The Value of an Ecological Approach to Improve the Precision of Nutritional Assessment: Addressing Contributors and Implications of the "Multiple Burdens of Malnutrition".

Globally, children are exposed to multiple health risks associated with diet and nutrition. Rather than simply being a condition of having too much or too little food, malnutrition is more a syndrome comprising multiple burdens of coexisting and reciprocal malnutrition, infection, or other conditions. Importantly, children with such syndromes (e.g., stunting and anemia, which are neither specific nor necessarily sensitive to nutritional status) are more likely to also have irreversible functional outcomes such as poor growth, impaired immune function, or cognitive delays. The global health community has identified nutrition-related targets (e.g., Sustainable Development Goals (SDGs) and World Health Organization (WHO) Global Nutrition Targets) that, for multiple reasons, are difficult to address. Moreover, as the complexity of the global health context increases with persistent pandemics of infectious diseases and the rising prevalence of noncommunicable diseases, there is a growing appreciation that conditions selected as nutrition/health targets indeed represent syndromes for which nutritional status serves as both an input and outcome. In recognition of the impact of these combined challenges and the role of the multiple manifestations of malnutrition, we suggest an approach to nutritional assessment that is intended to improve the precision of context-specific, equitable approaches to health promotion, disease prevention, and treatment.

Firm-Level and Public-Sector Costs Make Small-Scale Maize Flour Fortification Challenging in Uganda.

BACKGROUND: Maize flour in Uganda is milled by hundreds of enterprises, mostly small- (5-20 metric tons [MT]/day) and micro-scale (<5 MT/day) mills or firms. A mandatory maize flour fortification program exists for medium-scale mills (>20 MT/day) and policymakers are considering including smaller-scale millers. OBJECTIVE: We estimated the private and public costs of maize flour fortification at different scales and explored their implications for extending the mandatory fortification to include smaller-scale mills. METHODS: We used secondary data on the structure of the maize flour market and primary data on milling and fortification costs to estimate mill and regulatory costs at 3 scales of flour production: micro, small, and medium. RESULTS: For micro-, small-, and medium-size operations, respectively, operational costs of fortification were US$13, US$9, and US$7 per metric ton (MT) of maize flour, which represented 20%, 16%, and 16% of annual operating costs, and the ratio of fortification equipment cost to mill equipment costs was higher for micro-scale mills (2.7) than for small- (0.38) and medium-scale (0.54) maize mills. Governmental regulatory costs rise if smaller-scale mills are included due to the increased number of facility inspections. CONCLUSIONS: Fortification and regulatory costs increase as production scale decreases. Up-front capital costs of fortification would be daunting for micro- and small-scale mills. Medium-scale mills, which supply social protection programs, might be able to manage fortification costs and other challenges. Decision-makers should consider all costs and cost burdens, and the realities of enforcement capabilities before expanding fortification programs to include smaller-scale operations.

Plain language titleCosts of Small-scale Maize Flour Fortification in UgandaPlain language summaryA study of the costs of adding vitamins and minerals by small-scale maize flour millers in Uganda was undertaken to understand if it would be commercially beneficial from a business and operations perspective for them to do so, and if requiring them to do so would impose additional cost burdens on government to ensure that fortification standards were met.Why was the study done?Maize flour is consumed by the majority of Uganda's population, especially the rural poor. If the flour were fortified, it would reduce vitamin and mineral deficiencies among those at risk. The most important constraint to market-wide fortification is the presence of many small-scale mills or firms that neither have the resources nor the technology to adopt and sustain the fortification process. To date, no study has been done to calculate the costs that small-scale mills would have to face to fortify flour, or what the cost implications for government would be for including smaller-scale mills in a national fortification program, including the costs of enforcing regulations.What did the researchers do?The researchers interviewed millers of several scales of operation to collect cost information on their operations and interviewed representatives of government regulatory bodies to estimate the costs of testing maize flour to ensure compliance with regulations. Researchers estimated the cost to the mills of adding fortification to their business models, and the impacts on the government costs (eg, testing additional samples, etc.) of including smaller-scale mills in the fortification program.What did the researchers find?The researchers looked at 3 different types of mills based on their capacity to mill maize flour­micro-scale firms milled less than 5 metric tons (MT) a day, small-scale firms milled 5 to 20 MT per day, and medium-scale firms milled over 20 MT a day. For micro-, small-, and medium-size firms, respectively, fortification increased operational costs by US$13, US$9, and US$7 per MT of maize flour, which represented 20%, 16%, and 16% of annual operating costs. Similarly, governmental regulatory costs rose if smaller-scale mills were included because of the increased number of facility inspections required since the current legislation requires mandatory annual inspections.What do the findings mean?Fortification and regulatory costs increase as the scale of production by the millers decreases. If fortification by small- and micro-scale mills were made mandatory, up-front costs of fortification equipment and materials would be daunting for micro- and small-scale millers. Ugandan medium-scale millers might manage fortification costs and other challenges, but only if the social protection programs they supplied were of sufficient volume and regularity.

