Trends in Food Science & Technology 31 (2013) 55e62

Review

Micronutrient
deficiencies in South found among school-age children and adolescents in
Bangladesh and Sri Lanka. Vitamin D deficiency (VDD)

Asia e Current status

and strategies
Saeed Akhtara,*, Tariq Ismaila,
Sunethra Atukoralab and
N. Arlappac
a
Department of Food Science & Technology,
Bahauddin Zakariya University, Bosan Road, Multan
60800, Pakistan (Fax: D92 619270098; e-mails:
saeedbzu@yahoo.com; saeedbzu@hotmail.com)
b
Department of Biochemistry & Molecular Biology,
Faculty of Medicine, University of Colombo,
Colombo, Sri Lanka
c
Division of Community Studies, National Institute of
Nutrition, Indian Council of Medical Research,
Tarnaka, Hyderabad 500 007, India
This article provides a comprehensive review of the extent of
prevalence of micronutrient deficiencies (vitamin A & D,
iron, zinc and iodine) among different population groups in In-
dia, Pakistan, Bangladesh and Sri Lanka. The article also covers
several health implications associated with these deficiencies,
their economic impact and numerous strategies to combat this
issue in low income South Asian countries. An extensive
computer-based bibliographic review of the literature was per-
formed via PubMed, Web of Science, Scopus, and Google
Scholar by using keywords “micronutrients”, “vitamin A and
D”, “iron”, “zinc”, “iodine” and “South Asia”. Data were iden-
tified under various sections and the most relevant full-text ar-
ticles and abstracts were selected and screened for inclusion in
this review. The results indicate that micronutrient deficiencies
are widely prevalent in these regions and are now a significant
public health problem. Preschool-age and school children,
pregnant women and women of childbearing age are at the
risk of these deficiencies. Vitamin A deficiency (VAD) was
* Corresponding author.
0924-2244/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.tifs.2013.02.005
seemed to affect 84% of pregnant women in India, 70% of
healthy volunteers in Pakistan, 26% of male children in Sri
Lanka and 8% of children in Bangladesh. Data illustrate that
iron deficiency anemia (IDA), zinc and iodine deficiency affect
all population groups, suggesting immediate measures to be
taken to address the issue. Restricted dietary intake of these
nutrients associated with a number of socioeconomic con-
straints exacerbates the problem of micronutrient malnutrition.
Dietary diversification, food fortification and supplementation
are the pragmatic and recommended approaches to overcome
these nutritional deficiencies. However, the goal to virtually
eliminate micronutrient deficiencies in these poorer societies
demands a series of well integrated actions at all levels.
Introduction
Recent estimate shows that 870 million people, constituting
12.5 percent of the global population, are undernourished
and 852 million of these live in the developing countries.
Global estimates of undernutrition among children under
5 years of age suggest that 178 million children are stunted,
while wasting is reported among 55 million children
(Bhutta & Haider, 2008; Ejaz & Latif, 2011; FAO, 2012;
Khor, 2005; WHO, 2004). Deficiencies of iron, iodine,
vitamin A and zinc have been more damaging and predom-
inantly affect pregnant women, women of reproductive age,
infants and children below 5 years of age and adolescents
especially those belonging to developing countries. In
particular, vitamin A, iron and iodine deficiencies have
been recognized as public health problems in many Asian
countries, while precise national data on prevalence of
vitamin D and zinc deficiencies are not available in many
developing countries. Despite many efforts to reduce the
proportion of children, suffering from malnutrition in
developing countries, it still continues to affect a large
number of children resulting in poor health, low cognitive
performance and productivity.
Moderate to severe deficiencies of iron and zinc affect
growth, cognitive and reproductive performance and pro-
voke pregnancy complications, leading to low birth weight
and birth defects. Health implications associated with VAD
include xerophthalmia (night blindness and Bitot’s spots),
eventually resulting in the development of corneal xerosis,
corneal ulceration and keratomalacia. VDD results in
56 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
rickets and osteomalacia and is also considered a major risk
factor for cephalopelvic disproportion (Haskell & Brown,
1999; Seshadri, 2001; Sommer, 1995; Talat, Perry,
Parsonnet, Dawood, & Hussain, 2010).
Micronutrient deficiencies continue to be a major public
health problem in India, Pakistan, Bangladesh and Sri
Lanka. Estimated economic cost associated with micronu-
trient malnutrition in India accounts for 0.8%e2.4% of
the GDP (OMNI, 2005; Stein & Qaim, 2007; UNICEF,
2008; Vijayaraghavan, 2002). Similarly, micronutrient defi-
ciencies are widespread in Pakistan and pregnant women
constitute the most vulnerable group. Maternal undernutri-
tion and intrauterine growth retardation have been poten-
tially associated with these deficiencies (Bhutta et al.,
2009).
Undeniably, micronutrient deficiencies hamper produc-
tivity and economic growth and provoke poverty by reducing
physical work capacity, loss of cognitive development and
school absenteeism. Economic cost of micronutrient defi-
ciencies is reported to involve billions of dollars and this
cost is aggravated in the developing countries where this sit-
uation seems to prevail for an unknown length of time. Pre-
dictably, malnutrition in South Asian developing societies
will paralyze the entire health and economic infrastructure
if corrective measures are not taken in a timely manner.
Micronutrient deficiencies in South Asia
Child malnutrition in South Asian developing countries
particularly in India, Pakistan and Bangladesh has been
the highest in the world and is a substantial barrier to eco-
nomic growth and wellbeing of these communities. Poverty
is severely prevalent in these regions and is an underlying
cause of child undernutrition. Deficiencies of vitamins A
and D, iron, iodine and zinc in these countries exacerbate
the disease burden resulting in multiple health implications
and higher mortality.
Vitamin A deficiency (VAD)
Global estimates show that one third of world’s pre-
school-age population suffers from VAD and the popula-
tions from South Asian developing countries are the most
vulnerable groups. Around 44e50% preschool-age children
are severely affected by VAD and 1 to 2 million pregnant
women have been reported to die of childbirth-related com-
plications (Kaleem, 2004; WHO, 2009).
