Micronutrient

Supplementation
Program

Luz S. See
Chief Health Program Officer
NCDPC
 Outline of Presentation

Part 1: Micronutrient Status in the Philippines

Part 2: Response to the Micronutrient Problem

Part 3: Revised Guideline on Micronutrient

Supplementation
 Micronutrient

 Essential dietary element needed by the body

only in very small quantities for survival

• Every one needs micronutrients throughout

life but in different amounts depending on age
and physiologic state

• Lack can result to serious consequences on

health, physical and mental development, and
productivity of individual, community, nation
 Micronutrient Deficiencies in the Philippines
VAD
Vitamin A Deficiency IDA
Iron Deficiency Anemia

IDD
Iodine Deficiency Disorders
Vitamin A - an essential nutrient needed
by the body for normal sight, growth,
reproduction and immune competence

Vitamin A deficiency - a condition

characterized by depleted liver stores &
low blood levels of vit. A due to prolonged
insufficient dietary intake followed by poor
absorption or utilization of vit. A in the
body
Why Do People Need Vitamin A?
•One of the most essential vitamins in child
survival
•Death from measles can be reduced by 50%
•Death from diarrhea can be reduced by 40%
•Over-all mortality can be reduced by 23-35%

•For normal functioning of the immune

system which increases resistance to
infection
Vitamin A Reduces Child Mortality
Study Sites
Aceh, Indonesia 34
Bagor, Indonesia 45
NNIPS, Nepal 30
Jumla, Nepal 29
Tamil Nadu, India 54
Hyderabad, Sudan 6
Khartoum, Sudan -6
VAST, Ghana 19

-10 0 10 20 30 40 50 60 70
% Mortality Reduction
 Prevalence of Vitamin A deficiency among 6 Months to 5
year old, Pregnant and Lactating Women

45
40.1 1993 1998 2003 2008
38
35.3

30
22.2
20.1
16.4 17.5 16.4 16.5
15.2
15
9.5
6.4

0
6 mos-5y Pregnant Lactating

9
NNS, FNRI-DOST
Iron - an essential mineral and is part of
hemoglobin

Hemoglobin - the red protein in red blood

cells that carries oxygen from the lungs to the
cells

Iron Deficiency Anemia - a condition in which

there is lack of iron in the body due to low
hemoglobin concentration of the blood
 Folate or Folic acid -- functions

• Helps produce and maintain new cells

• Required to make RNA and DNA, which

are important for making and
maintaining new cells

• Particularly important during period of

growth– pregnancy and infancy

• Helps keep blood healthy

11
70

60 66.2
56.6 55.7
50 49.2
6 months - < 1y

40 37.4 1-5y
42 35.6
30 6-12y
29.6 29.1
25.7 20.8
20
19.8
10

0
1993 1998 2003 2008

Source: NNS-FNRI
Iodine - a mineral and a component of the
thyroid hormone
Thyroid hormones - needed for the brain and
nervous system to develop & function normally
Iodine Deficiency Disorders - refers to a group
of clinical entities caused by inadequacy of
dietary iodine e.g. goiter, cretinism,
mental/growth retardation, miscarriage and
still birth
 Iodine deficiency disorders at levels below
public health significance
Percent of children 6-12 years old Median UIE
with urinary iodine <50 mcg/L
40
among children 6-
35.8
12 y/o
Year Median
Percent

20 UIE
19.7

11.4 1998 71
0
2003 201
1998 2003 2008
2008 132

The indicator of iodine deficiency “elimination” is a median value

of 100 µg/L, that is , 50% of the sample should be above 100
µg/L, and not more than 20% of the samples should be below 50
µg/L.
15
 Nutrient intake
Percent adequacy
Pregnant Lactating 6 – 60
months
Energy 82.6 77.6 72.1
Protein 82.1 71.7 87.1
Iron 28.7 31.8 61.5
Vit A 61.7 50.6 75.9
Ca 49.3 49.5 66.0
Thiamin 62.2 58.1 94.7
Riboflavin 47.0 42.2 114.9
Niacin 109.5 124.2 133,9
Vit C 70.2 46.3 78.8 17
 Infant Mortality Rate