Improving Anemia Assessment in Clinical and Public Health Settings.

We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.

Systematic review of metrics used to characterise dietary nutrient supply from household consumption and expenditure surveys.

OBJECTIVE: To review existing publications using Household Consumption and Expenditure Survey (HCES) data to estimate household dietary nutrient supply to (1) describe scope of available literature, (2) identify the metrics reported and parameters used to construct these metrics, (3) summarise comparisons between estimates derived from HCES and individual dietary assessment data and (4) explore the demographic and socio-economic sub-groups used to characterise risks of nutrient inadequacy. DESIGN: This study is a systematic review of publications identified from online databases published between 2000 to 2019 that used HCES food consumption data to estimate household dietary nutrient supply. Further publications were identified by 'snowballing' the references of included database-identified publications. SETTING: Publications using data from low- and lower-middle income countries. RESULTS: In total, fifty-eight publications were included. Three metrics were reported that characterised household dietary nutrient supply: apparent nutrient intake per adult-male equivalent per day (n 35), apparent nutrient intake per capita per day (n 24) and nutrient density (n 5). Nutrient intakes were generally overestimated using HCES food consumption data, with several studies finding sizeable discrepancies compared with intake estimates based on individual dietary assessment methods. Sub-group analyses predominantly focused on measuring variation in household dietary nutrient supply according to socio-economic position and geography. CONCLUSION: HCES data are increasingly being used to assess diets across populations. More research is needed to inform the development of a framework to guide the use of and qualified interpretation of dietary assessments based on these data.

Modeling food fortification contributions to micronutrient requirements in Malawi using Household Consumption and Expenditure Surveys.

Large-scale food fortification may be a cost-effective intervention to increase micronutrient supplies in the food system when implemented under appropriate conditions, yet it is unclear if current strategies can equitably benefit populations with the greatest micronutrient needs. This study developed a mathematical modeling framework for comparing fortification scenarios across different contexts. It was applied to model the potential contributions of three fortification vehicles (oil, sugar, and wheat flour) toward meeting dietary micronutrient requirements in Malawi through secondary data analyses of a Household Consumption and Expenditure Survey. We estimated fortification vehicle coverage, micronutrient density of the diet, and apparent intake of nonpregnant, nonlactating women for nine different micronutrients, under three food fortification scenarios and stratified by subpopulations across seasons. Oil and sugar had high coverage and apparent consumption that, when combined, were predicted to improve the vitamin A adequacy of the diet. Wheat flour contributed little to estimated dietary micronutrient supplies due to low apparent consumption. Potential contributions of all fortification vehicles were low in rural populations of the lowest socioeconomic position. While the model predicted large-scale food fortification would contribute to reducing vitamin A inadequacies, other interventions are necessary to meet other micronutrient requirements, especially for the rural poor.

Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases.

OBJECTIVE: To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries. METHODS: The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire. RESULTS: Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries. CONCLUSIONS: The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

Double Burden of Undernutrition and Obesity in Palestinian Schoolchildren: A Cross-Sectional Study.

BACKGROUND: The coexistence of underweight and overweight (double burden) remains a major problem in many developing countries. Little is known about the factors associated with the double burden of malnutrition in Palestinian children. OBJECTIVE: To assess factors associated with undernutrition and overnutrition in 1500 schoolchildren aged 5 to 16 years, in the West Bank. METHODS: We surveyed a sample of 22 schools run by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the Palestinian government. Binary logistic regression was used to examine the factors associated with malnutrition. The hunger index, a composite score from 8 questions, was used to measure food insecurity. RESULTS: In the 1484 children enrolled in UNRWA and government schools in the West Bank, the prevalence of stunting was 7% and underweight 3%. Around 12% of students were overweight and 6% obese. The hunger index was negatively associated with height for age. Factors associated with being underweight were male sex, mother being unemployed, and households not having enough food to eat for at least 2 days in the previous month. Factors associated with obesity were older age and time spent watching television. When overweight and obesity were combined in the analysis, they were inversely associated with increasing number of days spent playing sports. CONCLUSION: Our results show that the important nutritional risks for school-age children in the West Bank would seem to be the simultaneous occurrence of undernutrition and obesity. The study highlights the need to balance obesity management and prevention with interventions to tackle undernutrition.

