyadverse health outcomes canresult from B12 deficiency includ-ing anemia, neuropathy. Thosewho would benefit most from B12fortification in developing coun-tries include low consumers ofanimal-source foods and, inwealthier countries, low con-sumers of animal-source foodswho do not eat fortified cereals ortake supplements. B12 deficiencyis prevalent because of low intakeof animal-source foods, affectingall ages. Consequences of severe –and possibly of marginal – defi-ciency are serious. Efficacy andeffectiveness need confirmation,including in elderly people withgastric atrophy.

Juliet Aphane presented forFAO, which views food fortifica-tion as one of the effective strate-gies in reducing micronutrientdeficiencies. She highlighted theneed to consider the conditions ofthe vulnerable whose micronutri-ent deficiencies cannot always beaddressed by fortified products,

Keith West (Johns Hopkins University Bloomberg School ofPublic Health)

Ralf Biebinger (DSMNutritional Products)


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including poor subsistence farmers whose main foodsupplies come directly from the land and haverestricted access to fortified foods, people with lowpurchasing power and undeveloped purchasing chan-nels, and those with multiple micronutrient deficien-cies that cannot all be addressed by fortified foods. Inthis context, FAO pursues the goals set by govern-ments as priority for overall nutrition improvementthrough food-based approaches, with emphasis ondietary diversity; and also assists governments inensuring that food fortification programs find theirappropriate place as one element of national nutritionimprovement policies, plans and programmes.

Regina Moench-Pfanner, presenting for GAIN,reiterated GAIN’s commitment to reducing malnutri-tion through food fortification and other strategiesaimed at improving the health and nutrition of popu-lations at risk. Large scale funding for flour fortifica-tion began in 2003 and the first technical workshopwas held in 2004. Government and industry partnersface many challenges in procuring premix for foodfortification programs, including high premix costsand lack of a system to ensure the product's quality.To address these barriers, GAIN is developing andimplementing the GAIN Premix Facility, which con-sists of four components: a certification process thatestablishes industry-wide standards and qualityguidelines for premix; a procurement facility thatmakes premix more easily accessible to countriesand the private industry engaged in fortification;revolving funds that will help projects finance theirpremix purchases; and a grant mechanism that pro-vides premix for fortification of food products usedto reach vulnerable groups, including public sectorprograms and emergencies.

Considerations for the Safe and Effective Use of IronInterventions in Malaria-Burdened Areas

A satellite session was convened by the EuniceKennedy Shriver National Institute of Child Healthand Human Development (NICHD) of the USNational Institutes of Health (NIH) and the WorldHealth Organization (WHO) to present a state-of-the-science technical report entitled ‘Considerationsfor the safe, effective use of iron interventions inareas of malaria burden.’ The report, co-funded bythe Bill and Melinda Gates Foundation (BMGF), wasdrafted by a Tech nical Working Group (TWG) con-

stituted to address three core areas related to iron andits potential interactions with malaria: mechanisms,biomarkers, and interventions. The technical reportwas created as part of a larger project conducted byNICHD, and co-funded by BMGF, to address issuessurrounding current strategies to ameliorate irondeficiency.

The meeting was opened by Francesco Branca,WHO Director of the Department of Nutrition forHealth and Development (NHD), who served as thesession chair and panel moderator.

Daniel Raiten, Project Officer at the NICHD, pro-vided the background for the larger iron and malariaproject, which aims to address historical concernsabout potential adverse interactions between iron andinfection, particularly malaria. The key questions tobe addressed by this project are: 1) Does iron defi-ciency predispose to or protect against malaria andother infections? 2) Does the correction of iron defi-

Regina Moench-Pfanner (GAIN)

Mosquito


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ciency raise or lower the risk of malaria and otherinfections? 3) Do iron interventions increase ordecrease the risk of malaria and other infections? Thefull technical report authored by the TWG and theproject Secretariat at the NICHD is expected to bepublished as a WHO monograph. As part of itsprocess for developing new guidance, WHO, in col-laboration with NICHD, is planning to host a consul-tation in 2010 at a location impacted by iron defi-ciency and malaria.

Gary Brittenham, of Columbia University, present-ed an overview of the potential mechanisms underly-ing adverse effects of iron interventions in the contextof malaria. Dr Brittenham discussed the conclusionsof the TWG with regard to the Pemba study of uni-versal iron and folic acid supplementation in childrenas follows. In summary, the technical report conclud-ed that, overall, iron deficiency seemed to increasesusceptibility to malaria and other infections, not toprovide protection. More research is required todetermine the nature of the interactions of iron statusand iron interventions with infection to determine theexact mechanisms of adverse effects in the context ofmalaria.

Sean Lynch, of Eastern Virginia Medical School,presented on the use of biomarkers to assess iron sta-tus. The indicators covered in the report includehemoglobin, serum iron/transferrin saturation, zincprotoporphyrin/heme ratio (ZPP/H), serum ferritin,soluble transferrin receptor and transferrinreceptor/ferritin ratio. The experimental indicatorsare hepcidin (urine and plasma) and NTBI (Non-transferrin-bound iron). Dr Lynch summarized the

report’s conclusions by noting that transferrin recep-tor/ferritin ratio should be the standard assessmenttool where the prevalence of malaria and other chron-ic infections is relatively low or seas onal. He suggest-ed that the results of serum ferritin, an acute phasereactant, can be compromised in the presence ofinflammatory or infectious diseases.

Kathryn Dewey, of the University of CaliforniaDavis, discussed the safe and effective use of current-ly available iron interventions. Dr Dewey shared theTWG conclusions that the provision of iron viatablets or liquids requires caution and may offer theleast desirable approach in malaria endemic areas.Fortified foods, including iron fortification (central orhome) of complementary foods for infants and youngchildren and of staple foods or condiments for womenand older children, may be the most viable alternativeintervention. Although there are few studies that havespecifically addressed the issue, the TWG concludedthat there is little evidence to suggest that iron-forti-fied foods are not safe in such areas.

Juan Pablo Pena-Rosas, Micro nutrients Unit,NHD/WHO, outlined the WHO Guideline Develop -ment Process as it relates to the use of the technicalreport and the overall goals of the iron and malariaproject. WHO’s role is to translate evidence intoWHO Guidelines for Member States and their part-ners. Among the questions for iron and malaria are:definition of the population at risk, prioritizing inter-ventions under study (including consideration ofdose, duration, and form), determining appropriatecomparison groups, and deciding on key primaryoutcomes.

Workshop for the Design, LegalFramework Formulation,Control and Monitoring of FoodFortification Programs

The satellite session convened by A2Z aimed todescribe the elements that experience has shown arecrucial to the success of food fortification programs.Carol Tom, from A2Z, welcomed everyone andintroduced the speakers: Dr Richard Hurrell, whowas presenting Dr Lindsay Allen’s talk, Dr OmarDary and Dr Hector Cori.

Richard Hurrell, ETH Zurich, presented on behalfof Lindsay Allen on the biological and scientific

Francesco Branca (WHO)


50

issues in food fortification programs. Ex amininghow to decide whether fortification is needed, andhow much, the first step that is needed is to providedocumented evidence that the micronutrient contentof the diet is insufficient and may be improved by theimplementation of a fortification program, or thatfortification will provide a health benefit. Bio -chemical assessment of micronutrient status anddietary assessment of food vehicle intake are neededto provide such evidence.

Omar Dary, A2Z, presented on the elements forsuccessful and effective fortification programs, high-lighting the dynamic cycle of the functional compo-nents of a food fortification program, which includesscientific assessment, design (national policies, stan-dards), implementation (fortification process, premixproduction), supervision (quality control/assurance),consumption (social marketing), impact assessment(measurement of biomarkers), and cost-effective-ness. His key points were that food fortificationshould respond to the assessed need (severity andprevalence), potential impact is dependent on addi-tional intake and coverage of the incorporatedmicronutrients, and standards should be constructedbased on averages, plus an analytical accepted rangedetermined experimentally for each food vehicle,process, sampling method, and chemical methodolo-gy.

Hector Cori, DSM Nutritional Products, presentedon quality as a critical driver for program effective-ness. Describing the critical quality issues relating to

the fortification programs, he highlighted that theimportance of ingredient quality is often missed,although international guidelines do exist, e.g.,Operations Manual for Quality Control andAssurance and Regulatory Monitoring of WheatFlour Fortification Programs, Code of Practice forFood Premix Operations. Cori called for a globalquality dialogue where all stakeholders could worktogether to raise the quality standard, establish con-sensual quality parameters, and convert existingguidelines into an adequate regulatory frameworkthat will maximize the effectiveness of food fortifica-tion programs.

DSM-WFP Partnership“Improving Nutrition –Improving Lives”

Moderated by Klaus Kraemer, SIGHT AND LIFE,and introduced by Martin Bloem, Chief of Nutritionfor WFP, this SIGHT AND LIFE-organized satellitesession highlighted the partnership establishedbetween the UN World Food Programme (WFP) andDSM in 2007, dubbed Im proving Nutrition –Improving Lives. Through this partnership, DSMprovides technical and scientific expertise, nutrient-rich products as well as financial support to improvethe nutritional value of WFP’s food assistance. Jointexpertise is the key to successful development ofnew products. As part of the partnership, some ofthese products, such as Micronutrient Powders(MNP), are being used at large scale in a few WFPprograms to learn lessons before a wider rollout toother WFP operations.

Presenting on evidence of the efficacy of MNPs,Stanley Zlot kin, of the Sprinkles Global HealthInitiative, gave an over view of the importance ofiron, the prevalence of iron deficiency, and publichealth interventions aimed at reducing micronutrient

New device “iCheck” for vitamin A, iodine andiron determination in foodstuffs and blood, suit-able for the field


51

deficiencies. Dr Zlotkin highlight-ed Home Forti fication and thedevelopment of multi-micronutri-ent SprinklesTM, and the results ofefficacy trials of these that consis-tently found improved iron status,health, and appetite, and highacceptability among families andchildren across various cultures.To date, Sprinkles beneficiariesnumber over 2 million across 18countries and Sprinkles home for-tification interventions have led to40–50% reductions in the preva-lence of vitamin and mineral defi-ciencies.

Georg Steiger, of DSM’sNutritional Im pro vement Program(NIP), presented on quality crite-ria for MNPs. MNPs are not newas a product category as they havebeen used for decades for industri-al food fortification concepts andproduced in bulk (for micronutri-ent blends for the food and phar-maceutical industry) in premixplants around the world. What isnew, Steiger explained, is the mar-ket positioning of MNPs in thepresent context, in which the end

consumer fortifies the food her-self. This creates new challengesfor the producer and requires addi-tional quality criteria and meas-urements. These criteria includemeeting consumers’ nutritionalrequirements, being accepted byconsumers, safety, stability, stor-age, affordability, technical man-ageability, and legal requirements.The three areas for which criterianeed to be set are ingredients,packaging, and the productionprocess and facilities. Toward thisend, the Home Fortification Tech -nical Advisory Group (HFTAG) isdeveloping a draft Guidebook onMNP quality.

Michael B Zimmermann, ofETH Zurich, presented on currentand future research on the efficacyof MNPs and described the opti-mization and efficacy testing oflow-iron MNP for complementaryfoods. In-home fortification ofcomplementary foods with micro -nutrient powders can be effective,with low levels of iron fortifica-tion potentially being safer thanhigh levels in high-risk areas for

infection. However, low irondoses have little nutritional im -pact, unless their absorption ishigh. Dr Zimmermann describedresearch to maximize iron absorp-tion from a low-iron MNP withphytase for in-home fortification.Results of the iron absorptionstudy indicated that optimizationof the MNP led to 5-fold increasein iron absorption from a highlyinhibitory meal, suggesting thatthis may allow for effective, untar-geted in-home fortification ofcomplementary foods with lowlevels of highly bioavailable iron.A double-blind randomized con-trolled trial in non-malarial areasin South Africa is currently beingconducted among iron-deficientschool-aged children to furtherverify efficacy.