India has the largest number of vitamin A deficient chil-
dren in the world (World Bank, 2005). Nearly, 62% of
preschool-age children in India are deficient in vitamin A
(Laxmaiah et al., 2011; MI, 2012a). Diets of rural
preschool-age children were grossly deficit in terms of
vitamin A, where the median intakes were deficit by
66e81% as against the RDA of 400 mg. About 84% of
preschool-age children were not even meeting 50% of their
RDA (NNMB, 2006).
VAD has been reported to be much damaging in
Pakistan as 9.4% of the population tolerated night blindness
and 60% child deaths are attributable to diarrheal and res-
piratory infections associated with VAD (Mahmood et al.,
2008). Restricted availability of balanced and diversified
diets is another potential determinant of VAD among
economically constrained population groups in Pakistan
(Bharmal & Omair, 2001; Bhutta & Haider, 2008; WHO,
1995). Various studies and surveys have demonstrated 5.7
million children under 5 to be affected with VAD and
0.057 million manifested xerophthalmia in Pakistan. Preg-
nancy complications due to VAD result in 25% under-
weight birth owing to mothers’ poor nutrition during
pregnancy (Kazi & Qurashi, 1998; Mahmood et al.,
2008). Recent National Nutritional Survey of Pakistan indi-
cates a gigantic increase in VAD prevalence among women
in Pakistan from 2001 (5.9%) to 2011 (30.3%) (NNS,
2011). However, coverage through National Nutrition Sur-
vey has been insufficient (study population comprising a
few thousand subjects only) to truly represent the gravity
of VAD hence, more concerted efforts are needed to
appraise the magnitude of VAD in Pakistan.
Sri Lanka has been considered a model country among
South Asian developing economies and the country has
shown exceptional success to achieve high literacy rate
and health outcomes even with limited resources. However,
a significant development could not be seen in the realm of
public health and nutrition (Rajapaksa, Arambepola,
Gunawardena, Rosa, & Opatha, 2011, p. 1). The magnitude
of the problem of VAD in Sri Lanka was assessed in a na-
tional survey during the period 1995/1996 (MRI, 1998)
which showed that although the prevalence of clinical man-
ifestations of VAD did not exceed the cutoff values, the per-
centage of children having subclinical deficiency (serum
vitamin A <20 ug/dl) was very high (36.3%). Subse-
quently, VAD control program in the form of vitamin A
supplementation was formulated with a focus on improving
the vitamin A status of pregnant and lactating mothers,
preschool-age and primary school children, and adults.
Around 51% of pregnant women in Bangladesh had
vitamin A deficit in diets and 18.5% suffered from VAD
(serum retinol <0.70 mmol/l). Likewise, 1.5% of 381
(ages 11e16 years) school children in Dhaka manifested
serum retinol level <0.70 mmol/l (Ahmed, Rahman, Noor,
Akhtaruzzaman, & Hughes, 2006; Ahmed et al., 2012;
Lee et al., 2008). The intervention programs of vitamin A
supplementation launched in the past (HKI, 1999a, 2006;
NIPORT, 2009, p. 346) yielded encouraging results to con-
trol VAD in Bangladesh. However, population coverage for
vitamin A supplementation still remains a significant chal-
lenge and more strenuous efforts to scale up vitamin A sup-
plementation programs are required to cover the entire
vulnerable population in Bangladesh.
Prevalence of VAD in South Asian developing countries
is possibility higher than the reported data as several cases
go unreported due to the absence of precise monitoring,
appropriate health services and inadequate nutritional edu-
cation. Extreme poverty in these regions seems to be one of
 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
the most significant markers for severe VAD prevalence.
Numerous success stories for elimination of VAD such as
sugar fortification in Guatemala and Honduras (Mora,
Gueri, & Mora, 1998) show the possibility to get rid of
this menace through sagacious planning and serious
actions.
Vitamin D deficiency (VDD)
Sufficient literature demonstrates worldwide prevalence
of vitamin D deficiency. One billion people have been
suffering from VDD. The problem is more common among
purdah [veil] observing women of childbearing age (Tare
et al., 2011). VDD is epidemic in India despite of the plenty
of sunshine. Almost 75% of the study population had hypo-
vitaminosis D [25(OH) D] <20 ng/ml (Shivane, Sarathi,
Bandgar, Menon, & Shah, 2011). Prevalence of VDD was
shown to be 76% and 70% respectively among women of
reproductive and postmenopausal-age groups in South In-
dia (Harinarayan et al., 2011). Several studies indicate
that VDD is very common among males and females of
all age groups in India (Harinarayan & Joshi, 2009;
Marwaha & Sripathy, 2008). Many groups of researchers
have reported 16.5% of women of reproductive age group
to be affected with VDD in South India and the prevalence
was estimated to be about 84% among pregnant women in
North India (Harinarayan et al., 2011; Marwaha et al.,
2011; Sachan et al., 2005).
Studies covering large samples of Pakistani population to
assess the magnitude of VDD prevalence are scant however,
numerous representative studies (Bhatty et al., 2010; Qamar,
Akbani, Shamim, & Khan, 2011; Sahibzada, Khan, & Javed.,
2004) illustrate that VDD is negatively correlated with
several health implications targeting almost all population
groups. Nearly, 95% of the children, 48% of nursing mothers
and 52% of breastfed infants are reportedly the victims of
VDD in Pakistan (Karim, Nusrat, & Aziz, 2011).
Multiple micronutrient deficiencies are prevalent in
various Sri Lankan population factions. Epidemiological
studies are scant to validate the gravity of prevalence of
vitamin D in Sri Lanka however; numerous small studies
have demonstrated that VDD prevails in the country.
Serum concentration of 25(OH)D <35 nmol/L among
male (26%) and female (25%) was reported, respectively.
Sri Lankans residing in Norway manifested lower 25(OH)
D (31.5 nmol/L) as compared with those living in Sri Lanka
(54.2 nmol/L). The study suggested that season had a sig-
nificant effect on vitamin D status among Sri Lankans
living in Kandy and those Sri Lankans living in Oslo,
Norway. Relatively lower prevalence of VDD noted among
Sri Lankans living in Sri Lanka could be due to increased
endogenous synthesis as a result of exposure to sunlight.
