Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean.

BACKGROUND: Hunger, food insecurity, stunting, anemia, overweight, and noncommunicable diseases (NCDs) may coexist in the same person, household, and community in Latin America and the Caribbean (LAC). The double burden of malnutrition (DBM) is an important cause of disability and premature death, which could be addressed with comprehensive policies such as the Plan of Action for the Prevention of Obesity in Children and Adolescents. This paper summarizes the main policies and actions aimed to prevent undernutrition and obesity. SUMMARY: Several countries are implementing the Plan of Action, Caribbean Public Health Agency is actively supporting Ministries of Health, Education, and Sport to develop school nutrition policies and strategies to create health-promoting environments at school and in their surrounding communities. Chile is implementing the comprehensive child protection system "Chile Crece Contigo" that integrates health, social development, and educational activities to optimize growth and childhood cognitive-motor development. Brazil is implementing policies and plans to commit to international targets regarding food and nutrition security, NCDs and their risk factors. Key Messages: The DBM exists in the Americas and contributes to disability and premature death. The Region is making progress implementing policies and actions addressing the DBM. However, stronger political will and leadership are needed to enact legislation and policies that create and support enabling -environments.

Experiences and lessons learned for programme improvement of micronutrient powders interventions.

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

Nutrition situation in Latin America and the Caribbean: current scenario, past trends, and data gaps.

OBJECTIVE: To determine the current nutritional status in Latin America and the Caribbean (LAC) and identify data gaps and trends in nutrition surveillance. METHODS: A systematic Internet search was conducted to identify official sources that allowed for monitoring of LAC countries' nutritional status, including progress toward World Health Organization Global Nutrition Targets 2025. Reports from national nutrition surveillance systems and reports on nationally representative surveys were collected and collated to 1) analyze nutritional status, based on life-course anthropometric indicators and biomarkers, and 2) identify gaps in data availability and trends in nutritional deficiencies. Information on iron, vitamin A, iodine, folate, and vitamin B12 deficiency was also collected and collated. RESULTS: Twenty-two of the 46 LAC countries/territories (48%) had information on undernutrition (stunting, underweight, and wasting) in children under 5 years old and women of reproductive age (WRA). Seventeen countries (38%) had information on anemia in children under 5 years old and WRA, and 12 (27%) had information on anemia in pregnant women. Although overall nutritional status has improved in the past few decades in all countries in the region, some LAC countries still had a high prevalence of stunting and anemia in children and WRA. Overweight affected at least 50% of WRA in nine countries with available data, and was increasing in children. Data for school-age children, adolescents, adult males, and older adults were scarce in the region. CONCLUSIONS: Overall nutritional status has improved in the LAC countries with available information, but more efforts are needed to scale up nutrition-sensitive and nutrition-specific interventions to tackle malnutrition in all its forms, as stunting, anemia, and vitamin A deficiency are still a public health problem in many countries, and overweight is an epidemic. Nutrition information systems are weak in the region, and countries need to strengthen their capacity to monitor nutritional status indicators.

Conditional cash transfer programs and the health and nutrition of Latin American children.

OBJECTIVE: To 1) describe the benefits, conditions, coverage, funding, goals, governance, and structure of well-established conditional cash transfer programs (CCTs) in Latin America and 2) identify their health and nutritional impacts among children under 5 years old. METHODS: A realist review was conducted. CCTs were included if they met the following inclusion criteria: 1) current national-level program; 2) coverage of at least 50% of the target population; 3) continuous operation at scale for 10+ years; 4) clear description of structure, funding sources, and governance; 5) both health/nutrition- and education-related conditions for participation; and 6) available impact evaluation studies with health, development, and/or nutrition indicators among children under 5 years old. Three CCTs (one each in Brazil, Colombia, and Mexico) met the criteria. RESULTS: There was consistent evidence that the three CCTs selected for review had positive impacts on child health and nutrition outcomes in their respective countries. In all three countries, the programs were scaled up and positive impacts were documented relatively quickly. All three programs had strong political support and clear and transparent governance structures, including accountability and social participation mechanisms, which might explain their success and sustainability. CONCLUSIONS: CCTs in Latin America have had a positive impact on child health and nutrition outcomes among the poorest families. A key challenge for the future is to reform these programs to help families move out of not only extreme poverty but all poverty in order to lead healthy and productive lives, as called for in the post-2105 Sustainable Development Goals.

