Micro-nutrient interventions

Module 14
(and parts of module 4)

Nov 20, 2020 1

 Learning objectives

• Understand the importance of micronutrients in the

human body
• Be aware of some examples of micronutrient
malnutrition
• Be familiar with risk factors that can lead to
micronutrient malnutrition
• Be able to provide options for the prevention of
micronutrient malnutrition in emergencies

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 Recap from Module 4:
Micronutrient malnutrition

• Can you give examples of micronutrient

malnutrition?
• What is the difference between Type 1 and
Type 2 (micro-)nutrients?

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 Nutrition basics: a review

Minerals

Protein Carbohydrates MICRONUTRIENTS

Trace
MACRONUTRIENTS Vitamins elements

Fat Essential cell function

Provide energy
WATER
5
 MICRONUTRIENTS

WATER SOLUBLE VITAMINS

ESSENTIAL MINERALS
Vitamin B-1 (Thiamin)
B3 - Niacin Calcium Sulphur
Vitamin B-2 (Riboflavin) Magnesium Iron
Folic Acid
Vitamin B-6 Sodium Phosphorous
Biotin Potassium
Vitamin B-12
Pantothenic acid
Vitamin C
TRACE ELEMENTS

Boron Molybdenum Fluoride

FAT SOLUBLE VITAMINS Iodine
Vitamin A Cobalt Selenium
Vitamin D Zinc
Vitamin E Copper Manganese
Chromium Silicon
Vitamin K
7
 Causes of Micronutrient Malnutrition
• Micronutrient malnutrition is mostly caused by
an inadequate intake of one or more vitamins
or minerals
- reduced immunity as well as an increased risk
of morbidity (illness) and mortality (death).

• In addition, there is a vicious cycle connecting

infection and malnutrition
- need for effective strategies to combat
micronutrient malnutrition in emergency
situations.

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 Quiz

Which deficiencies do you recognise?

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Quiz

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To insert here an example of a specific
micronutrient deficiency know to the country (i.e.
scurvy outbreak, vitamin A deficiency)
– Description of deficiency
– Where is was seen
– How many people were affected
– What were the causes
– What was done to treat it
– What was done to prevent it
– Did the measures work
– Were there any specific measures taken to prevent such a
deficiency in the future
– Etc.

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 Risk factors – when to be alert for micronutrient deficiencies (1)
Vit A Xeroph- Low intake of animal products or orange/yellow
thalmia vegetables and fruits, when high disease burden, use of
food ration without vit.A fortified oil, when routine vit.A
supplementation is disturbed

Vit B1 Beri-beri Staple food is mostly polished rice or highly milled cereals,
thiamine chronic alcoholism with little food intake, low intake of
vegetables and pulses

Vit B3 Pellagra Staple diet mostly maize (and sorghum)

niacin (low intake of niacin and/or tryptophan

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 Risk factors – when to be alert for micronutrient deficiencies (2)
Vit C Scurvy Low intake of fresh vegetables/fruits due to (a) lack of market
access, (b) seasonality/climate, (c) prolonged dependency on
food aid, high infectious disease burden

Vit D Rickets Low exposure to sunlight (detainees, seasonality: long winters,

cultural habits to largely cover skin outdoors) and low intake of
animal food/fat fish

Iron Anaemia Low intake of animal products or green leafy foods, high
malaria/helminthic burden, high fertility rate

Iodine Iodine Low iodine in soil: erosion/floods/mountainous areas, low sea

Def. fish intake, no availability of iodised salt
Disorders

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 Risk factors for micronutrient
deficiencies in emergencies

• Total dependence on the food ration

• Lack of vegetables and fruit in the local market
or lack of resources to trade for other food sources
• No access to land for cultivation
• Malnutrition prevalent in affected population before the
emergency
• High prevalence of infectious diseases
• Low rates of optimal infant and young child feeding

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 Treatment and Prevention
of micronutrient malnutrition
Treatment:
Prevention:
- Is life saving
- Can be life saving
- Can prevent long lasting
conditions (e.g. - Can prevent many
blindness, short and long lasting
goitre/cretinism) conditions (e.g.)
- Done by specialised - Done by nutrition staff
(health) staff
- Often by means of oral - Often by means of
supplement tablets or
capsules.

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What options do you know to prevent
micronutrient malnutrition in emergencies

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Options for the prevention of micronutrient malnutrition
in emergencies (complementing each other):

1. Inclusion of nutrient-rich commodities in food assistance rations

2. Provision of fresh food items that are complementary to a general
ration
3. Provision of fortified foods
4. Increasing the size of the general food ration to facilitate diet
diversification by exchange or trade
5. Distribution of food supplementation products for home fortification
6. Distribution of micronutrient supplements (powders, tablets)
7. Promotion of home gardening and agricultural development
8. Increasing income generation and improving access to markets
9. Promotion of recommended infant feeding practices
10. Ensuring adequate health care and a healthy environment
11. Ensuring access to adequate non-food items

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 1.Inclusion of nutrient-rich foods in food aid
rations

Food rations often only composed of a few

commodities, so it is important to select them
well to address the main deficiencies.

• Example: ground nuts are often added in food rations where

pellagra is prevalent because they are rich in vitamin B3.

• Food rations can be complemented to upgrade the micro-

nutrient contents (e.g. canned fish/meat).

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 2. Provision of fresh food items that are
complementary to a general ration

• Food rations can be complemented by other

food items (ideally fresh), depending on the
needs and situation.

• In camp situation fresh food (but also tea,

spices or therapeutic milk) can be supplied by
the UNHCR as per Memorandum of
Understanding signed with WFP.