Saskia de Pee, from WFP, pre-sented on the use of MNPs in pro-gram settings, highlighting theexperience thus far gained throughthe WFP/DSM partnership. Withthe aim of mainstreaming MNPsin its programs, WFP needs tolearn lessons and assess impacts

Martin Bloem, Joris van Hees, Stanley Zlotkin, Georg Steiger, Saskia de Pee, Klaus Kraemer, RichardSemba, Michael Zimmermann, Tina van den Briel


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under program circumstances. MNPs have been usedamong 8,500 underfive children in refugee camps inNepal; 101,000 underfives and 59,000 pregnant andlactating women in Bangla desh; and 55,000 refugeesin Kenya. Vitalita Sprinkles (a type of MNP) distrib-uted to internally displaced children aged 6–59months in post-tsunami Aceh resulted in 25% lowerrisk of anemia among these children compared totheir counterparts who had not received the MNP.The key issues to achieve effectiveness include pro-gram design and initiation, coverage and distribution,and acceptance, adherence and appropriate use of theMNP. WFP's partnership with DSM has allowed it togain traction with its Nutrition Improvement Strategyand develop an effective public-private partnershipmodel.

Klaus Kraemer concluded the satellite session withhis presentation on the lessons that have been learnedfrom the DSM-WFP partnership. For this, Dr Kraemerfocused on the experience of the partnership from theMNP program in Kakuma, Kenya, where there is ahigh rate of micronutrient malnutrition, particularlyanemia, among the refugee population. In 2007, 86%of underfive children and 41% of women of reproduc-tive age were anemic. The partnership between WFP

and DSM led to a program that currently provides55,000 individuals with a once-a-day MNP sachet fora period of one year. Dr Kraemer described the keychallenges faced in establishing and implementing theKakuma MNP Program, specifically in the areas ofcoordination, budgeting, formulation of the MNP,packaging, and communication – where shortfalls inplanning and preparation resulted in delays thatincreased costs. Nonetheless, the lessons learned werenot lost on the DSM-WFP partnership and the pitfallsencountered in the Kakuma MNP Program have led tobetter coordination, budgeting, formulation, packag-ing, communication planning and outcomes in otherprograms.

SIGHT AND LIFE released a series of briefs onthe MNP programs in refugee and emergency set-tings as well as other materials on the WFP-DSMpartnership, which were made available to attendeesof the satellite session. Visit http://www.sightan-dlife.org to download these materials.

Editor’s note: Major plenary sessions of the Forumas well as the WFP-DSM partership satellite meeting can be viewed as videocasts on the SIGHTAND LIFE website.

Magazine Issue 3/2009A Day in the Life

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SIGHT AND LIFE (SAL):Werner, what does your job atUNICEF involve, and what areyour key responsibilities?

Werner Schultink (WS): I’m incharge of the Nutrition section ofthe Programme Division atUNICEF headquarters in NewYork. My job involves advising onthe overall global direction ofUNICEF’s nutrition planning andliaising on UNICEF nutritionissues with other relevant UN agen-cies, NGOs and donor governmentsand agencies. I’m also responsiblefor the management of the Nu -trition section, which comprises 16professional staff. Tasks alsoinclude ensuring that our regionaloffices and selected country officesreceive adequate support, helpingwith fund-raising and also report-ing on nutrition programs.

SAL: A wide-ranging set ofresponsibilities! How long haveyou been in this position?

WS: About 2 years.

SAL: What took you into thisrole? Have you always beeninvolved in the nutrition arena?

WS: My first degree was from theAgricultural University of Wagen -ingen in the Netherlands, where Ispecialized in Human Nutrition. Ifollowed this up with a PhD thesisat Wageningen entitled Sea sonalchanges in energy balance of ruralBeninese women. These studiestook me to West Africa. I thenbecame an advisor on human nutri-tion to the GTZ, the GermanAgency for Technical Cooperation.This role took me to the Universityof Indonesia in Jakarta. In 1999 Ibecame Senior Advisor Micro -nutrient Programs at UNICEFheadquarters in New York. I thenbecame Officer in charge of theNutrition section at UNICEF HQbefore moving on in 2003 tobecome Chief Nutrition and ChildDevelopment Officer at UNICEF’sIndia office in New Delhi. In 2007I took up my current position. Soyes, I have always been deeply

involved in the nutrition arena. I’vespent 17 or 18 years working indeveloping countries and the pasttwo working here in New York.

SAL: What is the mandate ofUNICEF’s Programme Division?

WS: The Programme Divisionguides UNICEF’s programmingwork. For example, we will provideguidance as to whether as an organ-ization UNICEF should support theextensive use of MicronutrientPowder to im prove complimentaryfeeding. The discussion of such atopic may well commence in one ofour regional offices, but global pol-icy will ultimately be set by theProgramme Division here in NewYork.

SAL: You have dedicated your lifeto the subject of nutrition. Why isthis topic so important to the world,in your view?

WS: I think the importance ofnutrition has become abundantlyclear in recent years. The ChildSurvival Series published in TheLancet some while ago positionedadequate breast feeding and com-plementary feeding as potentiallythe most influential factors on the

A Day in the Life of Werner Schultink

Werner Schultink is Associate Director, Nutrition section, ProgrammeDivision, UNICEF. In the latest of our series A Day in the Life,Werner talks with SIGHT AND LIFE about his role at UNICEF andthe part that UNICEF plays in the global fight against micronutrientdeficiency.

Werner Schultink


survival of children. Such publications put it in a nut-shell: the importance of nutrition to the wellbeing ofthe world’s population is without question.

SAL: And what drew you personally to this field?

WS: I have always been interested by the way practi-cal interventions can have a profound effect on publichealth. In the developing world today, many peoplehave little or no choice as to where and how they live,and are not well informed as to what they can do tohelp foster their own health and that of their childrenvia their diet. There are many people in the West withnutritional problems too, but information on how totackle these problems is at least available in the Westfor those who are interested to learn more. In much ofthe developing world, the most basic information is notaccessible. So helping to provide it to those who real-ly need it has always been a great motivation for me.

SAL: Tell us a little about the UNICEF offices whereyou work, if you would, Werner.

WS: Well, I sit in a relatively small office in a rathersober-looking building. My colleagues and I inNutrition are located right next to the Health team, andwe work very closely together. UNICEF HQ is anextremely international environment. I have col-leagues from all over the world, and this creates a verydifferent atmosphere from that of a national ministry,for instance. Most people who work for UNICEF do sobecause they are passionate about what they do; it’smuch more than just a way of earning a living forthem. The working environment here is made all themore dynamic by the fact that we have a job rotationpolicy whereby people move on to a new positionevery three to five years. These positions may be herein HQ or else in the regions. So there is always aninflux of new people with fresh ideas drawn fromrecent practical experience. This is very valuable, for itmeans that the people who work at HQ actually knowwhat’s going on at country level – which is, for exam-ple, extremely helpful in a crisis, of course.

SAL: Is today a normal working day, Werner? Is thereindeed such a thing as a normal working day for you?

WS: It’s a normal working day in the sense that youcan never predict what’s going to happen! I very oftenhave to put to one side the things I was planning to dobecause our priorities have shifted or an emergency ofsome kind has arisen. There’s a lot of variety to thejob. I spend about a third of my time traveling to attendinternational meetings on the shaping of policy and

strategy or to visit specific countries or regions for thepurposes of planning strategy and capacity building.

SAL: What are the things that you enjoy most aboutyour work?

WS: I think the most enjoyable thing about my workis seeing the way it can make a difference on theground. It’s great to get feedback from around theworld telling us that programmes are making goodprogress, that so and so many children have been pro-vided with vitamin A or that breastfeeding rates incountries X, Y and Z are going up. These are thethings that count the most for me.

SAL: Are there things that you dislike about your job?

WS: By and large I like my job very much. It’s veryrewarding to know that your work can help make a dif-ference to people in need. If there is an aspect I dislike,it’s that my job is by its nature quite removed frompeople’s day-to-day lives. I do miss that direct inter-vention. But it’s in the nature of the role I performhere.

SAL: If you could change anything about your work-ing life, what would that be?

WS: I must say I would like to have a better work-lifebalance, but a position such as mine is by its naturevery demanding, so I shouldn’t complain too much!

SAL: You mentioned at the outset a large number oforganizations with which you are in regular contact.What does SIGHT AND LIFE mean to you in the con-text of the global fight against malnutrition?

WS: Work on micronutrient deficiencies, vitamin Asupplementation, salt ionization and so on is funda-mental to our programs, and SIGHT AND LIFE has animportant role to play here. SIGHT AND LIFE createsa very effective bridge between scientific publicationssuch as The American Journal of Clinical Nutritionand practical programs on the ground. It also helps cre-ate valuable links with the private sector.

SAL: And the magazine itself, Werner – are thereparts of it that you particularly enjoy?

WS: As you can imagine, we receive an enormousnumber of journals, so I don’t read every issue ofSIGHT AND LIFE Magazine cover to cover, but Ilook out for the articles on programming and also thesummaries of major meetings. I find these very useful.

SIGHT AND LIFE A Day in the Life

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Magazine Issue 3/2009A Day in the Life

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SAL: You mentioned that SIGHTAND LIFE has an important role toplay in helping children with vita-min A deficiencies. What is thebest way of reaching these chil-dren? How do you get through tothe neediest sections of the popu-lace?

WS: As is made clear by a newUNICEF report published thisNovember, the use of child nutri-tion days and child health weeks isby far the most effective way ofreaching the majority of children,especially in the least developedcountries. This means organizing aspecial day or week when trainedworkers go around the local vil-lages and spend a part of a day oreven a whole day there, offering apackage of services to all the moth-ers and children who should be tar-geted. Vitamin A is an importantpart of these services, but in manycountries it's now linked with otheraid interventions such as de-worm-ing, the provision of iron folictablets to women or the dissemina-tion of information on infant feed-ing and hygiene, for instance. Itmakes a big difference that theseworkers go out to the villagesrather than simply sitting in ahealth center somewhere. Thehealth center may just be too farremoved from the mothers whomost need its services, so going outin person is the best way to providethis essential support.

SAL: You mention mothers as akey target group. What is your viewof the appropriateness of multiplemicronutrient supplementation inthe case of pregnant women?

WS: There’s a wealth of evidenceto show that anemia is abundantlyprevalent in all developing coun-tries. Moreover, it is well docu-mented that anemia is an indicatorof a range of deficiencies, not justof iron deficiency. UNICEF ex -

plored the topic of multiple micro -nutrient supplementation 1999, tak-ing as our cue the fact that the dietavailable to many people in thedeveloping world is low in essen-tial micronutrients. We recom-mended the use of micronutrientsupplementation in pregnancy, andthis led to a range of additionalstudies on the subject being pub-lished in the Food and NutritionBulletin. The Micronutrient Forumbefore last also presented over-whelming evidence that the use ofthese multi-micronutrient supple-ments had a positive impact on themicronutrient states of women andalso resulted in a statistically sig-nificant improvement in birthweights. I therefore think that weshould consider this approach veryseriously.

SAL: Of course there are manybodies involved in the attempt tomitigate malnutrition, UNICEFbeing only one of them. How welldo you think these bodies worktogether?

WS: Each of these initiatives hasits own focus. Each tries to en -hance the implementation of a mul-tisectorial approach with a view toimproving nutrition levels. Goodplanning between different agen-cies can make a significant impact,greatly enhancing the effec tivenessof local interventions. I think it’sgenerally agreed that with a rela-tively limited simple set of inter-ventions we can make a big differ-ence if we all collaborate effective-ly. There is an enormous amountof collaboration and good commu-nication going on at the moment,and a drive to all think in the samedirection.

SAL: We haven’t talked a lotabout your personal life. What areyour interests outside work,Werner?

WS: I enjoy spending time withmy family and I love to be out ofdoors. I do water sports in the sum-mer, as well as biking and jogging.I also take pleasure in listening to awide variety of music and in read-ing, but I always like to be outsidewhen I can. We have a house inCanada where we try and spend agood amount of our leisure time.

SAL: Is there anything else thatyou’d like our readers to knowabout yourself and your work?

WS: I think this is a very goodtime to be working in the field ofnutrition. There are so many excit-ing developments occurring at themoment, and I hope that manyyoung academics will be attractedto the field. There is so muchimportant work to be done!