In fact, promotion of outdoor physical activity in Sri Lanka
would have the dual benefit of increasing endogenous
vitamin D synthesis and also maintaining desirable body
weight (Hettiarachchi & Liyanage, 2012; Meyer, Holvik,
Lofthus, & Tennakoon, 2008).
57
Bangladesh is mainly a Muslim society where purdah
(veil) is a common practice of women in almost all
socio-economical classes. Amongst several determinants
of VDD, restricted exposure to sunlight and intake of
vitamin D deficient diets have been shown to affect Bangla-
deshi population especially those living in poorer settings
(Ahmed et al., 2012; Islam et al., 2002). Lactating mothers,
having inadequate dietary intake of vitamin D, are at a
higher risk of bone loss. Rickets is primarily caused by
the clinical deficiency of calcium, hence a curative treat-
ment by supplementing calcium at a level of
350e1000 mg elemental calcium per day is generally rec-
ommended (Craviari et al., 2008).
Iron deficiency anemia (IDA)
Iron deficiency anemia (IDA) is the most widely preva-
lent nutritional problem across the world, affecting almost
all age, sex and physiological groups. Preschool-age chil-
dren, adolescent girls, pregnant women and lactating
mothers are vulnerable groups. IDA significantly contrib-
utes to heighten morbidity and mortality among children.
A plethora of publications in the literature is available to
suggest anemia to be highly prevalent and poses an
increased risk for maternal and child mortality (WHO,
2011) in low income developing countries. IDA exerts a
deleterious effect on productivity and cognition among
children (Fuglestad et al., 2012) suggesting immediate ac-
tions to be taken to overcome iron deficiency in South
Asian developing countries.
Nearly, 66% nonpregnant women, 85% pregnant women
and 90% adolescent girls in 16-districts of India were re-
ported to be iron deficient. Malnutrition is the underlying
cause of higher IDA prevalence among these vulnerable
population groups particularly the diets of preschool-age
children are grossly deficit in iron and the pregnant and
menstruating women do not meet additional iron require-
ments in India (Menon et al., 2010; Toteja et al., 2006).
Similarly, IDA has been shown to affect 90.5% pregnant
women and 65% children below 5 years in Pakistan (Baig-
Ansari et al., 2008; Nestel & Ritu, 2000). In addition to iron
deficiency, prevalence of folate and vitamin B12 defi-
ciencies in Pakistan have also been very common
(Hashim & Tahir, 2006; Iqbal & Kakepoto, 2009;
Kakepoto, Iqbal, & Iqbal, 2000). Numerous determinants
have been recognized for high prevalence of IDA in
Pakistan including poverty, consumption of cereal based di-
ets, incorrect dietary habits, poor hygiene and sanitation.
There is hardly any study conducted with a target popula-
tion in Pakistan showing any reduction in the prevalence
of IDA.
Bangladesh Bureau of Statistics and National Surveys
confirmed that 40% adolescent girls were anemic in
Bangladesh (HKI, 1999b, 38 p., 2006) associating IDA
with early age pregnancies (BBS, 2005). Low dietary intake
of iron, bioavailability in the presence of phytates, failure to
meet iron needs during rapid growth and pregnancy,
58 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
menstrual blood loss and parasitic infections are some of
the substantial determinants to provoke the risk of IDA
among Bangladeshi populations.
Iron deficiency is the commonest cause of anemia in Sri
Lanka and it has been used as a proxy for iron deficiency in
the national surveys. The prevalence of anemia is relatively
higher among nonpregnant women of childbearing age than
pregnant women in Sri Lanka, highlighting the need to
target this group for interventions. One survey conducted
in 2009 revealed that an individual dietary diversity score
of 4 or more was significantly associated with a lower
risk of anemia in Sri Lanka (Piyasena & Mahamithawa,
2003).
Zinc deficiency
Zinc deficiency, an important public health problem, af-
fects almost half of the population worldwide, and it is esti-
mated that 1e13% of the population in Europe and
68e95% in North America have low dietary intakes of
zinc. Children from developing economies are more prone
to zinc deficiency as 61% are at the risk of low zinc intake.
Zinc deficiency is a major risk factor for morbidity and
mortality contributing nearly 800,000 additional mortality
cases every year among children under 5 years (Brown &
Wuehler, 2000; Brown, Wuehler, & Peerson, 2001;
Haider & Bhutta, 2009; Yakoob et al., 2011).
Prevalence of zinc deficiency among preschool-age chil-
dren of five states in India was 43.8% (Kapil & Jain, 2011),
49.4% among adolescent girls in Delhi (Kapil, Toteja, Rao,
& Pandey, 2011) and 52% among non-pregnant women of
central India (Menon et al., 2010).
Assessment of the extent of prevalence of zinc defi-
ciency in Pakistan is hard due to the paucity of data as
no surveys or studies have been carried out at national
level. National nutrition survey conducted in 2011, however
gives a comprehensive picture of prevalence of zinc defi-
ciency in Pakistani population. The survey exhibited that
major population fractions (41.6% nonpregnant and
48.3% pregnant women) had zinc deficiency (NNS, 2011)
Limited studies revealed zinc deficiency to be prevalent
among children at 54.2% in addition to 37.1% of
preschool-age children in Pakistan. Approximately, 54%
pregnant women from Sindh province were reported to suf-
fer from zinc deficiency. High incidence of foodborne
illness has been reported in developing countries, therefore
mortality associated with infections like diarrhea, pneu-
monia and malaria is heightened among zinc deficient chil-
dren (Abdulla & Suck, 1998; Akhtar, 2012; Akhtar,
Mahfur, & Hossain, 2012; Bhutta, 2000; Yakoob et al.,
2011). Preventive zinc supplementation can be exploited
to reduce this mortality due to these common infections.
Similarly, zinc supplementation has shown to exert a posi-
tive effect on linear growth (Imdad & Bhutta, 2011).
Studies on zinc status in Sri Lanka are limited. Several
studies at small scale (de Silva & Atukorala, 1996;
Hettiarachchi & Liyanage, 2012) depicted high prevalence
of zinc deficiency that could be partly due to low intake of
animal foods and low bioavailability of zinc in plant based
diets that are commonly consumed.
Zinc deficiency at early pregnancy has been associated
with complications in pregnancy outcomes at later stages
(Lindstrom et al., 2011). Relatively serious outcomes are
observed in lactating mothers already experiencing zinc
deficiency and they are more prone to infectious diseases.