Tackling malnutrition in Latin America and the Caribbean: challenges and opportunities.

Undernutrition and micronutrient deficiencies are still a public health problem in Latin America and the Caribbean (LAC), and overweight and obesity have reached epidemic proportions. To assess the nutrition landscape in LAC countries and guide future nutrition efforts and investments, the Pan American Health Organization and the Micronutrient Initiative joined efforts to 1) identify information gaps and describe the current nutritional situation in the region; 2) map existing policies to address malnutrition in Latin America; 3) describe the impact of conditional cash transfer programs (CCTs) on nutrition and health outcomes; and 4) identify the challenges and opportunities to address malnutrition in the region. This article summarizes the methods and key findings from that research and describes the current challenges and opportunities in addressing malnutrition in the LAC region. LAC countries have advanced in reducing undernutrition and micronutrient deficiencies, but important gaps in information are a major concern. These countries have policies to address undernutrition and micronutrient deficiencies, but comprehensive and intersectoral policies to tackle obesity are lacking. CCTs in Brazil, Colombia, and Mexico have been reported to have a positive impact on child nutrition and health outcomes, providing an opportunity to integrate nutrition actions in intersectoral platforms. The current epidemiological situation and policy options offer an opportunity for countries, technical agencies, donors, and other stakeholders to jointly scale up nutrition actions. This can support the development of comprehensive and intersectoral policies to tackle the double burden of malnutrition, strengthen national nutrition surveillance systems, incorporate monitoring and evaluation as systematic components of policies and programs, document and increase investments in nutrition, and assess the effectiveness of such policies to support political commitment and guarantee sustainability.

Mapping of nutrition and sectoral policies addressing malnutrition in Latin America.

OBJECTIVE: To map existing policies addressing malnutrition in all its forms in Latin America and identify gaps in enabling environments supporting the five priority lines of action outlined in the World Health Organization Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (CIP) approved in 2014. METHODS: This descriptive study consisted of a systematic Internet search for and mapping of publicly available nutrition-related and sectoral policies already in place to address malnutrition in all its forms in 18 Latin American countries (Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, and Uruguay). The policies were described in documents retrieved from the websites of ministries of health, education, agriculture, labor, and development; the national congress; and other government agencies. RESULTS: All 18 countries had relevant policies to address malnutrition, especially undernutrition and micronutrient deficiencies, but only a few had policies to address overweight and obesity. Nutrition actions were incorporated in food and nutrition security and social protection policies in all 18 countries, and were part of education, environment, agricultural, development, and/or employment policies in some countries. Information on human and financial resources assigned to nutrition was not available through the search strategies used in the study. CONCLUSIONS: All 18 countries included in this review had established enabling environments to support CIP implementation. However, each of the 18 countries needs to develop integrated policies for the promotion of nutrition and prevention of noncommunicable diseases through cross-sector involvement and multi-stakeholder collaboration.

Factors Impacting the Uptake of Research into Dietary Sodium Reduction Policies in Five Latin American Countries: A Qualitative Study.