57
49

35
29
25
19

Source: NDHS
 Under-five Mortality

34

Source: NDHS
At current rate of decline, the Philippines is
unlikely to reach the MDG target for MMR by
2015
250 209

200 172
162
140
150

100

50 52

0
1993 1998 2006 2015
Malnutrition was associated with one in every two of
the 10.9 million deaths in children under-five years
in developing countries in 2000

ARI
Other 20%
29%
Malnutrition
54% Diarrhoea
12%

Measles
5%
Perinatal Malaria
22% HIV/AIDS
8%
4%

Sources: EIP/WHO 2000, based on 1999 data

1
Pelletier et al, J Nut 1994; 124:2.
 Vitamin and Mineral Deficiency:
Estimated Damage

• Deaths of >4,000 children each year from

increased susceptibility to infection (VAD)

• Approx. 20% of children with lowered

immunity leading to frequent ill health and
poor growth (VAD)

• Approx. 40% to 60% of 6-24 mos. old

children at risk of disrupted brain
development (iron deficiency)
 Vitamin and Mineral Deficiency:
Estimated Damage

• Deaths of est. 500 young Filipina women every

year in pregnancy and childbirth (severe IDA)

• Lowered productivity of adult work-force. Loss

to the Phils. estimated at 0.7% of GDP
(IDA/IDD)

• Approx. 10,000 Filipino infants a year at risk

of death in the period immediately before or
after birth (severe anemia in mothers)
 Vitamin and Mineral Deficiency:
Estimated Damage

• An est. 300,000 Filipino babies born each

year w/ intellectual impairment caused by
iodine def. in pregnancy

• In countries where goiter rate is 10% or

more (Phils. almost 15%), ave. IQ lowered
by as much as 10-15% points

• Significant but unmeasured burden on health

services, educational systems, and on families
caring for children left disabled or mentally
impaired
 Micronutrient malnutrition
is a public health concern…

Bad News

… but it is preventable!

Good News
 Strategies to Sustain Micronutrient
Malnutrition Elimination
Micronutrient Improving
1 Supplementation 2 Diet/Dietary
The provision of Diversification
pharmaceutically The adoption of proper
prepared vitamins & food & nutrition
minerals for treatment practices thru nutrition
or prevention of specific education & food
micronutrient deficiency production

Food Fortification
3 The addition of essential
micronutrients to widely consumed
food product at levels above its
natural state
 Food Fortification is …

 addition of a
micronutrient/s to food
items which are widely
consumed at levels
above its natural state Rice

Flour
 long term, cost
effective & sustainable
strategy to eliminate
micronutrient deficiency
GOAL

Increase vitamin A, iron and

iodine intake by at least 50% of
the RDA thru food fortification
particularly of the vulnerable
group (women and children)
Legal Mandates on Food Fortification

 ASIN LAW
Republic Act 8172, “An Act
Promoting Salt Iodization Nationwide
and for other purposes”
Signed into law on December 20, 1995

 Food Fortification Law

Republic Act 8976, “An Act
Establishing the Philippine Food
Fortification Program and for other
purposes”
Signed into law on November 7, 2000
 Legal Mandates on Food Fortification

• Executive Order No. 382:

Observance of National Food
Fortification Day on November 7 of
each year
• Local Ordinances/resolutions
Objectives of Food Fortification Program

To fortify
salt salt with
iodine
flour w/ Flour
vit. A & iron
edible oil
w/ vit. A
sugar w/ Sugar

rice
rice rice w/ iron vit. A

Processed foods thru

Sangkap Pinoy Seal
 Micronutrient Supplementation

Provision of vitamin A
capsules, iron/folate and
iodine supplements to
treat or prevent specific
micronutrient deficiency
DOH Administrative Order 2010-0010

