Micronutrient deficiencies and gender: social and economic costs1–3
Ian Darnton-Hill, Patrick Webb, Philip WJ Harvey, Joseph M Hunt, Nita Dalmiya, Mickey Chopra, Madeleine J Ball,
Martin W Bloem, and Bruno de Benoist
Vitamin and mineral deficiencies adversely affect a third of the
world’s people. Consequently, a series of global goals and a serious
amount of donor and national resources have been directed at such
micronutrient deficiencies. Drawing on the extensive experience of
the authors in a variety of institutional settings, the article used a
computer search of the published scientific literature of the topic,
supplemented by reports and published and unpublished work from
and social costs of micronutrient deficiencies, the paper found that:
(1) micronutrient deficiencies affect global health outcomes; (2)
micronutrient deficiencies incur substantial economic costs; (3)
health and nutrition outcomes are affected by sex; (4) micronutrient
deficiencies are affected by sex, but this is often culturally specific;
and finally, (5) the social and economic costs of micronutrient de-
ficiencies, with particular reference to women and female adoles-
cents and children, are likely to be considerable but are not well
quantified. Given the potential impact on reducing infant and child
mortality, reducing maternal mortality, and enhancing neuro-
intellectual development and growth, the right of women and chil-
dren to adequate food and nutrition should more explicitly reflect
their special requirements in terms of micronutrients. The positive
impact of alleviating micronutrient malnutrition on physical activ-
ity, education and productivity, and hence on national economies
suggests that there is also an urgent need for increased effort to
demonstrate the cost of these deficiencies, as well as the benefits of
addressing them, especially compared with other health and nutri-
vitamins, minerals, vitamin and mineral deficiencies, cost-
effectiveness, cost-benefits, gender, sex, women, children
Micronutrients, micronutrient deficiencies,
Micronutrient deficiencies are so important to public health
outcomes, particularly in the developing world, that a series of
global goals have been established, and significant amounts of
donor and national funds have been directed at them. A recent
report highlights the magnitude of the problem and attempts to
demonstrate the economic and health costs of vitamin and min-
eral deficiencies through a series of country-specific reports (1).
It also demonstrates the cost-effectiveness of known micronu-
trient interventions and the need for greater funding. To achieve
the Millennium Development Goals (2), improving the status,
health, and welfare of women will be critical (3). Women com-
prise the majority of the world’s poor (4). In poor households,
especially for infants and young children. Clearly, the reduction
of micronutrient deficiencies, given that they have an impact on
development, growth, and economic and social well-being,
needs to be aggressively tackled, not least to reflect the legal
human right of women and children to adequate nutrition, in-
However, given the emphasis particularly by most donor
there has also been a consistent call to demonstrate the cost
benefit of programs addressing micronutrients, especially com-
pared with other health and nutrition programs. The assumption
that such interventions are cost-effective has heavily relied on
micronutrient deficiencies might be up to 5% gross national
product (GNP) whereas interventions might only cost 0.3% of
the GNP (5). A recent report, the “Copenhagen Consensus” re-
sulted from economists setting priorities among a series of pro-
posals for confronting ten major global challenges, by prioritiz-
ing the use of a hypothetical $50 billion made available to
governments in developing countries. Providing micronutrients
through a combination of public health and private sector pro-
grams was ranked second, after control of human immunodefi-
ciency virus/acquired immunodeficiency syndrome (HIV/
micronutrient deficiencies by identifying and systematically
bringing together available information on: (1) micronutrient
1From the UNICEF Nutrition Section & Institute of Human Nutrition,
Columbia. University, New York (IDH, ND); the World Food Program
(PW), Rome, Italy; MOST, the USAID Micronutrient Program/Johns Hop-
kins Bloomberg School of Public Health (PWJH); the John Guggenheim
Memorial Foundation (Nutrition and Economics) (JMH); the University of
the Western Cape, South Africa (MC); Human Life Sciences, University of
Tasmania, Launceston, Australia (MJB); Helen Keller International, Singa-
pore (MWB), Micronutrients Unit, World Health Organization, Geneva,
Gap Throughout the Life Cycle,” held in New York, NY, June 5, 2004.
Nutrition Section, 3 U.N. Plaza, Nutrition Section (7th floor), New York,
New York 10017. E-mail: email@example.com.