Background: Diets high in sodium are a risk factor for cardiovascular disease (CVD). Latin American countries (LAC) consume more than double the recommended sodium levels. Research uptake in dietary sodium reduction policies has been inconsistent in LAC, and the factors impacting research uptake are largely unknown. This study aimed to describe the barriers and facilitators to the uptake of research into sodium reduction policies from a funded research consortium with 5 LAC (Argentina, Brazil, Costa Rica, Paraguay, and Peru). Methods: A qualitative case study included 5 researchers and 4 Ministry of Health officers from the funded consortium. Dimensions from Trostle's framework of actors, content, context, and process and relative advantages from the Diffusion of Innovation informed the semi-structured interview guide and analysis. One-on-one interviews were completed from November 2019 to January 2020. The participants validated transcripts, coded, and analyzed using NVivo software. Results: Key barriers to policy advancements included 1) conflicts of interest from the food industry and some government actors; 2) government turnover resulting in policy and personnel changes; 3) a lack of human and financial resources; and 4) and communication gaps among key actors. Key facilitators to policy advancement included: 1) the content and quality of health economic, food supply, and qualitative data; 2) support, technical assistance, and alliances with the government, non-governmental organizations, and international experts; and 3) researchers enhanced skillsets facilitated with communication and dissemination with policymakers. Conclusion: Researchers and policymakers are faced with several barriers and facilitators on research uptake in policies and programs in LAC; these factors should be addressed and leveraged to advance sodium reduction policy development. Future LAC studies can draw from the insights and lessons learned from this case study and apply the results to future efforts on policy nutrition to promote healthy eating and reduce CVD risk.

Micronutrient supplementation may reduce symptoms of depression in Guatemalan women.

Evidence for the impact of micronutrient supplementation trials on depression in women from developing countries is limited. This study examines this association and compares the impact of weekly versus daily combinations of micronutrient supplements on symptoms of depression. A randomized, positive-controlled trial was conducted in Guatemala. A total of 459 women were assigned randomly to 4 groups to receive weekly (5,000 or 2,800 microg) or daily (400 or 200 microg) folic acid (FA) plus iron, zinc and vitamin B-12 for 12 weeks. Depression was measured using the Center for Epidemiologic Studies-Depression 20-item Scale (CES-D). A score = 16 was used as an indication of depression. The association between micronutrient status and depression was assessed using baseline data. Generalized linear regression models were used to assess treatment effects. The baseline mean CES-D score was 17.1 +/- 8.5 and the prevalence of depression was 49.3%. Women in the lowest tertile of red blood cell folate (RBC) were 1.7 times more likely to be depressed than those in the highest tertile (OR=1.71; 95% CI: 0.91, 3.18). There were no associations between depression and serum folate, homocysteine, vitamin B-12, hemoglobin, ferritin or zinc (p > 0.05). Mean depression scores decreased by 2.3 points post-intervention and depression decreased to 37.7%, with no differences in degree of improvement by group (p = 0.64). Low RBC folate was associated with elevated symptoms of depression at baseline. Supplementation with FA-containing micronutrients may be equally efficacious in improving symptoms of depression when provided daily or weekly. Our findings that poor folate status may increase depression needs to be further investigated.

Risk of excessive intake of vitamins and minerals delivered through public health interventions: objectives, results, conclusions of the meeting, and the way forward.

The excessive consumption of certain vitamins and minerals could have deleterious consequences on health and development of individuals and populations. Simultaneous micronutrient-delivery interventions could be challenging in terms of safety as the target populations may overlap, posing a risk of excessive intake of certain micronutrients. The Evidence and Programme Guidance Unit of the Department of Nutrition for Health and Development of the World Health Organization convened a technical consultation on the risk of excessive intake of vitamins and minerals delivered through public health interventions in October 2017. The technical consultation's working groups identified important and emerging technical issues, lessons learned, and research priorities related to (1) planning, implementing, monitoring, and evaluating nutrition programs for the detection and control of the risk of excessive intakes; (2) safety, quality control, and assurance considerations; (3) coordination between public health nutrition interventions and other interventions and sectors; and (4) the legislative framework and policy coherence needed for simultaneous nutrition interventions. This paper provides the background and rationale of the technical consultation, synopsizes the presentations, and provides a summary of the main considerations proposed by the working groups.

Weekly may be as efficacious as daily folic acid supplementation in improving folate status and lowering serum homocysteine concentrations in Guatemalan women.