SAL: Werner, let’s hope that yourenthusiasm is passed on to theupcoming generation. Many thanksfor taking the time to speak withSIGHT AND LIFE.

WS: Thank you.

Werner Schultink was interviewedby Jonathan Steffen.

SIGHT AND LIFE Micronutrient Deficiencies and Affluence

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Deprivation, mortality and nutrition

In spite of the recent turbulence in the banking worldand its effects on the economy of many countries,food availability and living standards in the industri-alized countries of the west are vastly superior to theconditions of many people living in the developingcountries of Africa and Asia and many other parts ofthe world. Furthermore most of us would agree thatliving standards have improved in those industrial-ized countries over the last century, yet nutritionalproblems still exist and a recent study of deprivationand mortality in the UK found no significant changein the strength of the relation between the start andend of the 20th century.1

The objective of the study was to examine the geo-graphical relationship between mortality and depriva-tion in England and Wales at the start of the 20th and21st centuries and explore the evidence for thestrengthening or weakening of relationships over thattime. The 20th century saw dramatic improvements inpatterns of mortality. Age and sex specific mortalityrates declined across all ages. Life expectancy hasrisen from 46 and 50 for men and women in the 1900sto 77 and 81 respectively in 2001. These changes arelinked to major changes in the cause of death. Moderncauses of death are dominated by cancer, ischemicheart disease and stroke. In the 1900s classification ofmortality was less well organized; cancer and respira-tory disease were important, but infectious and para-sitic diseases accounted for nearly 20% of deaths.1

The definition of poverty has also changed over thecentury (Table 1). In the early 1900s, poverty meantthe income of an individual was not “sufficient toobtain the minimum necessary for the maintenance of

mere physical efficiency”. In fact this is the samemeaning it still carries in many poor African coun-tries today. However, in industrialized countries ofthe West, the 20th century has seen improvements instandard of living and the growth of the welfare statenow means that poverty is defined as a relative state.Relative poverty is usually expressed by comparingthe individual’s income or deprivation with that expe-rienced by society as a whole but there is a wellknown, direct relationship between poverty and mor-tality even today.2

The causes of death in industrialized countries havechanged over the century but in the UK there is astrong relationship between mortality levels a centuryago and those of today. This is not surprising whenyou realize that the highest rates of deprivation andmortality in the 1900s were found in urban and indus-trial areas, with low rates mainly in rural areas. Thepositions of our cities have not changed; they haveexpanded and the areas with the lowest and highest10th of mortality in the 1900s still have low and highmortality rates in 2001. Thus in spite of the changes indefinitions and the fact that the mortality gap betweenthe worst and the best has narrowed, there has been

Micronutrient Deficiencies and Affluence

David ThurnhamUniversity of Ulster, Northern Ireland Centre for Food and Health,Coleraine, UK and MRC Elsie Widdowson Laboratory, Cambridge, UK

Correspondence: David Thurnham, 46 High Street, LittleWilbraham, Cambridge CB21 5JY, UKEmail: [email protected]


Table 1: Definitions of poverty in industrializedcountries

1901 The income of an individual was not suf-ficient to obtain the minimum necessaryfor the maintenance of mere physicalefficiency.

2001 Income is now compared with that expe-rienced by society as a whole andexpressed as ‘relative poverty’.

Magazine Issue 3/2009Micronutrient Deficiencies and Affluence

57

little change in the geographic relationshipover the century.1

There is abundantevidence that povertyand deprivation are alsolinked to poor nutri -tion and health prob -lems throughout the lifecycle (Figure 1). Therecent Lancet series onmaternal, infant andyoung child nutritiondrew attention to theimportance of earlynutrition interventionsto improve child healthand development andincrease the chances forfuture economic pro-ductivity both for theindividual and the com-munity.3 Girls who arepoorly nourished mayfail to properly developand this can impair fetaldevelopment when theytoo become mothers.Evidence suggests that poor fetal nutrition not onlyreduces the survival chances of the infant but may alsolead to heart disease, diabetes and respiratory prob-lems in later life. Poor nutrition leads to poor healthwhich impairs working ability and the chance to pros-per and the cycle is perpetuated. As indicated abovehowever, deprivation is a relative term in industrial-ized and affluent countries in the 21st century, so whatare the nutritional problems that maintain the linkbetween deprivation and mortality?

Changing lifestyles in the 20th century and nutrition

The epidemic of overeating in North America and theUnited Kingdom together with sedentary lifestyleshas led to a growing prevalence of obesity, diabetesand metabolic syndrome in children. It is not myintention in this article to discuss ways of tacklingobesity but rather to discuss the way our changingfood habits impinge on micronutrient nutrition. Anexcess of calories does not imply adequate nutritionand vitamin and mineral deficiency syndromes canstill occur.4 Changing lifestyles, agricultural prac-tices, food habits and food sources in modern society

can also have an impact on micronutrient nutrition.Our intake of selenium in Europe has reducedmarkedly over the last 30 to 40 years as importationof North American wheat has been replaced byEuropean and home grown varieties for bread mak-ing.5,6 We know that selenium has an essential role inthyroid metabolism, sperm motility, antioxidant func-tions and immune defenses and may lower the risk ofcertain important cancers.6 Iodine status is reported tobe low to marginal in infants and pregnant women inparts of Europe and cow’s milk is an important sourceof dietary iodine in these people.7-9 Iodine in cow’smilk is influenced by the feed which it eats10 and onthe use of iodine-containing teat dips to prevent infec-tion in the udder.11 Alterations in dairy cow hus-bandry may alter the iodine content of consumermilk, and this may increase the risk of thyroid dis-eases in the population and affect mental develop-ment in infancy.12 An insufficiency of iodine causesan enlargement of the thyroid gland known as a goi-ter and was very common in many counties ofEngland in the 18th century, particularly inDerbyshire, where it gave rise to the name“Derbyshire neck”.

Figure 1: Interaction of obesity and poverty on health through the life cycle.Figure shows impact of obesity throughout the life cycle and someof the consequences on health and development outcomes. CHDmeans coronary heart disease. Refer to the text for explanation ofthe arrows which indicate increased risk.

Chronic disease,hypertension,CHD

Poor physicaland mentalperformance Underweitght, mentally

impaired babies

Fe requirements

Fe deficiency

Poor cognitivedevelopment

Risk ofasthma

Vitamin Ddeficiency

Metabolicsyndrome

Type IIdiabetes

Low economicproductivity

Poor schoolperformance

High ferritinand lowserum Fe

High ferritin

Adults

Children

Infants and small children

Poverty Obesity

Chronic Inflammation

Adolescents


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Inflammation and obesity

Currently selenium and iodine insufficiency appear tobe only of borderline significance in European coun-tries whereas the alarming rise in obesity prevalenceis a major concern. Studies on the socio-demograph-ic and life-style factors associated with obesity haveidentified poverty as a major factor related to child-hood,13 adolescent14,15 and general obesity.16 Whiteadipose tissue is now recognized as a multifunctionalorgan and in addition to its central role of lipid stor-age it has a major endocrine function.17 Studies onboth humans and animals demonstrate a close associ-ation between obesity and a state of low grade, chron-ic inflammation in which there is macrophage infil-tration in adipose tissue and increased circulatingconcentrations of pro-inflammatory moleculesincluding acute phase proteins, cytokines, adipokinesand chemokines.18 In obese states these pro-inflam-matory factors are produced predominantly fromenlarged adipocytes and activated macrophages inadipose tissue and liver and can directly induce glu-cose intolerance and insulin resistance leading to dia-betes and metabolic syndrome. It should be recog-nized however that these pro-inflammatory mole-cules are ‘alarm’ signals and that something triggersthe adipocyte to promote the acute phase process.

What is the cause of the inflammation in obesepeople? It was suggested in 200417 that inflammationin adipose tissue in obesity was a response to hypox-ia and more recently hypoxia has been demonstratedin the adipose tissue of several obese mouse mod-els.19 In exercise, as well as cancer and ischemia,

hypoxia is known to activate hundreds of genes vitalfor cell homeostasis and angiogenesis, including in -flammation.20 The inflammatory response is intendedas a rapid response to external or internal signals ofdanger but it should be of limited duration. The con-tinuing hypoxia in overweight and obese people pro-motes a state of chronic inflammation to which thebody attempts to adapt but in so doing can increasethe risk of anemia,21–23 diabetes and metabolic syn-drome.24

Iron deficiency and obesity

Anemia is one of the commonest clinical indicators ofpoor nutrition in industrialized countries and theprevalence of iron-deficiency is high particularly inoverweight toddlers.23 A report in which seculartrends in iron deficiency in children 1–3 years wereexamined in data from the US National Health andNutrition Examination Surveys (NHANES) from1976 to 2002 found little change in the prevalenceover 22 years. In children described as poor, preva-lence had declined to around 9% but in those whowere overweight (weight for length in the 85th to 94th

percentile) iron deficiency remained around 20–24%.The prevalence in non-poor households did notchange (~7%) and multivariate analyses suggestedthat Hispanic, younger and overweight children hadthe higher odds of iron deficiency.23

Similar results were found in another study whichexamined data from overweight children 2–16 yearsfrom NHANES III (body mass index (BMI) in 85th to94th percentile).21 These workers found that children

who were at risk of over-weight or who were alreadyoverweight were twice aslikely to be iron deficient asthose who were not over-weight. To identify irondeficiency, the authors usedthe criteria of the NHANESlaboratory, namely that irondeficiency existed if two ofthe following tests wereabnormal: transferrin satu-ration, free erythrocyte pro-toporphyrin levels andserum ferritin levels. Atleast two of these measure-ments are changed byinflammation; serum ironand therefore transferrinsaturation are depressed and

Obesity in Canada


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serum ferritin levels are elevated. Elevated ferritinconcentrations can lead to under-reporting of irondeficiency, i.e. there may be even higher levels ofiron deficiency in obesity.

Several workers have investigated the part playedby inflammation in the disturbances in iron metabo-lism in obesity.22,24 Yanoff et al22 studied 172 appar-ently healthy non-obese and 234 obese (BMI > 30kg/m2) adults (18–70 years). They found evidence ofboth inflammation (elevated C-reactive protein andferritin concentrations) and iron deficiency (elevatedtransferrin receptor concentrations) and concludedthe hypoferremia of obesity was due to chronicinflammation blocking the absorption of iron andeventually leading to iron deficiency.

As indicated above, obesity is considered to be achronic inflammatory state25 and it is now known thatinflammation up-regulates the production of hepcidinin the liver which disturbs the regulation of ironmetabolism by blocking iron absorption and re-uti-lization. See SIGHT AND LIFE Magazine26 fordescription of mechanism. The main source of hep-cidin in the body is the liver and expression of hep-cidin by hepatocytes is more than 100-fold higherthan that from adipocytes. How ever, in obese humansadipose tissue may be 20-fold greater than the livermass so the combined production of hepcidin mayhave relevance to iron control in obesity. The otheriron-regulating protein produced by adipocytes islipocalin-2 and recent evidence suggests that whiteadipose tissue is a dominant site of its production.27

Adipose lipocalin-2 expression is increased byinflammatory cytokines interleukin-1 and tumornecrosis factor-2 and it is an important component ofour innate immune system. It functions by competingwith invading pathogens for bacterial iron.28 Inhumans lipocalin-2 is positively correlated with adi-posity18 and the increased amount in obese peoplemay indicate that it is of pathological significance.

The other factor that might influence iron status inobese people is their large body mass. Iron require-ments may be higher in obese than the non-obesepeople since two thirds of the body iron is found inthe erythrocytes and blood volume is directly propor-tional to body mass.22 The anemia found in obesechildren21,23 therefore may be due to a combinationof diminished iron absorption, impaired re-utilizationand insufficient dietary iron.