Am J Clin Nutr 2005;81(suppl):1198S–1205S. Printed in USA. © 2005 American Society for Clinical Nutrition
by on September 19, 2009
and economic costs; (3) health and nutrition outcomes and sex;
(4) micronutrient deficiencies and sex; and finally, (5) the social
reference to women and female adolescents and children. Con-
clusions are then proposed along with policy and programmatic
implications. The background information was drawn from the
experience and information available to the authors, various
reviews using the key phrases micronutrients, vitamins, sex,
women, socioeconomic status and cost. Most of the informa-
tion comes from lower income country data, with limited
information from socially disadvantaged populations in more
MICRONUTRIENT DEFICIENCIES AND HEALTH
well documented, although some questions inevitably remain.
bidity, mortality, and overall reproductive performance and risk
of maternal death (7). Affecting the size of the health impact are
nutrient-to-nutrient interactions of micronutrients, age, sex, and
other host and environmental conditions such as pregnancy, ge-
economic status. For the purposes of this article, it is only nec-
essary to point to the extensive evidence base of established
also undergone re-positioning with regard to their public health
impact over the last several decades. The Global Burden of Dis-
global burden of disease (8), iron deficiency ranks ninth overall,
zinc deficiency is eleventh, and vitamin A deficiency, is thir-
teenth (Figure 1).
Iron deficiency remains a public health challenge despite its
long-recognized negative impact on the health and productivity
of women (and of adult men). Its role in impairing the cognitive
development in infants and young children has provoked a re-
newed interest in treating and preventing iron deficiency, al-
though questions of effective and safe delivery remain (9). Iron
deficiency in the 6–24 mo age group is impairing the mental
development of 40%–60% of the developing world’s children
(1). Widespread iron deficiency negatively impacts on national
productivity with losses of up to 2% of the gross domestic prod-
uct (GDP) in worst affected countries (1). Iodine deficiency in
born mentally impaired. This has been estimated to lower the
average IQ of those born in iodine-deficient areas by 10–15 IQ
points, which then adversely affects school performance, de-
creases productivity, and results in an enormous economic bur-
den to nations (1, 10). Vitamin A is recognized as a major factor
in reducing excess mortality from infectious diseases in devel-
oping countries, while deficiency remains the commonest cause
in some countries of preventable childhood blindness (11). Its
importance in public health terms has become more apparent in
terms of a likely role in women’s health (12) and its elimination
lar disease, and as an essential component of flour fortification in
most countries with fortification (15).
FIGURE 1. Global distribution of disease burden by leading risk factors [World Health Report, WHO 2002 (55)].
MICRONUTRIENT DEFICIENCIES AND GENDER
by on September 19, 2009
Given that single micronutrient deficiencies rarely occur in
isolation, the public health importance of other micronutrients
such as vitamin B12, riboflavin, and the role of multi-
micronutrient formulations are receiving increasing attention
why women in low- and medium-income countries should be
denied the presumed benefits of this, especially if the dosage is
endemic areas (17, 18), but may well have a role in delaying
progression of HIV infection to AIDS (17).
MICRONUTRIENT DEFICIENCIES AND ECONOMIC
Developing countries are emphasized in this article because
vitamin and mineral deficiencies are both highly prevalent in
developing countries and because such deficiencies have major
negative biomedical outcomes. However, there is also evidence
developing nations (such as China, Indonesia and Vietnam)
where the availability of staple foods (and thus energy defi-
ciency) are no longer problems. Some evidence shows vitamin
and mineral deficiencies continue to be prevalent among lower
income population groups in developed countries, such as the
the over 13 million children in the United States whose families
live below the poverty level, ?10% have overt micronutrient
In developing countries, intakes of expensive animal-derived
foods are often not accessible to the poor and this substantially
reduces intake of vitamins and minerals (21), whereas in indus-
vegetables (20). In the Philippines, Bouis (22) showed that vita-
min A deficiency was associated more strongly with a lack of
knowledge than with low income, in contrast to iron deficiency,
in rural Tamil Nadu, women’s intakes leading to low micronu-
trient intakes were most affected by eating customs and socio-
economic status (23). Poor people are more likely than others to
micronutrient status will generally improve.
and Horton (24) developed algorithms for estimating the eco-
productivity among adults, and premature births. The analysis
higher, even though iron deficiency is less widespread. Never-
(Figure 2). The dominant effect for all countries is the loss
an econometric model, estimates that just 3 types of
malnutrition—protein-energy malnutrition, iron deficiency and
iodine deficiency—are responsible for 3%–4% of GDP loss in
Pakistan in any given year and 2%–3% of GDP loss in Vietnam.