Daily folic acid (FA) supplementation improves folate status, lowers circulating homocysteine (Hcy) concentrations, and reduces the risk of neural tube defects. Little is known about the efficacy of weekly FA supplementation. The objective of this study was to compare the efficacy of weekly and daily FA supplementations in improving folate and vitamin B-12 status and lowering Hcy concentrations in healthy reproductive-aged women. A randomized, double-blind supplementation trial was conducted in Guatemala. A total of 459 women were assigned randomly to 4 groups to receive weekly (5000 or 2800 microg) or daily (400 or 200 microg) FA for 12 wk. Daily and weekly iron, zinc, and vitamin B-12 were also provided. We determined serum and RBC folate by microbiological assays, but the latter was available only at baseline. Serum Hcy and vitamin B-12 were also measured. We used generalized linear regression models to assess the effects of treatment on biochemical indicators. Supplementation improved folate status similarly across all 4 groups. Overall, mean serum folate concentrations increased by 15.4 nmol/L (95% CI: 13.8, 16.9) and the geometric mean serum Hcy concentration decreased by 9.8% (95% CI: -12.3, -7.1). Daily supplementation improved serum vitamin B-12 by 20% (95% CI: 8, 33.2), whereas weekly supplementation had no effect. In conclusion, weekly FA (either high or low dose) plus vitamin B-12 may be as efficacious as daily supplementation in improving serum folate and lowering Hcy concentrations in healthy women of reproductive age.

Estimated fumonisin exposure in Guatemala is greatest in consumers of lowland maize.

Fumonisin mycotoxins contaminate maize worldwide. Analysis of maize samples (n = 396) collected from fields in Guatemala from 2000 to 2003 found that lowland maize (<360 m) had significantly more fumonisin B1 than highland maize (>1200 m). For example, 78% of the lowland samples collected at harvest in 2002 contained >0.3 microg/g of fumonisin B1, whereas only 2% of the highland samples contained >0.3 microg/g. Maize from the 2002 crop collected from storage in the highlands just before the 2003 harvest contained significantly more fumonisin B1 compared with levels at harvest in 2002. All Fusarium-infected kernels analyzed from 9 random lowland locations in 2001 were infected with fumonisin-producing Fusarium verticillioides and no other Fusarium species, whereas in samples from the highlands, only 5% of the Fusarium-positive kernels were F. verticillioides. In 2005, maize samples (n = 236) from the 2004 crop were collected from local markets in 20 Departments across Guatemala. The analysis showed that maize from lowland locations was often highly contaminated with fumonisin and was frequently transported to and sold in highland markets. Thus, fumonisin exposure in the highlands will be greatest in groups that obtain their maize in the market place from commercial vendors. Based on a recall study and published consumption data, a preliminary assessment of daily intake of total fumonisins was estimated. Consumption of nixtamalized maize products made from >50% of the maize from commercial vendors in 2005 could result in exposure exceeding the recommended WHO provisional maximal tolerable daily intake.

Maternal and childhood nutrition and later blood pressure levels in young Guatemalan adults.

BACKGROUND: Low birth weight and subsequent rapid child growth are associated with later blood pressure levels. The role of maternal and child nutrition in this association remains unclear. METHODS: We studied 450 men and women (ages 21-29 years) born during a randomized trial of protein-energy supplementation (Atole) vs low energy/no protein supplementation (Fresco) in pregnancy and early childhood in four rural Guatemalan villages from 1969 to 1977. RESULTS: Protein-energy supplementation was not associated with differences in blood pressure in adulthood (diastolic blood pressure (DBP): beta = 0.69 mm Hg, 95% confidence internal (CI) (20.82-2.19); P = 0.37; systolic blood pressure (SBP): beta = 0.17 mm Hg, 95% CI (21.68-2.02); P = 0.86). Within the Atole group, maternal height was associated with later SBP (0.22 mm Hg/cm, 95% CI (20.002-0.45); P = 0.05). No other associations between maternal nutritional status, birth size, child growth, or supplement intake were observed for adult blood pressure. CONCLUSIONS: Our data do not support the role of maternal nutrition during pregnancy, birth size, or early child growth in programming adult blood pressure. Likewise, we found no effect of protein-energy supplementation in pregnancy or in early childhood on blood pressure in young adults.

The human capital study 2002-04: tracking, data collection, coverage, and attrition.