The second study to examine the role of inflamma-tion in obesity focused particularly on diabetes.24 The

authors recruited 239 post-menopausal women with aBMI >30 kg/m2 and with and without metabolic syn-drome (MET; defined according the InternationalDiabetes Federation guidelines29). The authors con-cluded that MET, and in particular type 2 diabetes,was the main contributor to the high ferritin levelsfound in obese people and that inflammation was anetiological factor.30 Other studies in apparentlyhealthy populations have shown, however, that highferritin concentrations independently predict thedevelopment of type 2 diabetes,31 that is, other fac-tors associated with obesity are responsible for thehigh ferritin concentrations. High ferritin levels couldindicate iron overload but liver autopsy studies intype 2 diabetics found iron levels no higher than thoseof non-diabetic patients.32 In other words, the studyindicates that high ferritin concentrations in obesityare not responsible for the type 2 diabetes but thatboth may be the product of the chronic inflammation.

Obesity and vitamin D status

Body fat indexes have also been related to vitamin Ddeficiency in obese adolescents33 while other studieshave reported the weight of adolescent girls to be cor-related negatively with vitamin D.34 Unfortunatelythere is no universally accepted concentration of vita-min D (i.e. 25 hydroxy-vitamin D, 25-OHD) thatdefines deficiency. Workers from the Centers forDisease Control and Prevention who analyzedNHANES III data (1988–1994) reported vitamin Ddeficiency (< 17 nmol/L) was unlikely in the US pop-ulation but that insufficiency of the vitamin (< 25nmol/L) was fairly frequent in younger individualsand non-Hispanic blacks.35 Adequate vitamin D isessential for normal growth and vitamin D deficiencyhas been associated with a wide variety of illnessesand chronic conditions.33 According to NHANESsurveys, 17.1% of children and adolescents wereobese based on a BMI > 95th percentile and obesity inboth sexes significantly increased over the period1999 to 2004. The growing problem of obesity inchildren and the association with vitamin D deficien-cy is therefore of concern.

The study by Lenders et al33 of 58 obese adoles-cents was an attempt to investigate thoroughly therelation between body fat indexes and vitamin D sta-tus. These workers defined vitamin D deficiency as25-OHD < 50 nmol/L and found 17 children weredeficient. Also included in these studies were meas-urements of bone mineral density and parathyroidhormone (PTH). Elevated PTH would be expected ingrowing subjects and those with vitamin D deficien-


60

cy. They found that PTH concen-trations were normal suggestingthat the children were neither vita-min D deficient nor growing. Inaddition bone mass was withinnational standards so there was noimmediate concern that the lowvitamin D status was affectinggrowth and mineralization ofbone. The association betweenobesity and lower 25-OHD con-centrations may have no function-al consequences and merely indi-cate greater sequestration of thevitamin in the large amount ofbody fat.

There are concerns about vita-min D however because manypeople are solely dependent onUVB irradiation from sunlight fortheir supply. Northerly latitudes,long winters, clothing, climate andexcessive use of sun-blockerscompete with our efforts to meetvitamin D requirements. Mothersespecially need sufficient vitaminD status to ensure the satisfactorystatus of their children. Low vita-min D status has been reported inpregnant women in America,Australia and the United Kingdomat latitudes where there is amarked seasonal variation in sun-light.36 During the winter seasonthere may be no UVB irradiationand people rely principally on theirstores because, where there is nosupplementation policy, there isvery little vitamin D in the diet. Astudy recently carried out inNorthern Ireland looked at theeffect of multivitamin supplementuse on vitamin D status of preg-nant (N = 99) and non-pregnantwomen (N = 38) through the win-ter and summer seasons. VitaminD in the supplements ranged from5 to 12.5 µg. Supplement users hadsignificantly higher 25-OHD con-centrations but it was notable thateven in the supplement users dur-ing the winter and spring seasons,the majority of pregnant women

had concentrations of 25-OHD < 50 nmol/L. In addition a risk ofsevere vitamin D deficiency (25-OHD < 12.5 nmol/L) was found in1–2% of pregnant non-users dur-ing the winter months.36

Sub-optimal vitamin D status inpregnancy may have significantconsequences for the health of thechild. There are suggestions that inutero or early life, vitamin D defi-ciency is associated with bothskeletal37 and non-skeletal conse-quences including increased riskof schizophrenia, type 1 diabetesand asthma.36 It is reported that theworldwide prevalence of asthmaand allergic diseases began to risein the 1960s and it is suggestedthat as populations became moreprosperous, there was less expo-sure to sunlight as more time wasspent indoors and therefore lesscutaneous vitamin D synthesis.38

To support their hypothesis, theauthors reported that higher vita-min D intakes by pregnant mothersreduced the asthma risk of children3–5 years old by 40%. It is certain-

ly true that vitamin D status isstrongly linked to daylight expo-sure. One study of peopleapproaching retirement age foundhabits like dog-walking or usingan allotment, or a holiday in asunny country in the recent past,all favored high 25-OHD concen-trations.39 Skin color is alsoreported to influence vitamin Dstatus with lower 25-OHD concen-trations being reported in AfricanAmericans.34,35 However, analy-ses of racial and income data from14,244 American children under18 years found poverty to be themore important factor in determin-ing risk of asthma and that it wasonly in the very poor where non-Hispanic black children had ahigher risk than non-Hispanicwhite children.40 Another studythat examined risk factors for asth-ma in 9,243 adults 20–85 yearsfrom the 2001–2 and 2003–4NHANES surveys found thatextreme obesity and living inpoverty were strongly associatedwith asthma in both men andwomen.41

Key messages

• Poverty is self perpetuating.• Poverty is associated with obesity.• Obesity is a chronic inflammatory state and hypoxia in white adipose

tissue may be the trigger for the inflammatory response in obese people.

• Obesity is associated with iron deficiency, high serum ferritin concen-trations, poor vitamin D status.

• Iron deficiency and high serum ferritin concentrations may be a consequence of the chronic inflammatory state in obese people.

• Obesity and high serum ferritin concentrations are risk factors for dia-betes and metabolic syndrome.

• Iron deficiency is associated with poor cognitive development whichmay impair economic productivity and, in conjunction with poorhealth, perpetuate poverty in later life.

• Poverty and obesity are strongly associated with asthma in childrenand adults and it has been suggested poor vitamin D status may be acontributory factor.


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Conclusions

The association between povertyin urban areas and a higher risk ofmortality is not a new phenome-non. Living conditions in industri-alized countries have improvedthrough the 20th century. We livelonger lives and the abject povertyof the 1900s has been removed toa large extent by the welfare statein industrialized countries. Nu tri -tion has both improved and deteri-orated. We now consume anexcess of calories and the resultingobesity is influencing the diseasesthat now end our lives. Somemicronutrient deficiencies likeiron and vitamin D still exist. Poordietary intakes may contribute tothese deficiencies but they are notjust a product of poor food butmore a product of poor lifestyle.Improving nutrition in the 21st

century will require lifestylechanges.

References

1. Gregory IN. Comparison betweengeographies of mortality and depriva-tion from the 1900s and 2001: spatialanalysis of census and mortality sta-tistics. BMJ 2009; 339:b3454:676-9.

2. Shelton NJ, Birkin MH, Dorling D.Where not to live: a geo-demograph-ic classification of mortality forEngland and Wales, 1981-2000.Health Place 2006; 12:557–69.

3. Bhutta Z A, Ahmed T, Black RE et al.Maternal and child undernutrition 3.What works? Interventions for mater-nal and child undernutrition and sur-vival. Lancet 2008; 371(9610):417–440.

4. McCallum Noble J, Mandel A,Patterson MC. Scurvy and ricketsmasked by chronic neurological ill-ness: revisiting "Psychologic Mal -nutrition". Pediatrics 2007; 119:e783–e790.

5. Rayman MP. Dietary selenium: timeto act. BMJ 1997; 314:387-8.

6. Thurnham DI. Selenium - Some noteson immune function and recent can-cer trials. SIGHT AND LIFEMagazine 2009;2:49–56.

7. Girelli ME, Coin P, Mian C et al.Milk represents an important sourceof iodine in schoolchildren of theVeneto region, Italy. J EndocrinolInvest 2004; 27:709–13.

8. Alvarez-Pedrerol M, Ribas-Fitó N,García-Esteban R et al. Iodinesources and iodine levels in pregnantwomen from an area without knowniodine deficiency. Clin Endocrinol(Oxf ) 2009; Mar 28 ahead of print.

9. Mian C, Vitaliano P, Pozza D et al.Iodine status in pregnancy: role ofdietary habits and geographical ori-gin. Clin Endocrinol (Oxf) 2009;70:776–80.

10. Grace ND, Waghorn GC. Impact ofiodine supplementation of dairy cowson milk production and iodine con-centrations in milk. N Z Vet J 2005;53:10–3.

11. Hemken RW. Milk and meat iodinecontent: relation to human health. JAm Vet Med Assoc 1980; 176:1119–21.

12. Laurberg P, Anderson S, Knudsen Net al. Thiocyanate in food and iodinein milk: from domestic animal feed-ing to improved understanding of cre-tinism. Thyroid 2002; 12:897–902.

13. Edwards KL, Clarke GP. The designand validation of a spatial microsim-ulation model of obesogenic environ-ments for children in Leeds, UK:SimObesity. Soc Sci Med 2009;69:1127–34.

14. BeLue R, Francis LA, Rollins B et al.One size does not fit all: identifyingrisk profiles for overweight in adoles-cent population subsets. J AdolescHealth 2009; 45:517–24.

15. Lohman BJ, Stewart S, Gundersen Cet al. Adolescent overweight and obe-sity: links to food insecurity and indi-vidual, maternal, and family stres-sors. J Adolesc Health 2009; 45:230–7.

16. Sellström E, Arnoldsson G, AlricssonM et al. Obesity prevalence in acohort of women in early pregnancyfrom a neighbourhood perspective.BMC Pregnancy Childbirth 2009;online Aug 25;9.

17. Trayhurn P, Wood IS. Adipokines:inflammation and the pleiotropic roleof white adipose tissue. Brit J Nutr2004; 92:347–55.

18. Wang Y, Lam KS, Kraegen EW et al.Lipocalin-2 is an inflammatory mark-er closely associated with obesity,insulin resistance and hyperglycemiain humans. Clin Chem 2007; 53:34–41.

19. Trayhurn P, Wang B, Wood IS.Hypoxia in adipose tissue: a basis forthe dysregulation of tissue function inobesity? Brit J Nutr 2008; 100:227–35.

20. Qutub AA, Popel AS. Reactive oxy-gen species regulate hypoxia-inducible factor 1alpha differentiallyin cancer and ischemia. Mol Cell Biol2008; 28:5106–19.

21. Nead KG, Halterman JS, Kaczo rowskiJM et al. Overweight children andadolescents: a risk group for iron defi-ciency. Pediatrics 2004; 114:104–8.

22. Yanoff LB, Menzie CM, DenkingerB et al. Inflammation and iron defi-ciency in the hypoferremia of obesity.

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Int J Obesity 2007; 31:1412–9.23. Brotanek JM, Gosz J, Weitzman M et

al. Secular trends in the prevalence ofiron deficiency among US toddlers,1976-2002. Arch Pediatr AdolescMed 2008; 162:374–81.

24. Lecube A, Hernández C, Pelegrí D etal. Factors accounting for high fer-ritin levels in obesity. Int J Obesity2008; 32:1665–9.

25. Greenberg AS, Obin MS. Obesity andthe role of adipose tissue in inflam-mation and metabolism. Am J ClinNutr 2006; 83:261S–465S.

26. Thurnham DI. Monitoring anemia-control programs. SIGHT AND LIFEMagazine 2009; 1:59–66.

27. Yan QW, Yang Q, Mody N et al. Theadipokine lipocalin 2 is regulated byobesity and promotes insulin resist-ance. Diabetes 2007; 56:2533–40.

28. Barasch J, Mori K. Cell biology: ironthievery. Nature 2004; 432:811-3.

29. International Diabetes Federation.The IDF consensus worldwide defini-tion of the metabolic syndrome.www.idf.org/webdata/docs/IDFmetasyndromedefinition.pdf. 2005.

30. Lecube A, Hernández C, Pelegrí D etal. Factors accounting for high fer-ritin levels in obesity. Int J Obesity2009; 32:1665–9.

31. Salonen JT, Tuomainen T-P, Ny -yssonen K et al. Relation betweeniron stores and non-insulin-dependentdiabetes in men: case-control study.BMJ 1998; 317:727.