Predicted efficacy of the Palestinian wheat flour fortification programme: complementary analysis of biochemical and dietary data.

OBJECTIVE: To utilize complementary biochemical and dietary data collected before the initiation of national flour fortification to (i) identify micronutrient insufficiencies or deficiencies and dietary inadequacies in Palestinian women and children in vulnerable communities and (ii) assess the suitability of the current wheat flour fortification formula. DESIGN: Quantitative dietary intake questionnaires were administered and fasting venous blood samples collected in randomly selected households in Gaza City and Hebron. The impact of fortification was simulated by estimating the additional micronutrient content of fortified wheat flour. SETTING: Households in Gaza City and Hebron that were not receiving food aid from social programmes. SUBJECTS: Non-pregnant women (18-49 years) and children aged 36-83 months. RESULTS: The micronutrients with highest prevalence of insufficiency were vitamin D in women (84-97 % with serum 25-hydroxyvitamin D <50 nmol/l) and vitamin B12 in women and children (43-82 % with serum B12 <221 pmol/l). Deficiencies of vitamin A, Fe and Zn were also of public health concern. Current levels of wheat flour fortificants were predicted to improve, but not eliminate, micronutrient intake inadequacies. Modification of fortificant concentrations of vitamin D, thiamin, vitamin B12, Zn and folic acid may be indicated. CONCLUSIONS: Micronutrient insufficiencies or deficiencies and intake inadequacies were prevalent based on either biochemical or dietary intake criteria. Adjustments to the current fortification formula for wheat flour are necessary to better meet the nutrient needs of Palestinian women and children.

Methods of using household consumption and expenditures survey (HCES) data to estimate the potential nutritional impact of fortified staple foods.

BACKGROUND: Micronutrient malnutrition, caused largely by inadequate dietary intake, is a global public health problem that adversely affects health, child growth and development, work capacity, and quality of life. Mass fortification of widely consumed edible products has the potential to increase micronutrient intakes and thus alleviate some nutritional deficiencies. Although individual-level data about food consumption patterns are ideal for informing the design of food fortification programs, they are often unavailable. Household Consumption and Expenditures Surveys (HCES) are nationally representative cross-sectional surveys conducted over a 12-month period every 2 to 5 years, primarily to characterize household expenditures. OBJECTIVE: We describe how expenditure data from HCES can serve as a proxy for household food consumption and thus aid in choosing which foods to fortify and in determining how much of a micronutrient to add to that food. METHODS: We describe methods of using HCES data to characterize apparent food consumption patterns among different strata within a population. RESULTS: There are several limitations of using HCES data to describe apparent food consumption. HCES do not directly capture information about true food intake, but rather describe food expenditures. We assume that purchased foods are not shared with guests, wasted, fed to animals, gifted, or stockpiled for later use. We also assume that foods are allocated within each household based on energy needs. CONCLUSIONS: Despite the limitations of using HCES data to estimate apparent food consumption, the dearth of individual-level data about food intake renders HCES data useful in designing food fortification programs.

Validation of dietary applications of Household Consumption and Expenditures Surveys (HCES) against a 24-hour recall method in Uganda.

BACKGROUND: The benefits of food fortification depend on the proportion of the population that uses the fortified food (coverage), the amount of the food being consumed, and the additional content of micronutrients in the food. Coverage and amounts consumed can be determined by 24-hour recall or Food Frequency Questionnaires (FFQs). However, these methods are rarely applied. Secondary analysis of data from Household Consumption and Expenditures Surveys (HCES) can be used for these purposes; however, such data analysis has not been validated. OBJECTIVE: To compare the results of HCES and 24-hour recall for estimating the consumption profile of potential fortification vehicles in Uganda. METHODS: Food intake estimates for 24- to 59-month-old children and 15- to 49-year-old women derived from a one-day 24-hour recall carried out in Uganda (Kampala, North, and Southwest) were compared with data from two HCES (2006, nationwide, and 2008, coupled with the 24-hour recall). The analyzed foods were vegetable oil, sugar, wheat flour, maize flour, and rice. RESULTS: Food consumption estimates calculated from HCES may be less accurate than estimates derived by 24-hour recall. Nevertheless, the HCES results are sensitive enough to differentiate consumption patterns among population strata. In Uganda, HCES predicted proportion of the population that consumes the foods, and approximated intakes of main food vehicles by the "observed" consumers (those who reported using the foods), although estimates for the latter were lower for wheat flour and rice. CONCLUSIONS: HCES data offer the basic information needed to provide a rationale for, and help design, food fortification programs. Individual intake surveys are still needed, however, to assess intrahousehold use of foods.