Between 2002 and 2004, the Institute of Nutrition of Central America and Panama (INCAP), in collaboration with Emory University, the International Food Policy Research Institute (IFPRI), and the University of Pennsylvania, re-surveyed young Guatemalan adults who had, as children, been participants in a nutrition supplementation trial conducted by INCAP between 1969 and 1977. This "Human Capital Study 2002-04" complements and extends data obtained in previous studies by collecting new information on measures of physical health and well-being, schooling and cognitive ability, wealth, consumption and economic productivity, and marriage and fertility histories. This paper describes the study domains and data collection procedures. Among 2,393 members of the original sample, 1,856 (77%) were targets for enrollment. Response rates varied by gender, current place of residence, and domain of data collection, with 80% of males and 89% of females completing at least one data collection instrument. Attrition was not random and appears to be associated with a number of initial characteristics of individuals and their households that should be controlled for in future analyses. We conclude that data collection was successful and data quality is high, facilitating the successful undertaking of our planned investigation of important study hypotheses.

Schooling, educational achievement, and cognitive functioning among young Guatemalan adults.

Quantity and quality of schooling obtained and the resulting skills and knowledge acquired are important components of human capital. We describe the distribution of selected measures of schooling, educational achievement, and cognitive functioning among individuals who participated as children in a nutrition supplementation trial in Guatemala and were followed up in 2002-04. Among 1,469 respondents (response rate 80%), who were 26-41 years of age in 2003, more than 90% of men and women had attended at least some school; more than half of men and more than one-third of women had completed sixth grade. Schooling attainment of both men and women has increased across birth cohorts but the schooling gap between men and women has increased. Parental socioeconomic status, as measured in 1975, is a strong predictor of schooling attainment. Basic literacy is high among those studied, with more than 80% able to read simple sentences. The gap in educational achievement favoring men narrowed across birth cohorts due to increases among younger women. The greater performance among men on the Raven's Progressive Matrices test persisted despite increased scores in the younger birth cohorts for both men and women. Migrants to Guatemala City have completed more years of school and scored higher on the tests of educational achievement and cognitive functioning than have cohort members who have remained in the study villages.

Fertility behavior and reproductive outcomes among young Guatemalan adults.

Fertility rates have declined in many developing countries and this has implications for health and development of subsequent generations. Guatemala has the highest fertility rates in Central America. Reproductive histories were obtained by interview in 2002-04, in a cohort of 779 women and 647 men who had participated as young children in a nutrition supplementation trial in Guatemala conducted between 1969 and 1977. Most women (77%) and men (79%) are currently married. Among the 700 women and 524 men reporting at least one birth, mean age at first birth was 20.7 +/- 3.8 years and 23.1 +/- 3.9 years respectively. Knowledge (> 80%) and use (approximately 70%) of modern contraceptive methods is fairly high; knowledge increases with parental socioeconomic status (SES) as measured in 1975. Younger respondents have experienced fewer pregnancies and live births compared with older respondents; age-specific fertility rates between 20 and 24 years were 294, 249, 236, and 261 births per 1,000 women, respectively, for women born from 1962-65, 1966-69, 1969-73, and 1974-77. Women in the top tertile of parental SES have had significantly fewer pregnancies (3.3) compared with those in the middle (3.7) and lower (3.8) tertiles. Migrants to Guatemala City reported greater knowledge of contraceptive methods, fewer pregnancies and living children, higher age at first birth, and more pregnancy and newborn complications as compared with cohort members who remained in the original villages (p < .05 for each comparison). Fertility rates, especially between 20 and 24 years, have declined over time. Differences in reproductive behaviors by parental SES and current residence suggest the role of social transitions in determining family formation in Guatemala.

Changes in maternal weight from the first to second trimester of pregnancy are associated with fetal growth and infant length at birth.