(25). Productivity of adult anemic agricultural workers (or other
heavy manual labor) is reduced by 1.5% for every 1% decrease
in hemoglobin (Hb) concentration below the established thresh-
old for safe health (26) (see Figure 2).
terms of cost per life saved and productivity gained per program
to at-risk groups (pregnant mothers for iron, under-fives for vi-
tamin A) is more cost-effective than fortification, although the
and households gain access to higher-quality primary health
FIGURE 2. Percentage of estimated loss in gross national product (GNP) due to iron deficiency [Ross & Horton 1998 (24), Horton 1999 (56)].
DARNTON-HILL ET AL
by on September 19, 2009
care. Nevertheless, properly targeted supplementation is justi-
fied while fortification programs are in the early stage and ex-
panding coverage, as long as the targeting principles reflect risk
assessment and are consistently applied. Food-based interven-
tions have the potential to be the most sustainable interventions
for micronutrient deficiencies, although they are unlikely to be
sufficient in the short term in poverty and emergency settings.
The multiple benefits of food-based approaches are clear but
rarely factored in. They include increases in intake of many
nutrients, improved food security, female empowerment, and
increased cash incomes that are likely to be spent on children’s
nutrition and girls’ education. An observational study in rural
India found that the micronutrient-rich food consumption by
pregnant women, specifically that of milk, green-leafy vegeta-
bles, and fruits, were independently associated with the size of
the infant at birth (23).
In addressing the returns on investments to reduce micronu-
4 micronutrients of public health interest.
By eliminating iodine deficiency in previously iodine-
deficient areas, the average economic gain produced by the in-
crease in cognitive development is similar to the average eco-
shown the benefits of different interventions to reduce iodine
deficiency (10). In Ecuador, people with moderate deficiency
were consistently paid less for agricultural work (Greene 1977
cited in 26). More recently, WHO looked at the cost-
effectiveness and benefit-to-cost ratios of micronutrient inter-
ventions, especially fortification and salt iodization programs;
ratios (29). Depending on the assumptions made, the benefit-to-
cost ratio is from 40 to 400:1 (10). The mortality risk associated
with iodine deficiency is the least well-known; limited results
indicate a possible 8% benefit in child mortality reduction (30).
Meta-analyses of field trials of mass vitamin A supplementa-
tion to children 6 to 59 mo of age have indicated an overall
reduction in child mortality by 25%–35%, despite less consis-
tency in the rates of reduction in morbidity, with greater reduc-
tion in severity than incidence of illness (31). Impacts on mor-
bidity are also mediated by presence or absence of other
the benefits from the productivity gains over decades of work
benefits from reducing early mortality. A series of careful coun-
try studies on costs of vitamin A supplementation programs for
under-5-year-old (Ghana, Guatemala, Nepal, Peru, and Philip-
pines), revealed that the unit costs of the vitamin A supplement
($0.04 per child for 2 doses) represent 5% of the delivery costs
when the full program is costed (32). Though additional thera-
the now standard practice of providing vitamin A to children
suffering from measles and the use of vitamin A to treat clinical
signs of xerophthalmia, the estimation concentrated on the ben-
efits from the prophylactic provision of vitamin A. The world-
A per child per year, highly cost-effective given the role of
vitamin A deficiency as a primary risk factor in infant and child
mortality. Eliminating vitamin A deficiency would save 16% of
the global burden of disease in children (30).
The estimation of the benefits of reducing iron deficiencies
must incorporate the fact that iron deficiency anemia can affect
adult worker productivity directly, as well as through its impair-
ment of child development. Behrman and Rozenweig (28) as-
sumed a 5% across the board loss of labor productivity due to
weight. However, increased benefits come at increased costs,
because to obtain these additional ongoing productivity gains,
there must be continued interventions over the work life in ad-
dition to the one-time intervention to reduce the number of low
birth weight infants being born by antenatal supplementation to
potentially reduce the maternal disease burden by some 13%.
Daily supplementation with zinc at home has been shown to
reduce infant mortality by 70% and it is now recommended
treatment for diarrhea, along with oral rehydration therapy (14,
33). There is little reported experience on delivery mechanisms
Noting that potential investments appear under-resourced,
Behrman and Rozenweig have also noted the high rates of
large for reducing micronutrient deficiencies in populations in
Costs and benefits of micronutrient interventions: returns on nutrition
gained per program
Supplementation of pregnant
Supplementation (all people
Vitamin A deficiency
Supplementation (under 5
Nutrition education and
1DALY ? disability-adjusted life year.