Comparison of estimates of the nutrient density of the diet of women and children in Uganda by Household Consumption and Expenditures Surveys (HCES) and 24-hour recall.

BACKGROUND: Individual dietary intake data are important for informing national nutrition policy but are rarely available. National Household Consumption and Expenditures Surveys (HCES) may be an alternative method, but there is no evidence to assess their relative performance. OBJECTIVE: To compare HCES-based estimates of the nutrient density of foods consumed by Ugandan women (15 to 49 years of age) and children (24 to 59 months of age) with estimates based on 24-hour recall. METHODS: The 52 food items of the Uganda 2006 HCES were matched with nutrient content of foods in a 2008 24-hour recall survey, which were used to refine the HCES-based estimates of nutrient intakes. Two methods were used to match the surveys'food items. Model 1 identified the four or five most commonly consumed foods from the 24-hour recall survey and calculated their unweighted average nutrient contents. Model 2 used the nutrient contents of the single most consumed food from the 24-hour recall. For each model, 14 estimates of nutrient densities of the diet were made and 84 differences were compared. RESULTS: Models 1 and 2 were not significantly different. Of the model 2 HCES-24-hour recall comparisons, 67 (80%) did not find a significant difference. No significant differences were found for protein, fat, fiber, iron, thiamin, riboflavin, and vitamin B6 intakes. HCES overestimated intakes of vitamins C and B12 and underestimated intakes of vitamin A,folate, niacin, calcium, and zinc in at least one of the groups. CONCLUSIONS: The HCES-based estimates are a relatively good proxy for 24-hour recall measures of nutrient density of the diet. Further work is needed to ascertain nutrient adequacy using this method in several countries.

Need for coordinated programs to improve global health by optimizing salt and iodine intake / Necesidad de programas coordinados para mejorar la salud a escala mundial mediante la optimización de la ingesta de sal y yodo

High dietary salt is a major cause of increased blood pressure, the leading risk for death worldwide. The World Health Organization (WHO) has recommended that salt intake be less than 5 g/day, a goal that only a small proportion of people achieve. Iodine deficiency can cause cognitive and motor impairment and, if severe, hypothyroidism with serious mental and growth retardation. More than 2 billion people worldwide are at risk of iodine deficiency. Preventing iodine deficiency by using salt fortified with iodine is a major global public health success. Programs to reduce dietary salt are technically compatible with programs to prevent iodine deficiency through salt fortification. However, for populations to fully benefit from optimum intake of salt and iodine, the programs must be integrated. This review summarizes the scientific basis for salt reduction and iodine fortification programs, the compatibility of the programs, and the steps that need to be taken by the WHO, national governments, and nongovernmental organizations to ensure that populations fully benefit from optimal intake of salt and iodine. Specifically, expert groups must be convened to help countries implement integrated programs and context-specific case studies of successfully integrated programs; lessons learned need to be compiled and disseminated. Integrated surveillance programs will be more efficient and will enhance current efforts to optimize intake of iodine and salt. For populations to fully benefit, governments need to place a high priority on integrating these two important public health programs.