BACKGROUND: Despite our knowledge of the negative consequences of stunting during early childhood and the important role that maternal nutritional status plays in the development of intrauterine growth retardation, we do not know the extent to which maternal nutritional status influences the growth in length of the fetus or whether a sensitive period for fetal linear growth exists during gestation. OBJECTIVE: Our objective was to explore the relation between maternal weight gain during different stages of pregnancy and linear growth of the fetus. DESIGN: Ultrasound examinations were conducted at 15-24 (x: 17.5) and 28-32 (x: 29.9) wk of gestation in 200 women from 4 rural Guatemalan villages. The associations between maternal weight gain from approximately 10 to 20 and 20 to 30 wk of pregnancy (from the first to the second and from the second to the third trimester, respectively) and fetal linear growth were tested with the use of ordinary least-squares regression. RESULTS: Maternal weight gain from the first to the second trimester was associated with fetal femur and tibia lengths measured at both means of 17 and 30 wk (P < 0.05) and infant length at birth (P < 0.001). Weight gain from the second to the third trimester of pregnancy did not predict fetal linear growth or infant length at birth. CONCLUSIONS: Maternal weight change from the first to the second trimester of pregnancy is strongly associated with fetal growth. Mid-gestation may be a sensitive period for fetal linear growth.

Rural-to-urban migration and cardiovascular disease risk factors in young Guatemalan adults.

BACKGROUND: Migration to cities may increase cardiovascular disease risk factors in developing countries. We examined rural and urban individuals who were born in the same villages and shared similar childhood experiences. METHODS: Blood lipids and glucose, blood pressure, anthropometry, body composition, physical activity, and food, tobacco and alcohol consumption were examined in 161 men and 193 women, 19-29 years old, living in their village of birth (76 commuted to work in Guatemala City), and in 76 men and 43 women living in the city. RESULTS: Rural and urban women had similar prevalence of overweight (28%), elevated body fat (29.8 +/- 6.1%) and low physical activity (83%). Compared to rural men, more urban men were sedentary (79 versus 27%), and they had higher body fat (15.3 +/- 5.3% versus 13.3 +/- 5.7%), serum cholesterol (4.27 +/- 0.75 versus 3.90 +/- 0.70 mmol/l [165 +/- 29 versus 151 +/- 27 mg/dl]), low density lipoprotein [LDL]-cholesterol (2.66 +/- 0.72 versus 2.30 +/- 0.62 mmol/l [103 +/- 28 versus 89 +/- 24 mg/dl]) and total cholesterol/high density lipoprotein [HDL]-cholesterol ratio (4.6 +/- 1.0 versus 4.1 +/- 0.9). Commuters showed intermediate values. Women had higher serum cholesterol (4.43 +/- 0.80 mmol/l [171 +/- 31 mg/dl]) than men in rural and urban areas. Urban residents ate/drank more saturated fats, red meat and sweetened beverages, and less legumes. CONCLUSIONS: High proportions of young Guatemalan women were overweight and sedentary. Migration to a city increased sedentarism and undesirable eating habits among men and women; men became fatter and their lipid profile worsened. Public health actions must address the prevention of emerging chronic diseases in countries still burdened by undernutrition and infections.

Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries.

The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991-98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia. Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia.

Effect of zinc on efficacy of iron supplementation in improving iron and zinc status in women.

Iron and zinc may interact in micronutrient supplements and thereby decrease efficacy. We investigated interactive effects of combined zinc and iron supplementation in a randomized controlled trial conducted in 459 Guatemalan women. Four groups were supplemented for 12 weeks: (1) weekly iron and folic acid (IFA); (2) weekly IFA and 30 mg zinc; (3) daily IFA; (4) daily IFA and 15 mg zinc. Effects were assessed by generalized linear regression. Baseline hemoglobin (Hb) concentration was 137.4 ± 15.5 g/L, 13% were anemic and 54% had zinc deficiency. Hb cconcentrations were similar by supplement type, but Hb concentrations improved significantly in anemic women at baseline (increase of 21.8 g/L). Mean percentage changes in serum ferritin were significantly higher in daily compared to weekly supplemented groups (86% versus 32%). The addition of zinc to IFA supplements had no significant impact on iron or zinc status. In conclusion, adding zinc to IFA supplements did not modify efficacy on iron status or improve zinc status, but daily supplementation was more efficacious than weekly in improving iron stores.