Supplementing zinc and iron as a multiple micronutrient
strategy can reduce morbidity and mortality rates in such
populations (Akhtar, Anjum & Anjum, 2011; Baqui et al.,
2003). Sufficient evidence indicates that intervening zinc
can prevent 30,000 to 75,000 child deaths by preventing
diarrhea in Bangladesh (Ahmed et al., 2012; Jones,
Steketee, Black, Bhutta, & Morris, 2003; Ruel, Rivera,
Santizo, Lonnerdal, & Brown, 1997).
Iodine deficiency
Estimates indicate that 60% of almost 600 million peo-
ple in Europe suffer from iodine deficiency (de Benoist,
McLean, Egli, & Cogswell, 2008; Vitti, Delange,
Pinchera, Zimmermann, & Dunn, 2003). Similarly, iodine
deficiency, resulting mostly from an insufficient dietary
supply of iodine is also a major public health problem in
most parts of India (Kapil, 2000). Iodine deficiency is
widely prevalent in Pakistan as well and a large part of pop-
ulation is at the risk of iodine deficiency. Pregnant women
suffer from iodine deficiency and expose their newborns at
high risk of disorders caused by iodine deficiency. Salt iod-
ization program initiated in Pakistan in 1995, appears to be
a viable approach and this project has shown promise for
the future with an increase in the production of iodized
salt from a mere 17 percent to as much as 67 percent
(Anon, 2007). Similarly, 250,000 MT of adequately iodized
salt, is being processed in Punjab, the most populous prov-
ince of Pakistan. The availability of iodized salt benefits
more than 90 million people in the region (Rose, Khan,
Larik, & Mohammad, 2007).
There have been several national surveys on prevalence
of iodine deficiency in Sri Lanka. Universal salt iodization
was launched in 1995 in Sri Lanka as the main approach to
control iodine deficiency. The impact of mandatory salt
iodization was assessed in a survey carried out among
8e10 year old children (Jayatissa, Gunathilaka, &
Fernando, 2005). Iodine deficiency control program was
strengthened by more effective monitoring of salt iodiza-
tion and distribution. Awareness and education about the
correct use of iodized salt is an important factor to ensure
success in overcoming iodine deficiency.
Prevalence of iodine deficiency was measured up to 71%
in different study population groups in Bangladesh in 1993
and a national salt iodization program was also initiated to
overcome the endemic iodine deficiency. Successful execu-
tion of the salt iodization program remarkably reduced
iodine deficiency therefore, a significant decline in total
goiter rate among children and women of ages 6e12 and
 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62 59

15e44 years respectively was witnessed in the country. A
mass survey program conducted in 2004e05 reported
very impressive data showing reduction of iodine defi-
ciency and total goiter rate in children from 71% and
49.9% to 33.8% and 6.2%, respectively (Yusuf, Khatun,
& Rahman, 2007, p. 158) (Table 1).
Interventions to combat micronutrient deficiencies
Dietary diversification, supplementation and food fortifi-
cation have been considered three potential approaches to
address micronutrient malnutrition in developing countries.
Successful application of these strategies demands a com-
plete knowledge of the foods, supplements, fortificants
and bioavailability (Akhtar et al., 2011).
Dietary diversification
Dietary diversification means consuming a variety of
foods to meet nutrients requirement. Economic, social
and cultural barriers substantially limit the consumption
of diversified foods that normally carry vital minerals and
vitamins to effectively lower micronutrient deficiency
burden among vulnerable groups. Dietary diversification
is more advantageous for being sustainable and does not
call for any external support. India being a vast and exten-
sively multicultural state, has been attempting to control
micronutrient deficiencies by exploiting dietary diversifica-
tion strategy. Recent studies reported significant success
through food based approaches to combat micronutrient de-
ficiencies (Arlappa, Balakrishna, Laxmaiah, Nair, &
Brahmam, 2011; Kapil & Tyagi, 2012).
Homestead gardening projects were initiated in 1999 by
HKI to promote fruits and vegetables production with an
aim of increasing micronutrient intake in Bangladesh.
The approach yielded outstanding results. About 719 bene-
ficiaries of the project revealed a significant increment in
the serum retinol level including mothers from 30 to 230
retinol equivalents (RE) (Faber, Phungula, Venter,
Dhansay, & Benade, 2002). Nevertheless, it appeared to
be a demanding task to carry on this practice in the absence
of adequate counseling in nutrition (Faber & Laurie, 2011;
Tontisirin, Nantel, & Bhattacharjee, 2002).
Food fortification
Being more economical, cost effective and socially
acceptable, food fortification has gained tremendous popu-
larity among nations facing micronutrient deficiencies. In
South Asian developing countries where wheat is the staple
food, emphasis is being laid down to fortify the wheat flour
with multiple micronutrients, therefore multiple fortifica-
tion of whole wheat flour is gaining much popularity in
this region. Flour fortification program was initiated in
Pakistan in 2007 and was centered in Khyber Pakhtunkhwa
province where half million people now have access to for-
tified flour (MI, 2012b) and coverage remains to be 11% of
the entire population.
Supplementation
Two significant determinants ensure the success of sup-
plementation programs namely, level of coverage and
compliance. Iron, zinc and vitamin A supplementation for
target population has been a successful approach in the
developing nations.
Iron supplementation was suggested in communities
with high prevalence of anemia. The strategy was found
to be more effective in improving iron status and reducing
morbidity from upper respiratory tract infections in chil-
dren aged 5e10 years (de Silva, Atukorala, Weerasinghe,
& Ahluwalia, 2003; Malkanthi, Silva, & Jayasinghe-
Mudalige, 2010). Educational intervention alone resulted
in a significant improvement in nutrition knowledge and
iron status in Sri Lanka. Evidently iron supplementation
seems more effective in communities with better health ed-
ucation, therefore this approach has been recommended in

Table 1. Prevalence of micronutrient deficiencies in South Asia.