El alto contenido de sal en la dieta es una causa principal de incremento de la presión arterial, el principal factor de riesgo de muerte a escala mundial. La Organización Mundial de la Salud (OMS) ha recomendado que el consumo de sal sea inferior a 5 g/d, una meta que solo logran una pequeña proporción de personas. La falta de yodo puede causar deficiencia cognoscitiva y motora y, si es grave, hipotiroidismo, con grave retraso mental y del crecimiento. Más de dos mil millones de personas en todo el mundo presentan riesgo de carencia de yodo. La prevención de la carencia de yodo mediante el empleo de sal yodada constituye una importante conquista de salud pública a escala mundial. Los programas cuyo objeto es reducir el contenido de sal en la dieta son técnicamente compatibles con los programas de prevención de la carencia de yodo mediante el enriquecimiento de la sal. Sin embargo, para que las poblaciones se puedan beneficiar plenamente de una ingesta óptima de sal y yodo, es preciso integrar ambos tipos de programa. Este estudio resume las bases científicas de los programas de reducción de sal y enriquecimiento con yodo, la compatibilidad de esos programas, y las medidas que deben adoptar la OMS, los gobiernos nacionales y las organizaciones no gubernamentales para garantizar que las poblaciones se beneficien plenamente de una ingesta óptima de sal y yodo. En concreto, es preciso reunir a grupos de expertos para ayudar a los países a aplicar programas integrados y llevar a cabo estudios de casos en contextos específicos de programas integrados eficaces; es preciso recopilar y difundir las enseñanzas extraídas. La integración de los programas de vigilancia los hará más eficaces y mejorará las iniciativas actuales para optimizar la ingesta de yodo y sal. Para que las poblaciones puedan beneficiarse plenamente, es preciso que los gobiernos asignen una alta prioridad a la integración de estos dos importantes tipos de programas de salud pública.

Need for coordinated programs to improve global health by optimizing salt and iodine intake.

High dietary salt is a major cause of increased blood pressure, the leading risk for death worldwide. The World Health Organization (WHO) has recommended that salt intake be less than 5 g/day, a goal that only a small proportion of people achieve. Iodine deficiency can cause cognitive and motor impairment and, if severe, hypothyroidism with serious mental and growth retardation. More than 2 billion people worldwide are at risk of iodine deficiency. Preventing iodine deficiency by using salt fortified with iodine is a major global public health success. Programs to reduce dietary salt are technically compatible with programs to prevent iodine deficiency through salt fortification. However, for populations to fully benefit from optimum intake of salt and iodine, the programs must be integrated. This review summarizes the scientific basis for salt reduction and iodine fortification programs, the compatibility of the programs, and the steps that need to be taken by the WHO, national governments, and nongovernmental organizations to ensure that populations fully benefit from optimal intake of salt and iodine. Specifically, expert groups must be convened to help countries implement integrated programs and context-specific case studies of successfully integrated programs; lessons learned need to be compiled and disseminated. Integrated surveillance programs will be more efficient and will enhance current efforts to optimize intake of iodine and salt. For populations to fully benefit, governments need to place a high priority on integrating these two important public health programs.

Establishing safe and potentially efficacious fortification contents for folic acid and vitamin B12.

Determining the micronutrient contents infortified foods depends not only on the health goal (additional intake to complement the diet), but also on ensuring that fortification does not raise micronutrient intakes beyond the Tolerable Upper Intake Level (UL), i.e., the safe limit. Technological incompatibility and cost may also restrict the fortification contents. For folic acid, the limiting factor is safety, while for vitamin B12, it is cost. However, adequate fortification contents that are both safe and efficacious can be estimated for both nutrients. In order to obtain the maximum benefit from the fortification programs, three different formulas responding to three categories of consumption, as specified by the median and 95th percentile of consumption, are proposed. The model presented is based on the estimation of a Feasible Fortification Level (FFL), which then is used to determine the average, minimum, and maximum contents of the nutrients during production, taking into consideration the acceptable variation of the fortification process. Finally, the regulatory parameters, which support standards and enforcement, are calculated by reducing the proportion of the nutrient that is degraded during the usual marketing process of the fortified food. It is expected that this model will establish a common standard for food fortification, and improve the reliability and enforcement procedures of these programs. The model was applied to flours as vehicles for folic acid in the United States, Guatemala, and Chile. Analysis of the data revealed that, with the exception of Chile, where wheat flour consumption is very high and probably within a narrow range, supplementation with folic acid is still needed to cover individuals at the low end of consumption. This is especially true when the difference in flour consumption is too wide, as in the case of Guatemala, where the proportional difference between consumption at the 95th percentile of the nonpoor group is as high as 100 times the consumption at the 5th percentile of the extremely poor group. Adoption of fortification content for staple foods near the safe limit brings together the need of restricting the voluntary addition of the specific nutrient to other foods and to dietary supplements.

Wheat flour fortification is unlikely to benefit the neediest in Guatemala.