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 3. Provision of fortified foods (1)

This is common practice in food rations (blended

food) since the mid 90s.

Fortification is done after the processing of the

food (why???)

It is done with the objective of making a

significant contribution to nutritional
requirements, without leading to a micronutrient
intake above the safe upper limit.

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 3. Provision of fortified foods (2)

Fortification can be done in cereals (flour), except rice

(as distributed in grains), but such is rarely done.

More common products being fortified are:

– Blended food, which have become a common
commodity in food rations (e.g. CSB+)
– Salt is routinely fortified with iodine
– Oil is usually fortified with vitamin A
– Special food items such as high energy biscuits that
can be provided in early stages of an acute
emergency

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4. Increasing the size of the general food ration to
facilitate diet diversification by exchange or trade

Useful when there are inadequate supplies of

micronutrient-rich food aid commodities, and the
beneficiaries have access to markets where
micronutrient rich foods are available

Under these conditions, providing a larger ration of

cereal grain, may allow recipients to exchange part
of their ration for other preferred food items,
thereby helping to ensure a more balanced diet.

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 5. Distribution of food supplementation products for
home-based fortification

• Approach under research for effectiveness.

• The two main products are micronutrient powders
(MNPs: e.g. sprinkles) and lipid-based nutrient
supplements (LNS)
• Home-based fortification, through the use of a
MNP or LNS, takes place by pouring, squeezing or
sprinkling the product onto food after cooking
• More studies necessary on the use of these
products at home and on their effect.

These products need extensive acceptability study prior

to introduction in a certain community.
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 6. Distribution of micronutrient supplements

The distribution of micronutrient supplements in the form of

capsules and tablets is important in combating micronutrient
malnutrition.
The most common are:
– Vitamin A supplementation (for children and breastfeeding
women)
– Use of supplements to prevent epidemics of other
micronutrient diseases (e.g. vitamin C against scurvy in
Afghanistan)
– Multiple micronutrient supplementation tablets during
pregnancy
– Iron and folate supplementation for pregnant women

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 One special supplementation

Iron and folate supplementation for pregnant women

Prevalence of Daily oral dose Duration of supplementation
anaemia in pregnant
women Iron Folic acid

< 40 % 60 mg 400 µg 6 months of pregnancy

6 months of pregnancy,
continuing to 3 months post
≥ 40 % 60 mg 400 µg partum

Source: WHO 2000

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 7. Promotion of home gardening and agricultural
development

• The distribution of seeds, tools and other agricultural inputs

may allow populations to grow vegetables and fruit or
livestock for home consumption or for sale.
• However, access to land may be a major constraint,
particularly in refugee camps or in areas which are insecure,
e.g., due to land mines/conflict.
• Water availability may also be a limiting factor
• Home gardening: good potential for diversification of food
(nutritious ‘greens’, herbs, spices, etc.)

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Examples of home gardening

Many
Options!

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8. Increasing income and improving access to markets

• Increases in income can help to improve the intake of

micronutrients through increasing the purchasing power*
of beneficiaries and therefore (ideally) their dietary
diversity or better quality products (e.g. eggs, milk, meat,
vegetables, fruits).
• Vouchers/cash for food may be used to increase the
purchasing power* while micro-credit and enterprise
development may promote sustainable development.
• In all cases adequate market access is essential.

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 9. Promotion of optimal infant feeding practices

• Promotion of exclusive breastfeeding and appropriate

complementary feeding practices contributes to maintaining
micronutrient status: exclusive breastfeeding up to six months
of age, followed by timely introduction of complementary foods
with continued breastfeeding for two years or longer.

• Complementary foods for infants should be rich in energy and

nutrients, as the growing child requires these for optimal growth
and development.

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10. Ensuring adequate health care and a healthy
environment

Good health is very important in maintaining good

nutrition and micronutrient status.
Some examples of public health interventions that may
contribute to preventing micronutrient deficiencies:
– Water, sanitation and hygiene promotion
– De-worming to control anemia
– Malaria control to combat anemia
– Vaccination against measles
– Health and nutrition promotion activities

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 11. Ensuring access to adequate non-food items

• Household economic decisions are critical in determining

the diet diversity and micronutrient status of all its
members.
• In situations of scarce resources, food may not be the top
priority.
• If households are short of non-food items (e.g. cooking
pots, soap or assets such as tools) then they may choose
to use their available food stocks or other assets to
procure these, rather than to improve the quantity or
quality of their diet.

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 Key messages
• Prevention of micronutrient malnutrition depends on achieving an adequate intake of the
many micronutrients (vitamins and minerals) required by the human body.
• Diseases can increase the requirements for micronutrients and can interact with
malnutrition to cause morbidity and mortality.
• Effective control of micronutrient malnutrition is likely to involve both curative and
preventive approaches.
• Options for the prevention of micronutrient malnutrition in emergencies can be classified
into 11, often complementary, approaches:
– Inclusion of nutrient-rich commodities in food assistance rations
– Provision of fresh food items that are complementary to a general ration
– Provision of fortified foods
– Increasing the size of the general food ration to facilitate diet diversification by exchange or
trade
– Distribution of food supplementation products for home fortification
– Distribution of micronutrient supplements
– Promotion of home gardening and agricultural development
– Increasing income generation and improving access to markets
– Promotion of recommended infant feeding practices
– Ensuring adequate health care and a healthy environment
– Ensuring access to adequate non-food items
• An effective prevention strategy with long-term impact is likely to use a combination of
these different approaches. Not all approaches can be used in all situations.
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