32. Dinneen SF, Silverberg JD, Batts KPet al. Liver iron stores in patients withnon-insulin-dependent diabetes mel-litus. Mayo Clin Proc 1994;69:13–15.

33. Lenders CM, Feldman HA, VonScheven E et al. Relation of body fatindexes to vitamin D status and defi-ciency among obese adolescents. AmJ Clin Nutr 2009; 90:459–67.

34. Harkness LS, Cromer BA. Vitamin Ddeficiency in adolescent females. JAdolesc Health 2005; 37:75.

35. Looker AC, Sawson-Hughes B,Calvo MS et al. Serum 25-hydroxyvi-tamin D status of adolescents andadults in two seasonal subpopulationsfrom NHANES III. 2002; 30:771–7.

36. Holmes VA, Barnes MS, AlexanderDH et al. Vitamin D deficiency andinsufficiency in pregnant women: alongitudinal study. Brit J Nutr 2009;102:876–81.

37. Dawodu A, Agarawal M, Sank -arankutty M et al. Higher prevalenceof vitamin D deficiency in mothers ofrachitic than non-rachitic children. JPediatr 2005; 147:109–11.

38. Litonjua AA, Weiss ST. Is vitamin Ddeficiency to blame for the asthmaepidemic? J Allergy Clin Immunol2007; 120:1031–5.

39. Holdsworth MD, Dattani JT, DaviesL et al. Factors contributing to vita-min D status near retirement age.Hum Nutr Clin Nutr 1984; 38C:139–49.

40. Smith LA, Hatcher-Ross JL, Wert -heimer R et al. Rethinking race/eth-nicity, income, and childhood asth-ma: racial/ethnic disparities concen-trated among the very poor. PublicHealth Reports 2005; 120:109–16.

41. McHugh MK, Symanski E, PompeiiLA et al. Prevalence of asthmaamong adult females and males in theUnited States: results from theNational Health and NutritionExamination Survey (NHANES),2001-2004. J Asthma 2009; 46:759–66.

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Summary of grantee accomplishments sinceAugust 2008:

• Eye clinics have been resourced and are function-ing smoothly in each of the nine refugee campsalong the Thai – Burma border and at the Mae TaoClinic in Mae Sot;

• 52 health workers received training in basic refrac-tion skills;

• Nearly 15,000 schoolchildren in the camps haveundergone vision screening;

• 670 eye surgeries have been completed;• More than 8,000 pairs of eyeglasses have been pro-

vided to adult patients.

Tackling avoidable blindness through partner-ships

Approximately 1.4 million children worldwide areblind. In addition, nearly 17 million children withlow vision or impaired sight lack visual aids, servic-es or eyeglasses to help them function. As a compo-nent of A2Z: The USAID Micronutrient and ChildBlindness Project, the A2Z Child Blindness Programuses competitive grants to reduce child blindness andimprove eye health. Grants provide support to NGOsto deliver services to populations in need. The goalsof the program are to:

• Expand delivery of high-impact direct services,including screening, treatment, education andrehabilitation;

• Scale-up innovative approaches to service provi-sion and program implementation; and,

• Contribute to the global knowledge base oneffective approaches to large-scale child eyehealth programs. Managed by the Academy forEducational Development (AED) since 2005, theA2Z Child Blindness Program has awarded 32grants to 23 organizations working in 25 coun-tries across Latin America, Asia, and sub-Saharan Africa. In 2008, a new grant award cat-egory – Refugee Service Delivery – was intro-

duced to fund initiatives which deliver compre-hensive eye care services for children and fami-lies in refugee populations. Given their long-standing experience working with vulnerablepopulations worldwide, the Inter national RescueCommittee (IRC) received two grant awards inAugust 2008 to support their efforts in Thailandand Kenya. The following case study provides anin-depth look at IRC’s experience and impactalong the border of Thailand and Burma.

The Border Eye Program: Restoring sight andexpanding services

The IRC has provided assistance to Burmeserefugees since 1990, though the Thailand programhas been operating since 1976 (initially assistingother groups of refugees – Cambodia, Laos andVietnam). Eye care services have been provided tothis population since 1997 through the Border EyeProgram. This is the only source of eye care servicesfor the estimated 134,401 refugees that currently livein the nine camps along the border of Thailand andBurma.

Health care in camps is provided by various inter-national agencies that train, equip and superviserefugee health workers who staff health outposts,clinics and inpatient departments. The Border EyeProgram trains and equips refugee health workers toprovide basic eye care, dispense simple eyeglasses,and facilitate cataract surgery so that the level of eyecare is compatible with and integrated into therefugee health care system. The program also workswith Karen Aid, a small private UK charity, to pro-vide cataract and other eye surgery to this population.

An estimated 2 million Burmese migrants, bothregistered and undocumented, are living outside ofrefugee camps in Thailand, and more than 500,000internally displaced persons (IDPs) are living in east-ern Burma. The Border Eye Program reaches part ofthese populations by providing services through the


IRC Border Eye Program

Mae Tao Clinic, which offers var-ious medical, health education andsocial services to migrant workersresiding in or around the Mae Sotarea. The Clinic also attracts anumber of IDPs and other patientsfrom Burma, where access tohealth services is limited. More -over, the program offers mobileeye care services to Thai villagesclose to the camps, conductingscreenings and providing eye-glasses.

The main objective of theBorder Eye Program is to restoresight by providing more than10,000 eyeglasses annually, andfacilitating 500 cataract surgerieseach year.

IRC’s approach: Capacitybuilding to strengthen localservices

IRC’s Border Eye Program focuseson training refugee health workersin basic refraction skills to conductexaminations and provide ready-

made eyeglasses in IRC-supportedeye clinics located in each refugeecamp and at the Mae Tao Clinic.The program coordinates its workwith the NGOs and refugee healthorganizations responsible forhealth services in each camp. Eyeclinics are open one to two days aweek in the refugee camps, andevery day in the Mae Tao Clinic.Patients attending eye clinics areoften self-selected, or referred byhealth clinics if a surgical problemor refractive error is suspected.

One innovative element of thecurrent program is the initiation ofstandardized vision screenings atschools in each camp. Health work-ers coordinate with camp adminis-trators and schools to train a groupof teachers to conduct the tests,with the aim of ensuring students inall 64 schools in the nine camps arescreened over a two-year period.Schoolchildren who fail the screen-ing are referred for further exami-nation at the eye clinic and are pro-vided eyeglasses as needed.

The program also provides eyesurgery to cataract and other sur-gical candidates identified in theeye clinics. Candidates who areregistered for possible eye surgeryare prioritized according to theseverity of their vision loss. IRChas a long-standing collaborationwith Karen Aid, which now sendsa team of eye surgeons to the bor-der three to four times a year. IRCfacilitates visits by providinglogistical support and IRC-trainedhealth workers from the eye clin-ics assist with pre-operativepreparations, surgery, and post-operative follow-up. Health work-ers conduct next day, day four,and six week check-ups. The sur-gical team typically deals withcataract problems, but also treatspatients with glaucoma and otherconditions that may require sur-gery. Referrals outside the campare arranged for congenitalcataract cases (involving chil-dren).

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Eye examination


65

Evolution of the program model

IRC has implemented the Border Eye Program since1997, when camp-based eye clinics and the provisionof primary eye care and basic refraction training forhealth workers were first introduced. Distribution ofeyeglasses began in 1998, and between 1998 and2001, eye clinics were established in each refugeecamp. A working relationship was established

between IRC and a surgical team from the UK, withmedics trained to screen patients for eye surgery. Atthat time, an aim of the Border Eye Program was toaddress preventable forms of blindness, such as tra-choma. The program helped to deliver a series ofcommunity health education messages for promotingimprovement in sanitation and hygiene to control tra-choma infection. The program also emphasized theimportance of a nutritious diet in preventing vita-

A2Z Child Blindness Program

Overview

There are 45 million blind people living in the worldtoday. 269 million others are visually impaired. 1.4million of these people are children. Although theprevalence of blindness is lower in children, theyhave a lifetime of blindness ahead of them, which cansignificantly limit education and work opportunities.Although 80% of these cases can be prevented, curedor treated, 90% of blind and visually-impaired indi-viduals live in low-income countries where compre-hensive eye care services are limited or nonexistent.Managed by AED since 2005, the USAID-fundedA2Z Child Blindness Program works with US andinternational NGOS to improve and expand eye careservices in Latin America, sub-Saharan Africa, andAsia. To date, the A2Z Child Blindness Program hasawarded 32 grants to 23 organizations deliveringquality eye care services in 25 countries.

The goals and priorities of the CBP are to:

• Expand delivery of high-impact direct services(including screening, treatment, and rehabilita-tion)

• Scale-up innovative approaches to service provi-sion and program implementation

• Contribute to the global knowledge base on effec-tive approaches to large-scale child eye healthprograms

Primary interventions include eye health educa-tion, vision screening, provision of eye glasses, sur-gery and other treatment, rehabilitation services, andcapacity-building of health workers and community-members.

Results

The A2Z Child Blindness Program collects dataacross 16 service delivery indicators. As of June2009, grant-funded activities have contributed to thefollowing results:

• More than 13,000 health workers, volunteers, andcommunity members trained to screen for basiceye conditions

• Nearly 2 million children screened for eye condi-tions

• More than 75,000 referrals by screening for addi-tional services and advanced consults

• 23,000 eyeglasses provided to correct refractiveerror in children

• 2,500 cataract operations provided• Additional 39,000 medical (non-surgical) proce-

dures provided to treat eye conditions

In addition to these results, grant recipients haveled advocacy efforts worldwide to shed light on eyecare as a global health concern and to increase edu-cational opportunities for blind and low vision chil-dren.

Contact

For additional information on the A2Z ChildBlindness Program, please contact:Roshelle Payes, A2Z Child Blindness Manager A2Z:The USAID Micronutrient and Child BlindnessProject AED, 1825 Connecticut Ave, NW,Washington, DC 20009Tel: 202-884-8071Fax: [email protected]

SIGHT AND LIFE IRC Border Eye Program

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min A deficiency. Incidence of trachoma infectionand vitamin A deficiency were significantly reduced,and ongoing vitamin A duties have been handed overto the border-wide nutrition program.

Since 1999, the focus of the program has increas-ingly shifted towards restoring sight and furtherdeveloping the work of eye clinics, including pilot-testing the provision of services to children. Closecollaboration with Karen Aid enables more frequentvisits by the surgical team, increasing the surgicalcapacity of the program. The program also began totarget rural Thai villages in collaboration with theMinistry of Public Health, dispensing eyeglasses fora small fee ($3 per pair). This effort contributes toincreasing acceptance in the Thai community for the

many Burmese migrants and refugees livingamongst them.

Activities implemented under the A2Z/USAIDgrant reflect the continuation and expansion of theapproach established during previous phases of theprogram. For example, funding has facilitated theintroduction of school screenings in all refugeecamps, enabling systematic identification of childrenwith vision problems. The program’s aim of restor-ing sight through improving the quality of eye carevia provision of eyeglasses and cataract surgery con-tributes to IRC Thailand’s objective of strengtheningthe quality of health care services available to dis-placed persons. Working in partnership with MaeTao Clinic to service the eye care needs of BurmeseIDPs aligns with a broader goal of ensuring partnersprovide effective, documented and well-coordinatedhealth support to vulnerable populations from east-ern Burma.

Program achievements

Since the commencement of the USAID-fundedproject in August 2008, IRC’s Border Eye Programhas provided resources (diagnostic equipment, sup-plies and eyeglasses) for eye clinics in all nine

refugee camps and the Mae Tao clinic. It hasscreened 14,492 schoolchildren in two refugeecamps, with 724 children referred for further exami-nation, and 152 children provided eyeglasses.Overall, 8,375 eyeglasses have been provided toadult patients in the nine camps, the Mae Tao Clinic,and through a mobile eye clinic servicing Thai vil-lages in border areas. 670 surgical operations havebeen completed during three visits from Karen Aid,comprising 204 patients across five refugee campsand 466 patients in the Mae Tao Clinic. The programhas also trained an additional 52 health workers towork in the eye clinics.