The potential impact of wheat flour fortification with iron and folic acid was assessed using data about food purchases from the nationally representative 2000 Guatemalan Living Standards Measurement Survey. Of 7265 households, 35% were indigenous and 57% rural; 11% were extremely poor, 35% were poor, and 54% were nonpoor. The percentage of households that purchased wheat flour, sweet bread, French rolls, and sliced bread in the previous 15 d was 10, 88, 59, and 11%, respectively. The median amount of fortified wheat flour equivalents in purchased foods was 50 g/d per adult equivalent; fortified wheat flour equivalents were 7, 25, and 110 g/d for the poverty groups, 16 g/d in indigenous households and 24 g/d in rural households. Wheat flour fortification contributed 2.3 mg/d of iron and 90 microg/d of folic acid per adult equivalent. Assuming 5% bioavailability, wheat flour fortification provided 2% of the recommended dietary allowance (RDA) and 6% of estimated average requirement (EAR) iron levels for women of reproductive age; values were 1, 3, and 12% of EAR levels for the poverty groups, respectively. Wheat flour fortification met 26% of folic acid RDA and 33% of EAR levels for women; values were 5, 16, and 71% of EAR levels for the poverty groups, respectively. In conclusion, the impact of fortification is likely to be substantial for folate status in nonpoor and urban women but limited in the case of iron status among all social groups. The poorest, rural, indigenous populations who suffer the highest burden of nutritional deficiencies likely benefit least from wheat flour fortification.

Deficiencia de vitamina A y acciones para su prevención y control en América Latina y el Caribe, 1994 / Vitamin A deficiency and actions for its prevention and control in Latin America and the Caribbean, 1994

Desde la década de los años setenta, en los países de América Latina y el Caribe se ha reducido la prevalencia de desnutrición proteinoenergética. Sin embargo, las carencias de micronutrientes, especialmente de yodo, hierro y vitamina A, no han disminuido en la misma proporción. Según criterios clínicos, la deficiencia de vitamina A continúa siendo un problema de salud pública en el Brasil, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua y la República Dominicana. Esta deficiencia también es frecuente en comunidades pobres de Bolivia, en algunas regiones de México y el Perú y en grupos indígenas de Panamá. Las tendencias de los indicadores generales de salud y nutrición de Colombia, Cuba, Guyana, Paraguay y Venezuela sugieren la necesidad de actualizar la información sobre la deficiencia de vitamina A en estos países. A finales de los años ochenta, aumento el interés por reducir la deficiencia de vitamina A en la Región de las Américas, lo que ha estimulado la realización de estudios epidemiológicos, reuniones nacionales y regionales, y la puesta en marcha de planes e intervenciones a nivel local, nacional y regional. La solución permanente a la deficiencia de vitamina A se podrá logar, a mediano y largo plazo, a través de un desarrollo económico y social sostenido, acompañado de acciones específicas de diversificación alimentaria encaminadas a aumentar el consumo de alimentos que son fuente de la vitamina, incluidas las fortificación de los de consumo popular y la educación nutricional. A corto plazo se pueden emplear medidas transitorias como la suplementación periódica con vitamina A a grupos de alto riesgo (AU)

Deficiencia de vitamina A y acciones para su prevención y control en América Latina y el Caribe, 1994 / Vitamin A deficiency and actions for its prevention and control in Latin America and the Caribbean, 1994

Desde la década de los años setenta, en los países de América Latina y el Caribe se ha reducido la prevalencia de desnutrición proteinoenergética. Sin embargo, las carencias de micronutrientes, especialmente de yodo, hierro y vitamina A, no han disminuido en la misma proporción. Según criterios clínicos, la deficiencia de vitamina A continúa siendo un problema de salud pública en el Brasil, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua y la República Dominicana. Esta deficiencia también es frecuente en comunidades pobres de Bolivia, en algunas regiones de México y el Perú y en grupos indígenas de Panamá. Las tendencias de los indicadores generales de salud y nutrición de Colombia, Cuba, Guyana, Paraguay y Venezuela sugieren la necesidad de actualizar la información sobre la deficiencia de vitamina A en estos países. A finales de los años ochenta, aumento el interés por reducir la deficiencia de vitamina A en la Región de las Américas, lo que ha estimulado la realización de estudios epidemiológicos, reuniones nacionales y regionales, y la puesta en marcha de planes e intervenciones a nivel local, nacional y regional. La solución permanente a la deficiencia de vitamina A se podrá logar, a mediano y largo plazo, a través de un desarrollo económico y social sostenido, acompañado de acciones específicas de diversificación alimentaria encaminadas a aumentar el consumo de alimentos que son fuente de la vitamina, incluidas las fortificación de los de consumo popular y la educación nutricional. A corto plazo se pueden emplear medidas transitorias como la suplementación periódica con vitamina A a grupos de alto riesgo (AU)