Iron deficiency Vitamin A deficiency Iodine deficiency

IDA in IDA in IDA in Maternal Child deaths Children Children Children Total Total
children women pregnant death from precipitated <6 w/ <6 w/ born goiter goiter
<5 y (%) 15e49 y women severe (no.) subclinical clinical mentally rate rate
(%) (%) anemia/yr VAD (%) VAD (%) impaired (TGR) (TGR)
(no.) (no.) (%) in school
children
(%)
Afghanistan 65 61 50,000 53 535,000 48 e
Bangladesh 55 36 74 2800 28,000 28 0.7 750,000 18 50
Bhutan 81 55 68 <100 600 32 0.7 e e 14
India 75 51 87 22,000 330,000 57 0.7 6,600,000 26 19
Nepal 65 62 63 760 6900 33 1.0 200,000 24 40
Pakistan 56 59 e 56,000 35 e 2,100,000 38 e
South Asia region 25,560 471,500 10,185,000
Total world 50,000 1,150,000 19,000,000
Source: UNICEF/MI (2004).
60 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
iron supplementation programs (Senanayake, Premaratne,
Palihawadana, & Wijeratne, 2010).
Progressive development of iron deficiency during preg-
nancy was reported in Bangladesh. Iron deficiency appears
to be low, during early pregnancy and can develop into iron
deficiency anemia as the pregnancy progresses (Lindstrom
et al., 2011). One group of researchers demonstrated the
ameliorating effect of early supplementation in pregnancy
on the occurrence of stunting among boys aged 0e54
months. The study further elucidated food supplementation
to women during early pregnancy to be a pragmatic
approach to reduce early childhood malnutrition, especially
stunting (Khan et al., 2011).
A practical strategy to control anemia and deficiencies of
vitamin A &D, iodine and zinc in Bangladesh is critically
needed in addition to launching of large scale training pro-
grams for workers. Community awareness campaigns can
play a vital role to reduce the extent of micronutrient defi-
ciencies in addition to routine approaches like dietary diver-
sification, supplementation and fortification of staple foods.
Conclusions and future research needs
High prevalence of micronutrient deficiencies, espe-
cially in low income countries, has led the world’s scientific
community and international organizations to critically
appraise health and economic consequences associated
with micronutrient malnutrition. South Asia constitutes an
important region in today’s world. Extreme poverty and
malnutrition remain two instrumental determinants that
hamper economic growth of this region. Compelling evi-
dence suggest high prevalence of vitamin A & D, iron,
zinc and iodine deficiency in India, Pakistan, Sri Lanka
and Bangladesh, afflicting a substantial segment of the pop-
ulation especially children and pregnant women. High
maternal and infant mortality rate has been documented
as a corollary of the deficiency of these vital nutrients in
this region. This situation warrants immediate actions and
implementation of several potential approaches that can
go long way towards enhancing nutritional status of vulner-
able and the neediest population of these poverty stricken
economies. Priority setting for elimination of micronutrient
deficiencies, conducting extensive national level surveys to
assess and document the real burden of micronutrient defi-
ciencies and putting existing strategies and solutions into
action are a few widely accepted approaches to combat mi-
cronutrient deficiencies. Besides, launching media advo-
cacy campaigns, making huge investment and new
legislation to successfully implement fortification and sup-
plementation programs, promoting dietary diversification
as an effective approach to minimize the dependence
upon fortification and supplementation would play a pivotal
role to successfully address the issue. Further research and
development is needed especially in the realm of bio-
fortification and crop production with enhanced micronu-
trient status through exploiting biotechnology, to overcome
this multipronged issue of hidden hunger in the region.
Acknowledgments
We, the coauthors highly appreciate and acknowledge
the significant contribution and the substantial amount of
time and efforts by the author Saeed Akhtar in the prepara-
tion and revision of this manuscript.
References
Abdulla, M., & Suck, C. (1998). Blood levels of copper, iron, zinc, and
lead in adults in India and Pakistan and the effect of oral zinc
supplementation for six weeks. Biological Trace Element
Research, 61, 323e331.
Ahmed, T., Mahfuz, M., Ireen, S., Ahmed, A. M. S., Rahman, S.,
Islam, M. M., et al. (2012). Nutrition of children and women in
Bangladesh: trends and directions for the future. Journal of Health,
Population and Nutrition, 30, 1e11.
Ahmed, F., Rahman, A., Noor, A. N., Akhtaruzzaman, M., &
Hughes, R. (2006). Anemia and vitamin A status among
adolescent schoolboys in Dhaka City, Bangladesh. Public Health
Nutrition, 9, 345e350.
Akhtar, S. (2012). Food safety challenges e a Pakistan’s perspective.
Critical Reviews in Food Science and Nutrition. http://dx.doi.org/
10.1080/10408398.2011.650801, (Accepted).
Akhtar, S., Anjum, F. M., & Anjum, M. A. (2011). Micronutrient
fortification of wheat flour: recent development and strategies.
Food Research International, 44, 652e659.
Akhtar, S., Mahfuzur, R. S., & Hossain, A. (2012). Microbiological
food safety e a dilemma of developing societies. Critical Reviews
in Microbiology. http://dx.doi.org/10.3109/
1040841X.2012.742036, (Accepted).
Anon. (September 20, 2007). WFP’s salt iodization initiative yields
positive results. Daily Times, http://www.dailytimes.com.pk/
default.asp?page¼2007%5C09%5C20%5Cstory_20-9-2007_
pg7_35.
Arlappa, N., Balakrishna, N., Laxmaiah, A., Nair, K. M., &
Brahmam, G. N. (2011). Prevalence of clinical and sub-clinical
vitamin A deficiency among rural preschool-age children of West
Bengal, India. Indian Pediatrics, 48, 47e49.
Baig-Ansari, N., Badruddin, S. H., Karmaliani, R., Harris, H., Jehan, I.,
Pasha, O., et al. (2008). Anemia prevalence and risk factors in
pregnant women in an urban area of Pakistan. Food and Nutrition
Bulletin, 29, 132e139.
Baqui, A. H., Zaman, K., Persson, L. A., El Arifeen, S., Yunus, M.,
Begum, N., et al. (2003). Simultaneous weekly supplementation of
iron and zinc is associated with lower morbidity due to diarrhea
and acute lower respiratory infection in Bangladeshi infants.
Journal of Nutrition, 133, 4150e4157.