Border eye program results:August 2008–June 2009

Result Total Health workers trained in basicrefraction skills 52Schoolchildren screened 14,492Schoolchildren referred for examination 724Number of eyeglasses providedto schoolchildren 152Eyeglasses provided to adultpatients 8,375Adults whose significant refractiveerror is corrected 1,033Adults who have received cataractsurgery 591Adults who have received surgeryfor an eye condition otherthan cataract 79

Dr Frank Green, an eye surgeon who has been vis-iting the Thai-Burma border region for almost 20years, says “without the training the Border EyeProgram provides to the many medics and clinicsthey run, there would be no system of detection ofeye disease amenable to our surgical treatment.”Dr Green and the other surgeons use their annualleave to undertake the visits, lasting 1–3 weeks,with support and encouragement from family. Hesays “I regard this work as a great privilege and ablessing in my life.”

Health workers' training


67

The Border Eye Program was the first healthprogram to collaborate with all health NGOsworking in the Burmese refugee camps along theThai-Burma border. This unique approach extend-ed the reach of the program and increased aware-ness of the difficulties faced by those sufferingfrom visual impairment.

Challenges, setbacks, and lessons learned

An imminent challenge faced by the Border EyeProgram is that implementation of activities is occur-ring in the context of large-scale resettlement ofBurmese refugees to third countries, such as theUnited States. A disproportionate number ofrefugees being resettled are skilled and experiencedhealth workers. All camp-based programs face therisk of insufficient numbers of trained staff. Thisissue is particularly important for the Border EyeProgram given the central role performed by eyeclinic staff. According to a recent assessment of eyeclinics in the nine camps along the Thailand-Burmaborder, a majority of medics plan to resettle or arecurrently going through the resettlement process. Toaddress potential shortfalls, 52 health workers(including 41 camp-based staff), have received train-ing through the Border Eye Program in recentmonths. This figure is more than double the numberoriginally envisaged for the first year of activity.

Another notable challenge faced by the programhas been bringing together camp-based staff for jointtraining in a single location. Generally, camp resi-dents are not allowed to leave the camps, whichmeans that individual training – a more time consum-ing and costly exercise – has to take place in eachcamp. Successful advocacy with the Thai govern-ment has enabled staff to overcome this challenge,and camp-based health workers from five differentcamps were recently granted permission to travel forgroup training in Mae La camp. The program alsofaces the challenge of accessing remote camps dur-ing extended rainy seasons, and depending on thepolitical situation in Burma, the possibility of anincrease in camp populations.

The Border Eye Program is experiencing anincreasing demand for eye care services at the MaeTao Clinic, where a cost recovery model is beingpiloted in selected paying cases. The increased tech-nical capacity to provide the exact prescription need-ed requires an upgrade of the technical skills andequipment in the Clinic. In addition, achieving a sus-

tainable approach for providing and selling eyeglass-es to rural areas of Thailand near the border is neces-sary to enable the Ministry of Public Health to fullyincorporate services into the health care system.

Way forward

As the Border Eye Program enters its second year ofUSAID funding, the program will continue to roll outschool vision screenings in the remaining camps, andthere will be further visits by the UK surgical team torefugee camps and the Mae Tao Clinic.

Long-term, local capacity will be further strength-ened, with a camp-based medic currently goingthrough the process of being trained in basic cataractsurgery. It is expected that more local medics couldbe trained in the future. Nay Hser, the eye medic incharge at Mae La camp selected to receive the sur-gery training, says, “It is huge challenge in my life. Ihope that after I complete this course I will be able tohelp people not just in the camp but also in Karenstate, my homeland.”

Further, as ready-made eyeglasses do not fullycorrect vision in all cases, IRC is considering a rangeof options to provide astigmatic correction in thelong term, including developing a local lensedging/fabrication center at Mae Tao Clinic.

Key informants expressed the desire for servicesto be expanded so that, for example, eye clinics incamps could be open on a daily basis, and extend therange of services offered. The program would like toexpand to focus on blindness rehabilitation and relat-ed needs in the future.

For more information on the IRC’s work inThailand please visit http://www.theirc.org/where/Thailand. For more information on A2Z: TheUSAID Micronutrient and Child Blindness Program,please visit us on the web at www.a2zproject.org orvia email at [email protected].

SIGHT AND LIFE Reader Survey

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SIGHT AND LIFE Magazine Reader Survey

Almost 71% of readers find the SIGHT AND LIFEMagazine that you are currently reading very interest-ing and 85% read it to get useful information relevantto their work! Good news from our recent reader’ssurvey, which was undertaken to ensure that theMagazine remains relevant and adds value to thoseworking in the fascinating field of micronutrients.The Magazine is one of the core activities of SIGHTAND LIFE and aims to disseminate, as widely as pos-sible, the latest information on micronutrients: fromscientific findings, to events, to who’s who and whois doing what. And just as the survey tells us what youthink about the Magazine, it also tells us about you:

• Almost 60% have at least a Masters degree andare aged between 30 and 50 years. Yet some 14%have high school or college experience, whichshows that the Magazine reaches a wide targetaudience and we need to meet a variety of needs(Figure 1);

• 42% are based in Africa and 35% in Asia; • the majority work for non-governmental organiza-

tions (NGOs) (35%) and universities (28%)(Figure 2);

• 67% have been reading the Magazine for morethan 3 years and almost half for more than 5 years;

• and not surprisingly the majority work in the fieldof nutrition (62%) and health (68%).

Despite great diversity amongst our readership, theMagazine manages to be relevant to the work of mostof the respondents (84.7%) and is viewed as a valu-able source of information to update knowledge forabout two thirds of them. Some 45% use it in theirteaching and almost 40% believe it assists them withnetworking (Figure 3).

Half the respondents state that the Magazine is the‘most important’ or a ‘very important’ source ofinformation for their work and 38% consider it their‘preferred source’ of information. This might bebecause some 70% find the articles ‘very interesting’,feel that the focus is good and find the articles neithertoo long nor too short. However, just over 1 in 4

respondents, especially those working in the NGO,private and government sectors, state that theMagazine is too technical and in terms of content thegreatest negative expressed is that it is too diverse andthe articles are too long rather than too short. Thisagain highlights the wide range of needs of our read-ers, but we will continue to strive to meet as many ofthem as possible.

Of interest is that the Magazine is the preferredsource, if not the only source, of relevant informationon micronutrients for many of our readers. One outof four readers from NGOs stated that the SIGHTAND LIFE Magazine was nearly their only source ofinformation and this was also noted, although to alesser extent, amongst governmental organizationsand UN agencies.

For a large proportion of our readers, theMagazine also remains a useful bridge to keep up todate with SIGHT AND LIFE’s activities, especially

Figure 1: Educational background

PhD, DrPH, MD or equivalent 31.4%

Master’s degree 27.7%

Bachelor’s degreee 17.6%

High school or some college experience 13.6%

Other 9.7%


Magazine Issue 3/2009Reader Survey

69

amongst those working in NGOs, where 70% consid-er the Magazine as a source of information on pro-grams supported by SIGHT AND LIFE.

Figure 4 gives an indication of how readers feelabout the different sections of the Magazine andshows a particularly high interest in the scientificarticles – 95% rating this section as being of high andmedium interest – so not surprisingly almost half therespondents felt that the Magazine could includemore scientific articles. The project reports and newssections were also highly rated and it is interesting tonote that even when sections were not rated as beingof ‘high interest’, the majority are certainly of ‘medi-um interest’, which confirms that readers value theMagazine covering more than just the science andhighlighting the role it plays in keeping people up-to-date with the broader micronutrient field. TheSIGHT AND LIFE Magazine is unique in offeringthe broadest range of topics and article types in themicronutrient field which undoubtedly adds to itsappeal amongst our readers.

In addition to its interest, 59% felt that the contentis objective and impartial while 34% stated that itwas neither impartial nor biased. We assure you thatimpartiality is a key objective and we will alwaysattempt to ensure it stays that way – if you feel wearen’t achieving this goal in any way or in any arti-cle, let us know by writing a letter to the editor.

We also received unanimous support for theMagazine remaining available in the printed versionbut also having it electronically on the website isappreciated. Eighty percent of readers expressedtheir interest in receiving email notification when thelatest electronic edition is available and, as perhapscould have been expected, half of the readers inEurope and North America would be satisfied to justreceive email notification when the latest edition ofthe Magazine is available on the website, and wouldread the Magazine online. This might assist us inmanaging costs, especially as although 42% statedthat they would be prepared to pay for the Magazine,many of our readers state that they cannot afford tobuy it and we wish to continue to offer it as a freeresource for as long as we can, knowing its value toour readers, especially in the developing world – afact highlighted in the survey.

Topics that are repeatedly named as being impor-tant to our readers are HIV/AIDS, immunity andinfection, food based approaches and agriculture andfood security, and there is interest expressed in theMagazine covering practical issues such as the appli-cation of new science and insights and lessons learntfrom programs. It would seem that our readers alsoenjoy the visual and 66% of respondents would likemore visual elements to accompany the articles and52% requested more photographs. We also appreciat-ed other suggestions that were made that included

Figure 2: Affiliation

Non-governmental organization (NGO) 34.1%

Education institution 28.5%

Governmental organization 13.6%

Private sector company 10.9%

Other (donor agency etc.) 10.1%

UN agency 2.8%

Affiliation

Figure 3: Value attributed

To get information relevant to my work.

To keep myself up to date.

To find out more about the programs supported by SIGHT AND LIFE.

For teaching.

For networking.

Other.

84.7%

68.4%

57.0%

44.5%

37.3%

7.1%

having a glossary of terms, providing abstracts or asummary highlighting the key findings/facts/conceptsof the articles and giving advance notice of trainingcourses and conferences – so watch this space! Just asthe SIGHT AND LIFE Magazine has evolved overthe years, we will continue to look at ways of increas-ing its value and take cognisance of the feedback ofour readers.

Thank you to the over 1,000 readers who respond-ed to the survey either online or by post - your viewsand feedback are much appreciated. We are alwayshappy to hear from our readers and encourage yourinputs to the publication, so feel free to write to uswith opinion pieces, let us know about events beinghosted in your part of the world or interestingresearch/projects and programs that you might beinvolved with. After all, the SIGHT AND LIFEMagazine belongs to our readers and we look forwardto many more years of fulfilling our role as definedby Saskia de Pee of the World Food Programme:SIGHT AND LIFE’s role as a bridge between scienceand programs is almost unique, very valuable andmuch needed.

SIGHT AND LIFE Reader Survey

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Figure 4: Rating of the sections

0

100

80

(%)

Scie

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ticle

s

60

40

20

Proj

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SectionHigh InterestMedium InterestNo or Low Interest

Did you know?

• For the more than 50% ofreaders who would like toalso have the Magazineelec tronically, visit www.sightandlife.org as theSIGHT AND LIFE Maga -zine is available onlinetogether with many of ourother resources.

• 85% of our readers sharetheir copy of the SIGHTAND LIFE Magazine withothers (half sharing it with2-5 people and 33% sharingit with more than 10 people),so if you don’t already, whynot pass your copy on whenyou have finished reading it!

• If you don’t want to passyour copy on, why not rec-ommend the SIGHT ANDLIFE Magazine to your col-leagues (they can subscribeonline), as that how 41% ofour readers got to knowabout it...

SIGHT AND LIFEMagazine Issue No 2/2009

Face-changer at 2nd Micronutrient Forum, Beijing2nd International Meeting of the Micronutrient Forum – Micronutrients,

Health and Development: Evidence-Based ProgramsThe 2nd International Meeting of the Micronutrient Forum, held in Beijing, China, from

May 12–15, 2009, brought together delegates from more than 90 countries, including

country-level program implementers and their partners, multi-laterals, donors,

researchers, and representatives of the private sector. Read the executive summary

from the Forum on pages 25, 34 and 57

Carotenoids, Retinoids andMetabolic SyndromeGood Start in Life Program inPeru

Filling the Gaps in Maraland

Iodized Salt Use in PakistanMicronutrient Forum: Executive SummaryMicronutrient Forum: Concluding RemarksCARIG ConferenceUGAN Conference

A Day in the Life

Selenium

News

Letters to the EditorPublications

Magazine Issue 3/2009News

71

NewsMicronutrientDeficiencies inWomen andChildren: Latest FindingsSymposium held at theInternational Conference onNutrition, Bangkok, Thailand,4–9 October, 2009

Micronutrient deficiencies are amajor, preventable public healthnutrition problem in the developingworld, affecting women of repro-ductive age and young children.Supplementation by a variety ofmeans offers a practical, directapproach to prevention across allage groups.