Revised Policy on Micronutrient

Supplementation to Support
Achievement of 2015 MDG Targets to
Reduce Underfive and Maternal
Deaths and Address Micronutrient
Needs of Other Population Groups
Guiding Principles
1. Rights-Based Approach – anchored on the
rights of children and women

2. Systems Approach – sustained MS provisions

is contingent on the adoption of a systems
approach

3. Life cycle based intervention – aligned with

the requirements and conditions of
individuals at various stages of the life cycle

4. Equity – priority to be given to population

groups with least capacity to access MS and
those vulnerable to the deficiency
Guiding Principles
5. Complemention of Interventions – to ensure
maximum results
6. Evidence-Based Interventions & Approach
7. Integrated Service Delivery – align with
existing public health program packages &
expand provision to other health and non-
health sector settings
AO on Micronutrient Supplementation

Shall be provided to the following

priority groups:

• Low birthweight babies

• 6-59 months old chidren
• Pregnant women & Lactating mothers
• Female Adolescent girls (10-14 years)
• Non-pregnant/non-lactating Women of
Reproductive Age (15-49 years)
AO on Micronutrient Supplementation

Given current evidences, there is

no recommended micronutrient
supplementation for the following
groups except diagnosed with a
deficiency

•Children 5-9 years

•Adult males, <50 years
•Adults, > 50 years
Micronutrient Packages
 Infants: 0-11 month old

• 0-5 month old infants need not be given

supplements

• LBW infants need iron supplementation starting

at 2 months as they have lower iron stores

• 6-11 month old infants need regular iron and vit.

A supplementation for rapid growth and
development

• Vit. A supplementation to infants with high risk

conditions (measles, severe pneumonia, severely
underweight, persistent diarrhea, xerophthalmia)
 Infants: 0-11 months old

• Therapeutic dose for 6-11 months

old clinically diagnosed with IDA

• Do not give iodine supplements to

infants. Use iodized salt to
complementary food

• Treat 0-11 month old with diarrhea

with reformulated ORS and Zinc
 Children 12-59 month old (1-<5 year old)

• Regular iron and vit. A to 12-23 month old

because of high prevalence of anemia and
increased daily requirement
• Therapeutic dose to those clinically diagnosed
with anemia and with xeropthalmia
• Two doses of vit. A every 6 months for 12-59
months
• Vit A supplementation to those with high risk
conditions
• Children with measles should be given two doses
of VAC given upon diagnosis and after 24 hours
• Treat diarrhea with reformulated ORS and zinc
• Iodized salt and consumption of fortified foods
 Children 5-9 Years old
• MS not recommended; Prevalence of
micronutrient deficiencies not of public health
significance

• Vitamin A, iron and iodine needs can be met

through diet and use of fortified foods

• Therapeutic doses of iron and vit. A given for

those clinically diagnosed with anemia and
xerophthalmia

• Bring child with malaria and schistosomiasis

for treatment and iron supplementation to
health facility
 Female Adolescents (10-14 yrs) and
Non-Pregnant/Non-Lactating Women of
Reproductive Age (15-49 yrs)
Risk of developing anemia esp. when
menstruating
Once a week iron-folate supplementation
for adolescent girls at start of
menstruation until they become pregnant
(60 mg elemental iron with 2.8 mg folic acid)
 Female adolescents (10-14 yrs) and non-
pregnant/non-lactating WRA (15-49 yrs old)

• Regular diet and use of fortified foods

for their iodine and Vit. A needs

• Therapeutic dose of iron and Vit. A for

those clinically diagnosed with
deficiency
 Dosages for 10-49 years old women
• For malaria in endemic areas
– With signs and symptoms, refer for diagnosis
and treatment for malaria
– Give malaria drugs first, then at least 24 hours
administer 60 mg elemental iron with 400 ug
folic acid once a day for 2 months