BBS. (2005). National low birth weight survey of Bangladesh
2003e2004. Dhaka, Bangladesh: Bangladesh Bureau of Statistics/
UNICEF.
Bharmal, F. Y., & Omair, A. (2001). Evaluation of vitamin A
supplementation in Gulshan-e-Sikandarabad. Journal of Pakistan
Medical Association, 51, 248e250.
Bhatty, S. A., Shaikh, N. A., Irfan, M., Kashif, S. M.,
Vaswani, A. S., Sumbhai, A., et al. (2010). Vitamin D
deficiency in fibromyalgia. Journal of Pakistan Medical
Association, 60, 949e951.
Bhutta, Z. A. (2000). Iron and zinc intake from complementary foods,
some issues from Pakistan. Pediatrics, 106, 1295e1297.
Bhutta, Z. A., & Haider, B. A. (2008). Maternal micronutrient
deficiencies in developing countries. Lancet, 371, 186e187.
Bhutta, Z. A., Rizvi, A., Raza, F., Hotwani, S., Zaidi, S.,
Hossain, S. M., et al. (2009). A comparative evaluation of multiple
micronutrient and iron folic acid supplementation during
pregnancy in Pakistan, impact on pregnancy outcomes. Food and
Nutrition Bulletin, 30, 496e505.
 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
Brown, K. H., & Wuehler, S. E. (2000). Zinc in human health: The
results of recent trials and implications for program interventions
and research. Ottawa, Canada: Micronutrient Initiative.
Brown, K. H., Wuehler, S. E., & Peerson, J. M. (2001). The importance
of zinc in human nutrition and estimation of the global prevalence
of zinc deficiency. Food and Nutrition Bulletin, 22, 113e125.
Craviari, T., Pettifor, J. M., Thacher, T. D., Meisner, C., Arnaud, J., &
Fischer, P. R. (2008). Rickets: an overview and future directions,
with special reference to Bangladesh. A summary of the Rickets
Convergence Group meeting, Dhaka, 26e27 January 2006.
Journal of Health, Population and Nutrition, 26, 112e121.
de Benoist, B., McLean, E., Egli, I., & Cogswell, M. (2008). Worldwide
prevalence of anemia 1993e2005: WHO global database on
anemia. Geneva: World Health Organization.
de Silva, L. D., & Atukorala, T. M. (1996). Micronutrient status of
plantation workers in Sri Lanka during pregnancy and postpartum.
Journal of Obstetrics and Gynaecology Research, 22, 239e246.
de Silva, A., Atukorala, S., Weerasinghe, I., & Ahluwalia, N. (2003).
Iron supplementation improves iron status and reduces morbidity
in children with or without upper respiratory tract infections: a
randomized controlled study in Colombo, Sri Lanka. American
Journal of Clinical Nutrition, 77, 234e241.
Ejaz, M. S., & Latif, N. (2011). Stunting and micronutrient deficiencies
in malnourished children. Journal of Pakistan Medical Association,
60, 543e547.
Faber, M., & Laurie, S. (2011). A home gardening approach
developed in South Africa to address vitamin A deficiency and
combating micronutrient deficiencies. In B. Thompson, &
L. Amoroso (Eds.), Food-based approaches (pp. 163e182). CAN
International and FAO.
Faber, M., Phungula, M. A., Venter, S. L., Dhansay, M. A., &
Benade, A. J. (2002). Home gardens focusing on the production of
yellow and dark-green leafy vegetables increase the serum retinol
concentrations of 2e5-y-old children in South Africa. American
Journal of Clinical Nutrition, 76, 1048e1054.
FAO. (2012). The state of food insecurity in the world. Retrieved; Oct
20, 2012. Rome. Italy. http://www.fao.org/docrep/016/i2845e/
i2845e00.pdf.
Fuglestad, A. J., Georgieff, M. K., Iverson, S. L., Miller, B. S.,
Petryk, A., Johnson, D. E., et al. (2012). Iron deficiency after arrival
is associated with general cognitive and behavioral impairment in
post-institutionalized children adopted from Eastern Europe.
Maternal and Child Health Journal, 1e8. http://dx.doi.org/
10.1007/s10995-012-1090-z.
Haider, B. A., & Bhutta, Z. A. (2009). The effect of therapeutic zinc
supplementation among young children with selected infections: a
review of the evidence. Food and Nutrition Bulletin, 30, 41e59.
Harinarayan, C. V., & Joshi, S. R. (2009). Vitamin D status in India e
its implications and remedial measures. Journal of the Association
of Physicians of India, 57, 40e48.
Harinarayan, C. V., Sachan, A., Amaresh, R. P., Satish, K. M.,
Prasad, U. V., & Srivani, P. (2011). Vitamin D status and bone
mineral density in women of reproductive and postmenopausal
age groups: a cross-sectional study from South India. Journal of the
Association of Physicians of India, 59, 698e704.
Hashim, H., & Tahir, F. (2006). Frequency of vitamin B12 and folic
acid deficiencies among patients of megaloblastic anaemia.
Annals of Pakistan Institute of Medical Sciences, 2, 192e194.
Haskell, M. J., & Brown, K. H. (1999). Maternal vitamin A nutriture
and the vitamin A content of human milk. Journal of Mammary
Gland Biology and Neoplasia, 4, 243e257.
Hettiarachchi, M., & Liyanage, C. (2012). Coexisting micronutrient
deficiencies among Sri Lankan preschool-age children: a
community-based study. Maternal and Child Nutrition, 8, 259e266.
HKI. (1999a). Iron deficiency anemia throughout the life cycle in rural
Bangladesh. Dhaka, Bangladesh: Helen Keller International/
Institute of Public Health and Nutrition.
61
HKI. (1999b). Vitamin A status throughout the lifecycle in rural
Bangladesh: National vitamin A survey, 1997e98. Dhaka: Helen
Keller International.
HKI. (2006). Bangladesh: The burden of anaemia in rural Bangladesh:
The need for urgent action. Dhaka: Helen Keller International,
Nutritional Surveillance Project Bulletin. 16, 4.
Imdad, A., & Bhutta, Z. A. (2011). Effect of preventive zinc
supplementation on linear growth in children under 5 years of age
in developing countries: a meta-analysis of studies for input to the
lives saved tool. BMC Public Health, 11, 22.