At a plenary session of the 19th

International Congress of Nutrition(ICN) held on 4–9 October, 2009,scientists researching micronutrient

supplementation summarized andshared their research findings andexperiences to date on the extent ofthe problem of micronutrient defi-ciencies around the world and theimpact of micronutrient supple-mentation on the status and healthof vulnerable population groups.

The session started with an intro-duction by the chair, KlausKraemer (Switzer land) who madereference to the Innocenti Process,which seeks to clarify the linksbetween evidence and programs.Juan Pablo Pena-Rosas (Switzer -land) then presented on the globalmagnitude of the most commonvitamin and mineral deficiencies(vitamin A, iron, iodine, zinc,folate), as recently updated by theWHO. Dr Pena-Rosas also des -cribed the WHO’s efforts toupgrade and expand its Vitamin andMineral Nutrition InformationSystem.

Tommaso Cavalli-Sforza (Phi -lip pines) spoke next on the effec-tiveness of weekly iron/folate sup-plementation in reducing the preva-lence of anemia in women of repro-ductive age, particularly before

pregnancy and during first tri -mester, followed by Parul Christian(USA), who highlighted the impactof antenatal iron-folic acid supple-mentation on pregnancy outcomesfor both mothers and their off-spring, in terms of immediate aswell as long term benefits. BarrieMargetts (UK) presented on a meta-analysis that found supplementationof pregnant women with 1 RDA ofmultiple micronutrients (MMN)increases birth weight and substan-tially reduces low birth weight andsmall-for-gestational-age (SGA)

births. There was an increased(23%), although not statisticallysignificant risk of early neonatalmortality in women taking MMN,which requires further research.Deanna Olney (USA) described astudy that found a significant posi-tive effect of multiple micronutri-ent supplementation on motordevelopment among children aswell as small but significantimprovements in length, height,weight, and hemoglobin, serumzinc and serum retinol status,though the effect on morbidity wasnot clear.

Saskia de Pee (Italy) presentedon the World Food Programme’s(WFP) experience in providingmulti-micronutrient powder (MNP)

Parul Christian (Johns HopkinsUniversity Bloomberg Schoolof Public Health)

SIGHT AND LIFEMagazine 3/2009 • Supplement

Micronutrients,Health and

Development: Evidence-

BasedPrograms

The 2nd InternationalMeeting of the

Micronutrient Forum

MICRONUTRIENT FORUM A2Z, the USAID Micronutrient and Child Blindness Project serves as theSecretariat for the Micronutrient Forum. A2Z is managed by the Academy for Educational Development (AED).

12–15 May 2009 • Beijing, China


at scale to WFP beneficiaries,including children, pregnant andlactating women, and refugees, andhow MNPs were found to reducemicronutrient deficiencies andimprove the nutritional quality ofcomplementary foods, especiallywhere there is a low intake of ani-mal-sourced and fortified foods,and where the prevalence of ane-mia and stunting is high. JacquesBerger (France) described theresults and experience of a school-based intervention in Viet Nam thatfound multi-micronutrient-fortifiedbiscuits, providing 50 per cent ofthe daily recommended intake ofiron, vitamin A, iodine, zinc andother essential micronutrients,reduced the prevalence of anemia,significantly improved iron stores,and enhanced deworming.

Michael Dibley spoke on a studyexamining the effects of startingmultiple micronutrient supplemen-tation early in pregnancy, whichfound that there was a significantincrease in birth weight when sup-plementation started earlier than 12weeks for both iron/folic acid andmultiple micronutrient supplemen-tation compared to folic acid alone.

Multi-micronutrient supplementa-tion reduced SGA, while iron/folicacid reduced low birth weight andearly preterm delivery (< 34weeks). Only iron/folic acid signif-icantly reduced early neonatal mor-tality.

Florentino Solon (Philippines)concluded the session sharing adeveloping country perspective

appreciative of the global efforts toestablish a rigorous evidence baseto support appropriate nationalpolicies and programs. He high-

lighted four key issues of interest topolicy makers: evidence of effica-cy, context (applicability to localsettings), priority (which interven-tion is more likely to have impact,which age group will benefit), andimplementation mechanisms (howthe government will fund it, whowill deliver it). The PhilippineDepartment of Health is currentlyrevising the country’s micronutri-

ent supplementation guidelines,based on the latest evidence, whichDr Solon said would be ready bythe end of 2009.

SIGHT AND LIFE News

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Fortified biscuits given to schoolchildren in Vietnam (GRET)

On 26 October 2009, SIGHTAND LIFE and DSM along withseven other Life Sciences compa-nies met over 90 students on theNatural Science Day in Zurich,Switzerland. Throughout the day12 students explored the possibil-ities of fighting “hidden hunger“and presented their results to allparticipants (fellow students andcompany representatives) in theafternoon before enquiring aboutcareer opportunities at the standsof the participating companies.

Sabine Zimmer (DSM Nutritional Products) discusses job opportu-nities with students

Magazine Issue 3/2009News

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Helen Keller InternationalReceived AntónioChampalimaud Vision Award

In September 2009, Helen Keller International(HKI) received the prestigious António Cham -palimaud Vision Award from the ChampalimaudFoundation, which is based in Lisbon. HKI was rec-ognized for our achievements in preventing blind-ness in the developing world, particularly ourefforts to find effective and sustainable means tocombat vitamin A deficiency (VAD).

The Champalimaud Foun dation, one of thelargest global science foundations in the world, ini-tiated the €1 million (US$1.4 million) Cham -palimaud Award in 2006. Since then, it has alter-nately been given for blindness prevention on theground and scientific research. The Award has thesupport of WHO’s VISION 2020 initiative, and hasbeen referred to as the “Nobel Prize for Vision” bythe former President of India, A.P.J. Kalam.

Giving the award to HKI has the potential tobring much-needed attention to the world-wideproblem of vitamin A deficiency. As those of uswho work to prevent vitamin A deficiency know,while the problem is widespread, the solutions thatexist are extremely cost-effective – we just need toget them into the hands of those who desperatelyneed them.

Working with partners, HKI currently offers vita-min A supplementation in 13 African countries and

5 Asia-Pacific countries. Our work is focused oncreating sustainable delivery systems that will reachmore than 80% of targeted children. Last year, 41million African children and 46 million Asian chil-dren benefitted from our programs.

The 2009 António Cham pali maud Award is atremendous honor for HKI, and we hope that thisnew attention will translate to even more childrenreceiving sufficient vitamin A and living happy andproductive lives.

Kathy Spahn (Helen Keller International)

Expert Panel Convened toAdvance Unified Advocacy onGlobal Problem of HiddenHunger

On the eve of the 2009 International Congress ofNutrition (ICN) in Bangkok on 5–9 October, 2009,SIGHT AND LIFE convened an expert consultation toadvance a unified advocacy strategy for includingessential micronutrients as part of commitments to alle-viate global hunger in all its forms. The meeting soughtto develop a shared framework for consistently com-municating issues on micronutrient malnutrition, or

hidden hunger, and start the process of mapping globalhidden hunger, in advance of the next World EconomicForum in Davos, Switzerland, in January 2010.

Given this ambitious goal, SIGHT AND LIFE invit-ed a panel of renowned experts in nutrition, publichealth, agriculture, development and related disciplinesto offer their opinions, insights and other contributions.Participating on the panel were high-level scientists,academics and decision makers from a range of globalinstitutions, including UN agencies, US governmentagencies, universities, and international NGOs.

The consultation has its roots in SIGHT AND LIFE’sefforts to develop an advocacy strategy to advance the

understanding of hidden hunger, specifically in light ofdeclarations by world leaders at the recent G8 and G20summits to commit resources toward global food secu-rity initiatives. SIGHT AND LIFE's Klaus Kraemercited growing attention in the lay media to the problemof hidden hunger and stressed the need to ensure consis-tent messages are communicated in order to maximizeawareness-raising and reduce potential confusion on theissue.

The panel drafted a working definition of hiddenhunger and discussed options for a hidden hunger glob-al prevalence map. These would be valuable tools foradvocacy around hidden hunger and visually depictingits impact. It was emphasized that the definition wouldspecifically be used for advocacy purposes, hence, itneeded to be broad and all-encompassing but simpleenough to gain buy-in from a wide range of non-tech-nical stakeholder groups. A more technical definition toguide specific programmatic actions would be devel-oped at a later stage.

The global hidden hunger map was agreed to be animportant tool for enhancing the current perception ofhunger with a broader understanding of the impact andreach of hidden hunger, which affects people in bothdeveloping as well as industrialized countries. Yet,many challenges remain in the development of such amap, particularly in relation to data availability, data

sources, indicators, cut-offs, risk groups, and overlap-ping data.

While the discussion was dominated by the technicalissues surrounding an agreed definition of hiddenhunger and left a number of issues open, an importantconversation had nonetheless been initiated that willcontinue among the expert panel. Highlighting thatadvocacy is as important as the science, Klaus Kraemer

underscored that, given the intensity of competitionbetween ideas and messages in the scientific communi-ty, the challenge is to develop broad consensus andconsistent messages that are endorsed and used by allorganizations working towards the eradication of hid-den hunger.

He concluded „Working together on advocacy, com-munications and science is the new horizon.“

SIGHT AND LIFE News

74

Martin Bloem (WFP), Keith West (JHU), Parul Christian (JHU), Kenneth Brown (UCD/HKI), KerrySchulze (JHU), Alain Labrique (JHU), Saskia de Pee (WFP), Akoto Osei (HKI), Lynette Neufeld (MI),Pieter Jooste (MRC), Klaus Kraemer (SAL), Sean Lynch (EVMS), Federico Graciano (SAL), ReginaMoench-Pfanner (GAIN), Salahuddin Ahmad (RMIT), Arnaud Laillou (GAIN), Jane Badham (SAL)


75


Dear Sir,

We are pleased to inform you that the Project Agencyfor Initiatives Promoting Sustainable Development(APRIDD) has successfully completed its distributionof vitamin A capsules (VACs) donated by SIGHTAND LIFE.

The distribution activities went very smoothly andaccording to plan. However, the demand for VACs byour partner health centers exceeded the quantity avail-able. We followed the example presented in yourDVDs carefully and are trying to imitate the programand the activities of Nutrimad in order to improve thenutrition of children in northern and southern Benin.To better meet the needs of children aged 0–5 yearsand promote a balanced diet, we have launched a cam-paign for the production and processing of local agri-cultural products (maize, groundnuts, soybeans, rice,

etc.) with the support of a partner, SEL France, whichhas allowed us to build mills and workshops to processagricultural products.

Considering the importance of our activities andprogram, we hope to be recognized among SIGHTAND LIFE’s partner organizations that are active inthe fight against malnutrition. Some of our work tocombat malnutrition, currently on hold, can continueto be implemented through further partnership withand support by SIGHT AND LIFE.

Communicated by: Nestor Tawaga, Executive Director, Project Agencyfor Initiatives Promoting Sustainable Development(APRIDD), BP 1061 Abomey-Calavi, Republic of BeninEmail: [email protected]


SIGHT AND LIFE Magazine 2009;3:75

Registration of the children receiving one vitamin A capsule

SIGHT AND LIFE Publications

76

Carotenoids Volume 5: Nutrition and Health

Britton G, Liaaen-Jensen S, and Pfander H (eds.).Carotenoids Volume 5: Nutrition and Health. Basel:Birkhäuser, 2009. ISBN: 9783764375003.

This final volume of the Carotenoids book series –which details the fundamental chemistry ofcarotenoids, basic methods used in its research, andcritical discussions of its biochemistry, functions andapplications – focuses on carotenoids in human healthand nutrition.