• For schistosomiasis endemic areas

– 60 mg elemental iron with 400 ug folic acid, 2
tablets daily for 30 days. Administer iron
supplement first before giving Praziquantel
 Pregnant Women and
Postpartum/lactating Mothers

• Give iron-folate daily once pregnancy is

determined (180 tablets)
(1 tablet of 60 mg elemental iron with 400 ug folic acid
once a day)

• Continue giving weekly iron-folate at

postpartum until one gets pregnant

• Give Therapeutic doses for those

clinically diagnosed with deficiencies
 Pregnant and Postpartum/lactating Women

• Give iodine supplements in the ff. situations

IDD is moderate or severe (UIE is
<20ug/1-49ug/l)
 Cretinism and neonatal hypothyroidism are
present
Areas where <90% of HH are using iodized salt
and the median urinary iodine is 100ug/l among
school children
Iodine supplementation should be given 1st
trimester but no later than the 2nd trimester.
 Adults 50-59 year old
• No regular MS; through consumption of fortified foods and
regular diet
• Give therapeutic doses for those clinically diagnosed
• For malaria in endemic areas
- With signs and symptoms, refer for diagnosis and
treatment for malaria
- Give malaria drugs first, then at least 24 hours administer
60 mg elemental iron with 400 ug folic acid once a day
for 2 months
• For schistosomiasis endemic areas
- 60 mg elemental iron with 400 ug folic acid, 2 tablets
daily for 30 days.
- For schistosomiasis cases, administer iron supplement
first before giving Praziquantel
 Older Persons (60 years old & above)

• Diet of older persons do not usually meet

nutrient requirements
• Recommend MS based on individual
assessment
• Once established, long-term MS
supplementation (6 months+)
• For older Filipinos, the aim is still balanced
diet, regular physical activity, continued
mobility and social engagement
Conditions where Older Persons need MS

• Calcium (~1000 g/d) & Vit. D (400 to 900

IU/d) in postmenopausal women to prevent
further decrease of bone density and
minimize hip fractures
– caution for those at risk of calcium stone
formation

• Antioxidants (Vit.C & E at 5 to 15 times the

requirement) with zinc (10 times the
requirement) to prevent progression of
intermediate stage age-related mucular
degeneration
MS during Disasters and Emergency Situations

• Continue routine MS for infants, children,

pregnant and lactating mothers and WRA
• Additional Vit.A to 6-11 mos. old(100,000 IU), 12
– 59 months old (200,000IU), postpartum women
(200,000 IU) unless received a similar dose in the
past 4 weeks
• Children with measles given VAC regardless of
last dose given
• MNP to children 6-23 month old; expand to 24-59
yr old, pregnant and lactating women if available
• Reformulated ORS and Zinc for children with
diarrhea. Zinc is given for no less than 10 days
Therapeutic Dose of Vitamin A for Xeropthalmia Cases
Treatment of Xeropthalmia
1 VAC Today
1 VAC Tomorrow
1 VAC after two weeks
(Nightblindness, Bitot’s Spots, Corneal
Xerosis, Corneal Ulcer/ Keratomalacia)
TARGET
- 6-11 months (100,000 IU)
- 12-59 months (200,000 IU)
- 5-9 years (200,000 IU)
- 10-14 years Female adolescents
(200,000 IU)
- 15 – 49 years (200,000 IU)
- Lactating mothers (200,000 IU)
-50-59 years Adult (200,000 IU)

1 VAC 10,000 IU once a day for

-Pregnant Women (10,000 IU
4 weeks upon diagnosis,
regardless of age of gestation
(but if currently taking
multivitamins with vit. A, do
not give VAC)
 Roles & Responsibilities of Hospitals on
Micronutrient Supplementation
• Integrate the MS policy into the treatment
protocols
• Provide budgetary allocation for
procurement of micronutrients
• Conduct orientation of hospital staff on MS
policy
• Coordinate with PHO/RHU on referral &
follow-up of patients