Iqbal, S. P., & Kakepoto, G. N. (2009). Vitamin B12 deficiency e a
major cause of megaloblastic anemia in patients attending a
tertiary care hospital. Journal of Ayub Medical College
Abbottabad, 21, 92e94.
Islam, M. Z., Lamberg-Allardt, C., Karkkainen, M., Outila, T.,
Salamatullah, Q., & Shamim, A. A. (2002). Vitamin D deficiency:
a concern in premenopausal Bangladeshi women of two socio-
economic groups in rural and urban region. European Journal of
Clinical Nutrition, 56, 51e56.
Jayatissa, R., Gunathilaka, M. M., & Fernando, D. N. (2005). Iodine
nutrition status among schoolchildren after salt iodization. Ceylon
Medical Journal, 50, 144e148.
Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., & Morris, S. S.
(2003). How many child deaths can we prevent this year? Lancet,
362, 65e71.
Kakepoto, G. N., Iqbal, M. P., & Iqbal, S. P. (2000). Megaloblastic
anaemia in a hospital-based population. Medical Science
Research, 28, 45e47.
Kaleem, A. (2004). An unnoticed monster blocking Pakistan progress.
Daily Times, Available at: http://www.dailytimes.com.pk/default.
asp?page¼story_29-3-2004_pg6_18.
Kapil, U. (2000). Progress made in elimination of iodine deficiency
disorders and possible impact of lifting ban on sale of non-iodized
salt. Journal of the Academy of Hospital Administration, 12,
33e41.
Kapil, U., & Jain, K. (2011). Magnitude of zinc deficiency amongst
under five children in India. Indian Journal of Pediatrics, 78,
1069e1072.
Kapil, U., Toteja, G. S., Rao, S., & Pandey, R. M. (2011). Zinc
deficiency amongst adolescents in Delhi. Indian Journal of
Pediatrics, 48, 981e982.
Kapil, U., & Tyagi, M. (2012). Etiology of severe anemia amongst
adolescent children. Indian Journal of Pediatrics, 79, 401e402.
Karim, S. A., Nusrat, U., & Aziz, S. (2011). Vitamin D deficiency in
pregnant women and their newborns as seen at a tertiary-care
center in Karachi, Pakistan. International Journal of Gynecology &
Obstetrics, 112, 59e62.
Kazi, A. Q., & Qurashi, M. M. (1998). A critical analysis of nutritional
studies in Pakistan (1965e87) part-I. The nutritional deficiencies
and loss of productivity. Pakistan Journal of Medical Research, 37,
89e101.
om, E. C., 
Khan, A. I., Kabir, I., Ekstr€ Asling-Monemi, K., Alam, D. S.,
Frongillo, E. A., et al. (2011). Effects of prenatal food and
micronutrient supplementation on child growth from birth to 54
months of age: a randomized trial in Bangladesh. Nutrition
Journal, 10, 134.
Khor, G. L. (2005). Micronutrient status and intervention programs in
Malaysia. Food and Nutrition Bulletin, 26, 281e285.
Laxmaiah, A., Nair, M. K., Arlappa, N., Raghu, P., Balakrishna, N.,
Rao, K. M., et al. (2011). Prevalence of ocular signs and subclinical
vitamin A deficiency and its determinants among rural preschool-
age children in India. Public Health Nutrition, 15, 568e577.
Lee, V., Ahmed, F., Wada, S., Ahmed, T., Ahmed, A. S., Parvin, B. C.,
et al. (2008). Extent of vitamin A deficiency among rural pregnant
women in Bangladesh. Public Health Nutrition, 11, 1326e1331.
Lindstrom, E., Hossain, M. B., Lonnerdal, B., Raqib, R., El Arifeen, S.,
& Ekstrom, E. C. (2011). Prevalence of anemia and micronutrient
62 S. Akhtar et al. / Trends in Food Science & Technology 31 (2013) 55e62
deficiencies in early pregnancy in rural Bangladesh, the MINIMat
trial. Acta Obstetricia et Gynecologica Scandinavica, 90, 47e56.
Mahmood, K., Samo, A. H., Jairamani, K. L., Ali, G., Talib, A., &
Qazmi, W. (2008). Serum retinol binding protein as an indicator of
vitamin A status in cirrhotic patients with night blindness. Saudi
Journal of Gastroenterology, 14, 7e11.
Malkanthi, R. L. D. K., Silva, K. D. R. R., & Jayasinghe-Mudalige, U. K.
(2010). Risk factors associated with high prevalence of anemia
among children under 5 years of age in paddy-farming households
in Sri Lanka. Food and Nutrition Bulletin, 31, 475e482.
Marwaha, R. K., & Sripathy, G. (2008). Vitamin D & bone mineral
density of healthy school children in northern India. Indian Journal
of Medical Research, 127, 239e244.
Marwaha, R. K., Tandon, N., Garg, M. K., Kanwar, R., Narang, A.,
Sastry, A., et al. (2011). Vitamin D status in healthy Indians aged
50 years and above. Journal of the Association of Physicians of
India, 59, 706e709.
Menon, K. C., Skeaff, S. A., Thomson, C. D., Gray, A. R.,
Ferguson, E. L., Zodpey, S., et al. (2010). Concurrent micronutrient
deficiencies are prevalent in nonpregnant rural and tribal women
from central India. Nutrition, 27, 496e502.
Meyer, H. E., Holvik, K., Lofthus, C. M., & Tennakoon, S. U. (2008).
Vitamin D status in Sri Lankans living in Sri Lanka and Norway.
British Journal of Nutrition, 99, 941e944.
MI. (2012a). Micronutrient initiative. http://www.micronutrient.org/
english/View.asp Accessed on: Feb 27, 2012.
MI. (2012b). Micronutrient initiative-Pakistan: The state of health and
development. <http://www.micronutrient.org/english/view.asp?
x¼606>.
Mora, J. O., Gueri, M., & Mora, O. L. (1998). Vitamin A deficiency in
Latin America and the Caribbean: an overview. Revista
Panamericana de Salud P u blica, 4(3).
MRI. (1998). Vitamin A status of children in Sri Lanka, 1995/96.