The era of ‘functional foods’ began with the identi-fication of chemical components of foods as importantmicronutrients. Carotenoids have featured highlyamong such micronutrients. Volume 5 traces thecarotenoid story from food to biological actions, fol-lowing on from the foundation provided in its compan-ion Volume 4 on the fundamental properties of

carotenoids. Other vol-umes in the series alsoprovide key informationrelevant to studies ofbiological functions andactions.

Volume 5 consistsof three parts. Part 1,on nutrition, coverscaro tenoids as dietarysources and supple-ments as well as theirbioavailability. Part 2discusses the actionsof carotenoids andpractical approachesthat are beneficial tohuman health, likeepidemiology andintervention trials,in vitro studies,

and studies of anti-oxidant and pro-oxidant effects.Part 3 describes the protective effects of carotenoidsagainst diseases, like cancer, coronary heart disease,and eye and skin diseases, and effects on the immunesystem.

Written for a target audience of researchers, clini-cians, scientific libraries, food industry, biotech indus-try and pharmaceutical industry, Carotenoids Volume5 is a coordinated, integrated treatment providing up-to-date and critical research surveys by leading author-ities in the field, and incorporating some backgroundmaterial to help make the chapters accessible to non-specialist readers.

For more information, please visit the website ofthe publisher, http://www.springer.com/chemistry/book/978-3-7643-7500-3.

Nutrition: A Lifespan Approach

Langley-Evans S. Nutrition: A Lifespan Approach.Oxford: Wiley-Blackwell, 2009. ISBN:9781405178785.

Nutrition has arisen from many older establisheddisciplines to become an active entity in its own rightand is now rightly at the forefront of modern under-standing of health and disease. Interest in nutrition hasincreased exponentially since the early 1990s and it isnow recognized as a key element in the training of allhealth professionals.

One of the main challenges for the modern nutri-tionist is to translate complex scientific concepts intosimple advice about food and health that can be under-stood by the lay public. Nutrition textbooks have tradi-tionally divided human nutrition into basic science,public health and clinical nutrition; however, inNutrition: A Lifespan Approach, Simon Langley-Evans spans these divisions, bringing together the full


PublicationsEditor’s note: SIGHT AND LIFE reviews recent publications whichmay be of particular interest to our readers. However, no publicationsother than SIGHT AND LIFE publications are available from us, nordo we have any privileged access to them.

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range of disciplinesinto one accessiblebook through thelifespan approach.Taking the readerthrough how thebody’s demandfor nutrients con-tinues to changeacross the manystages of life,such an approachallows full con-sideration of howdiet relates tohealth, wellbe-ing and disease

and provides an excellent vehicle toillustrate the key concepts in nutrition science.

Nutrition: A Lifespan Approach is an importantresource for undergraduate students of nutrition aswell as those studying or working in areas such ashuman biology, health studies and sports science,where an understanding of human nutrition is required.

For more information and additional resources,please visit the book’s website,http://www.wiley.com/go/langleyevans.

Introduction to Human Nutrition, Second Edition

Gibney MJ, Lanham-New SA, Cassidy A, andVorster HH (eds.). Introduction to Human Nutrition,Second Edition. London: The Nutrition Society,2009. ISBN: 9781405168076.

The Nutrition Society Textbook Series started 10years ago as an ambitious project

to provide undergradu-ate and graduate stu-dents with a compre-hensive suite of text-books to meet theirneeds in terms of refer-ence material for theirstudies.

This textbook isdesigned to provide anintroduction to humannutrition for students and

professionals in related disciplines. Those who go onto study human nutrition will also be introduced to themany areas of diet and health that can be studied ingreater depth in other Nutrition Society series text-books. Besides the basic biology, readers are intro-duced to the concept of food policy and to the dualchallenges to the global food supply, i.e., over- andunder-nutrition.

The study of human nutrition at universities acrossthe globe is rapidly expanding as the role of diet inhealth becomes more evident. This second edition ofthe book has been revised and updated to meet theneeds of the contemporary student. Introduction toHuman Nutrition is an essential resource for studentsof nutrition and dietetics, and also for those studentswho major in other subjects that have a nutrition com-ponent, such as food science, medicine, pharmacy andnursing. Pro fessionals in nutrition, dietetics, food sci-ence, medicine, health sciences and many relatedareas will also find much of great value within its cov-ers.

For more information, please visit the NutritionSociety’s website, http://www.nutritionsociety.org, orthe publisher’s website, http://as.wiley.com.

Nutrition Through the LifeCycle, Third Edition

Brown JE. Nutrition Throughthe Life Cycle, Third Edition.Florence: Wadsworth, 2008.ISBN: 9780495116370.

One of the most respectednutrition life cycle texts inthe higher education market,Nutrition Through the LifeCycle, Third Edition usescurrent research to explainthe nutritional foundationsnecessary for the growth,development, and normalfunctioning of individuals in each stage of the lifespan. From preconception to the final stages of life,this text covers clinical and nutritional interventionsfor each part of the life cycle.

The book is organized systematically, with clinicalnutrition topics following normal nutrition topics. Itmaintains a consistent level of pedagogy throughout,highlighting key nutrition concepts, nutritional needs,

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nutrition and health disease outcomes, model pro-grams, and case studies.

Knowledge about nutrition and health through thelife cycle is advancing remarkably. New research istaking our understanding of the roles played by nutri-ents, nutrient-gene interactions, body fat, physicalactivity, and dietary supplements to new levels.Recom mendations for dietary and nutrient supple-ment intake and for physical activity in health and dis-ease are changing due to new insights.

This third edition of the book incorporates emerg-ing areas and updated information of direct relevanceto nutrition. Additionally, this edition highlights keypoints at the end of each chapter; it includes ‘InFocus’ boxes that provide background information onthe major conditions and disorders addressed in thevarious chapters throughout the book; provides addi-tional case studies, tables, illustrations, margin defini-tions, and headings have been added to chapters; andlists updated Web and other resources, includinginteractive and streaming media sites, and newlydeveloped nutrition education and information sites.

For more information, please visit the publisher’swebsite, http://www. cengage.com.

Community Nutrition in Action: AnEntrepreneurial Approach, Fifth Edition

Boyle MA and Holben DH. Community Nutrition inAction: An Entrepreneurial Approach, Fifth Edition.Florence: Wadsworth,2009. ISBN:9780495559016.

With the idea of social in -novation becoming in creas -ingly important in nutritionand development efforts,Community Nutrition inAction: An Entre pre neurialApproach, Fifth Edition pro-vides an important resourceto professionals, researchersand students in this field. Thistextbook introduces the pro-gram planning, policies, re -sources, and nutrition issuesspecific to community nutri-tion and provides an understanding of the developmentand implementation of nutrition programs among var-

ious constituencies (e.g., elderly populations, children,impoverished populations, college students).

Successful practitioners in community nutritionhave proven to have a mind and skill set that opensthem up to new ideas and ventures. Incorporating anentrepreneurial approach, this book helps readers learnhow to take risks, try new technologies, and use freshapproaches to improving the public's nutrition andhealth status. The book also delivers the core materialimportant to those who will be active in solving com-munity nutritional and health problems, including pro-gram delivery, nutrition education, nutrition assess-ment, and planning nutrition interventions.

The book is organized into three sections. SectionOne shows the community nutritionist in action withinthe community. Section Two describes current US fed-eral and non-governmental programs designed to meetthe food and nutritional needs of vulnerable popula-tions. Section Three focuses on the tools used by com-munity nutritionists to address nutritional and healthproblems in their communities.

For more information, please visit the publisher’swebsite, http://www.cengage.com/wadsworth.

Community Nutrition: A Handbook for Healthand Development Workers

Burgess A, Bijlsma M, and Ismael C. CommunityNutrition: A Handbook for Health and DevelopmentWorkers. Oxford: Macmillan Education, 2009. ISBN:

9780230010635.

Written in an easy to read style andgenerously illustrated, CommunityNutrition: A Handbook for Health andDevelopment Workers was written forhealth and other development profes-sionals working at community and dis-trict levels as well as for teachers andstudents of nutrition. It provides accu-rate, reliable and relevant informationbased on established internationalguidelines.

Covering the basics, such as nutri-ents and foods, feeding the family,and the causes, diagnosis and controlof malnutrition through the life cycle,

the book delivers insights on undernutrition andmicronutrient deficiencies. In particular, it brings

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attention to the em ergingchallenge of chronic condi-tions (such as diabetes, obe-sity, hypertension and car-diovascular diseases) and tothe links between nutritionand HIV.

The book not only deliv-ers on theory and science, italso gives guidelines onprogram implementationand changing behaviorthrough better communi-cation. There are appen-dices on energy and nutri-ent needs, sources of nutrients, food compositiontables and anthropometric measurements as well as a

list of recent materials and other sourcesof information.

The book is available from:

• Teaching-aids At Low Cost (TALC)www.talcuk.org and [email protected] UK£5.50 plus distributioncosts;

• African Medical and ResearchFoundation (AMREF) bookshop, POBox 30125-00100, Nairobi, Kenyahttp://www.amref.org/info-centre [email protected];

• Macmillan Education, BetweenTowns Road, Oxford OX4 3PP, [email protected] andthrough good bookshops.

NEW + NEW + NEW + NEW + NEW

Special Supplement Impact of climate change, the economic crisis and the increase in foodprices on malnutrition

It cannot be ignored; the global food supply system is facing serious new challenges as a result of both theeconomic and related crises and climate change. These directly affect the nutritional well-being of the poor,by reducing their nutrition security together with their food security. Diet quality and eventually diet quan-tity decline and this exacerbates the vulnerability of the already vulnerable, who find themselves fast-tracked along the downward spiral of malnutrition and poverty. These shocks lead to nutrition insults thathave the greatest impact on infants and children – negative effects that persist into their adult life. So whilethe crisis itself might appear to be relatively short lived, the effects last through generations.

Following a meeting hosted by SIGHT AND LIFE at Castel Gandolfo, Italy, in early 2009, a set of 17papers will form a supplement entitled, ‘Impact of climate change, the economic crisis and the increase infood prices on malnutrition’, in the January edition of the Journal of Nutrition, but are already available onthe ‘Articles in press’ section of the journal website http://jn.nutrition.org/

This unique supplement, the first to address the impact of the triple crisis on malnutrition, covers an exten-sive range of topics from the importance of safety nets and the need for nutrition surveillance systems, tothe impact on child mortality and the role of complementary food supplements. The series includes an edi-torial comment by David Nabarro, Special Representative of the United Nations on Food Security andNutrition.

So while the world continues to focus its attention on the direct environmental effects of climate changeand the pain of the economic recession continues to be felt, the 2 billion suffering from micronutrient mal-nutrition (hidden hunger) remain largely neglected and yet their plight is likely to have the most devastat-ing long term effect. The time for action and the up-scaling of programs is NOW.

Colophon

SIGHT AND LIFE Magazine Incorporating the XerophthalmiaClub Bulletin

Publisher: SIGHT AND LIFEEditor: Klaus KraemerEditorial team: Jee Rah, Anne-Catherine Frey,Svenia Sayer-Ruehmann,

Communication consultancy andtext writing: Frederico Graciano,Jonathan Steffen

Layout and graphics: GAS - graphic art studio,Grenzach-Wyhlen

Printer: Burger Druck, Waldkirch

Language services:transparent, Berlin

Opinions, compilations and figurescontained in the signed articles donot necessarily represent the pointof view of SIGHT AND LIFE andare solely the responsibility of theauthors.

SIGHT AND LIFEDr Klaus KraemerSecretary GeneralPO Box 21164002 Basel, SwitzerlandPhone: +41 61 815 8756Fax: +41 61 815 8190Email: [email protected]

ISBN ISBN 978-3-906412-57-3

SIGHT AND LIFE is a humanitarian initiative of DSM

Photo credits: Janice Carr, Content Providers(s): CDC/ Dr. Patricia Fields, Dr. Collette Fitzgerald, page 16, 17Martin Malungu, page 31

Documents

SIGHT AND LIFE · SIGHT AND LIFE Magazine Issue N o3/2009 Elderly woman in Micronesia Micronutrient Status, Immune Response and Infectious Disease in Elderly of Less Developed Countries