Colombo, Sri Lanka: Medical Research Institute, Ministry of
Health and Indigenous Medicine.
Nestel, P., & Ritu, N. (2000). Manual for flour fortification with iron.
Guidelines for the development and implementation of a national
program for the fortification of flour with iron. Micronutrient
Initiative/OMNI/USAID, October (2000) IDPAS# 189.
NIPORT. (2009). Bangladesh demographic and health survey 2007.
Dhaka: National Institute of Population Research and Training.
NNMB. (2006). Diet and nutritional status of population and
prevalence of hypertension among adults in rural areas.
Hyderabad, India: National Nutrition Monitoring Bureau;
National Institute of Nutrition, Indian Council of Medical
Research, Report No.24.
NNS. (2011). National nutrition survey Pakistan. Nutrition Wing,
Cabinet Division, Government of Pakistan.
OMNI, U. S.. (2005). Micronutrient fact sheets. India.
Piyasena, C., & Mahamithawa, A. M. S. (2003). Assessment of anemia
status 2001. Colombo, Sri Lanka: Medical Research Institute,
Ministry of Healthcare and Nutrition.
Qamar, S., Akbani, S., Shamim, S., & Khan, G. (2011). Vitamin D
levels in children with growing pains. Journal of College of
Physicians and Surgeons Pakistan, 21, 284e287.
Rajapaksa, L. C., Arambepola, C., Gunawardena, N., Rosa, C., &
Opatha, S. (2011). Nutritional status in Sri Lanka, determinants
and interventions: A desk review.
Rose, M. A., Khan, N. A., Larik, Z., & Mohammad, F. (2007).
Situational analysis of salt production and iodization in Pakistan.
http://www.micronutrientforum.org/meeting2007/posters/Food%
20Fortification/Iodized%20Salt%20in%20Pakistan%20Rose%
20et%20al.pdf.
Ruel, M. T., Rivera, J. A., Santizo, M. C., Lonnerdal, B., &
Brown, K. H. (1997). Impact of zinc supplementation on morbidity
from diarrhea and respiratory infections among rural Guatemalan
children. Pediatrics, 99, 808e813.
Sachan, A., Gupta, R., Das, V., Agarwal, A., Awasthi, P. K., &
Bhatia, V. (2005). High prevalence of vitamin D deficiency among
pregnant women and their newborns in northern India. American
Journal of Clinical Nutrition, 81, 1060e1064.
Sahibzada, A. S., Khan, M. S., & Javed, M. (2004). Presentation of
osteomalacia in Kohistani women. Journal of Ayub Medical
College Abbottabad, 16, 63e65.
Senanayake, H. M., Premaratne, S. P., Palihawadana, T., &
Wijeratne, S. (2010). Simple educational intervention will improve
the efficacy of routine antenatal iron supplementation. Journal of
Obstetrics and Gynaecology Research, 36, 646e650.
Seshadri, S. (2001). Prevalence of micronutrient deficiency
particularly of iron, zinc and folic acid in pregnant women in
South East Asia. British Journal of Nutrition, 85, S87eS92.
Shivane, V. K., Sarathi, V., Bandgar, T., Menon, P., & Shah, N. S.
(2011). High prevalence of hypovitaminosis D in young healthy
adults from the western part of India. Postgraduate Medical
Journal, 87, 514e518.
Sommer, A. (1995). Vitamin A and measles vaccination. Lancet,
346, 252.
Stein, A. J., & Qaim, M. (2007). The human and economic cost of
hidden hunger. Food and Nutrition Bulletin, 28, 125e134.
Talat, N., Perry, S., Parsonnet, J., Dawood, G., & Hussain, R. (2010).
Vitamin D deficiency & tuberculosis progression. Emerging
Infectious Diseases, 16, 853e855.
Tare, M., Emmett, S. J., Coleman, H. A., Skordilis, C., Eyles, D. W.,
Morley, R., et al. (2011). Vitamin D insufficiency is associated with
impaired vascular endothelial and smooth muscle function and
hypertension in young rats. Journal of Physiology, 589,
4777e4786.
Tontisirin, K., Nantel, G., & Bhattacharjee, L. (2002). Food-based
strategies to meet the challenges of micronutrient malnutrition in
the developing world. Proceedings of the Nutrition Society, 61,
243e250.
Toteja, G. S., Singh, P., Dhillon, B. S., Saxena, B. N., Ahmed, F. U.,
Singh, R. P., et al. (2006). Prevalence of anemia among pregnant
women and adolescent girls in 16 districts of India. Food and
Nutrition Bulletin, 27, 311e315.
UNICEF. (2008). State of the world children 2008: Child survival.
New York: UNICEF.
UNICEF/MI. (2004). Vitamin and mineral deficiency e A global
progress report. New York: UNICEF.
Vijayaraghavan, K. (2002). Control of micronutrient deficiencies in
India: obstacles and strategies. Nutrition Reviews, 60, 73e76.
Vitti, P., Delange, F., Pinchera, A., Zimmermann, M., & Dunn, J. T.
(2003). Europe is iodine deficient. Lancet, 361, 1226.
WHO. (1995). Global prevalence of VAD. World Health
Organization, MDIS Working Paper 2.
WHO. (2004). Vitamin and mineral requirements in human nutrition.
Geneva: World Health Organization Publications.
WHO. (2009). Global prevalence of vitamin A deficiency in
populations at risk 1995e2005. WHO Global Database on VAD.
Geneva, Switzerland.
WHO. (2011). World Health Organization Guideline: Use of multiple
micronutrient powders for home fortification of foods consumed
by infants and children 6e23 months of age. Geneva, Italy.
World Bank. (2005). India’s undernourished children: A call for
reform and action. New Delhi: World Bank.
Yakoob, M. Y., Theodoratou, E., Jabeen, A., Imdad, A.,
Eisele, T. P., Ferguson, J., et al. (2011). Preventive zinc
supplementation in developing countries: impact on mortality
and morbidity due to diarrhea, pneumonia and malaria. BMC
Public Health, 11, 23.
Yusuf, H. K., Khatun, F., & Rahman, A. K. M. (2007). National survey
on iodine deficiency disorders and universal salt iodization survey
of Bangladesh 2004e5. Dhaka: Institute of Public Health
Nutrition.