MICRONUTRIENT DEFICIENCIES AND GENDER
by on September 19, 2009
which prevalences are high’ (28). The portion of the global bur-
den of disease (mortality and morbidity, 1990 figures) in devel-
oping countries that would be removed by eliminating malnutri-
This includes the effects of malnutrition on the most vulnerable
groups’ burden of mortality and morbidity from infectious dis-
eases only. This is therefore a conservative figure, but nonethe-
less much higher than previous estimates, mainly due to now
overall disease burden (all population groups, all causes, all
developing countries), eliminating micronutrient malnutrition
18% of the global burden of disease, with eliminating child
underweight an additional 15% (30).
HEALTH AND NUTRITION OUTCOMES AND SEX
in the developing world whereas this may not be the case in the
more industrialized world where women routinely outlive men.
an excess of some diseases such as depression (4). In most af-
fluent countries, being a single mother is a strong risk factor for
mother or widow, and thus heading a female-headed household,
almost invariably results in reduced income and increased like-
female-headed households though, Lemke et al found that this
did not necessarily mean they were less likely to have adequate
that a lower value is placed on women in many societies, is
indisputable based on routine statistical indicators such as
female-to-male life expectancy, and literacy (3) and with evi-
dence, especially from South Asia, that they have less control
over economic resources, than women in Norway or even Latin
reflect women’s status. This is important because low birth
weight is the best single predictor of malnutrition (and likely
some key limiting micronutrients) because it is associated with
poor growth in infancy and throughout childhood (36), and in-
increased obesity and noncommunicable disease morbidity and
in the United States or Europe (38).
antenatal sex identification is increasingly performed, as in
China and South Asia, there is a striking imbalance in male-to-
The differences in ratios of girls to boys having primary educa-
adult literacy rate in South Asia for women as a percentage of
North Africa and in sub-Saharan Africa (13, 36). Across differ-
ences in wealth, not only is it harder for a girl living in impov-
erished circumstances to get primary education, but even if she
does receive it, it is likely to be of shorter duration. She is more
in most countries, to go onto higher education (3).
It has been pointed out—eg, by the UN Secretary General—
AIDS epidemic as they are biologically, socially, and culturally
more HIV-susceptible than men. HIV rates are 20% higher than
men in sub-Saharan Africa, and much higher in younger age
groups, with nearly 60% of those living with HIV/AIDS in sub-
Saharan Africa being women (40). They are also less likely to
avail themselves of health services for the treatment of opportu-
nistic infections and more likely to forego food consumption in
their household than men (41).
economic growth, social discrimination against women is com-
mon (42). In Pakistan, for example, widespread discrimination
against girls and women is high and child malnutrition rates are
among the highest in the world, as is the proportion of low birth
weight infants, at 25%. Meanwhile in Thailand, where nutrition
high literacy, high participation in the labor force, and a strong
place in social and household-level decision-making. Within
pared with other states, and Kerala has better health, social and
nutrition indicators, and not coincidently, the highest levels of
female education (42).
MICRONUTRIENT DEFICIENCIES AND SEX
As previously noted, the evidence that infant, young child,
adolescent, and adult females have significantly worse health
and nutrition is strong, while this depends on the region con-
cerned and social and status factors (35). There is surprisingly
important differences do exist in prevalence rates for various
generalized (43). For example, 3 broadly accepted “facts” are
often repeated in the micronutrient literature. The first is that
boys are “at greater risk of xerophthalmia (night blindness and
reproductive age suffer a higher prevalence of iron deficiency
[of iodine deficiency] than boys,” especially from adolescence
deficiency is commonly reported to be up to 10 times more
common in males than females (44). Similarly, there is a well-
due to menstruation and repeated pregnancies (45), with preg-
nant women at greater risk of being iron deficient when anemia
studies confirm empirically that the vitamin A status of boys is
the environmental, epidemiologic, and disease profiles of com-
munities, as does iron deficiency anemia among men and chil-
the sex of child, and focus on the status of mothers without
considering the status of fathers or sons. The undifferentiated
aggregation of people into broad categories of “children” or
DARNTON-HILL ET AL
by on September 19, 2009
proceed through the life cycle in different socioeconomic, cul-
tural, and agro-ecological contexts.
Examples of micronutrients linked to sex disadvantage in-
women compared with non-night-blind women even after the
end of the pregnancy and the resolution of night blindness (38).
Anemia affects 50%–70% of women during pregnancy and in
that the intake of iron was ?50% of the RDA for children 1–6 y
old. For pregnant and lactating women, the intake was 37% and
49% of RDA respectively (47). In South Asia, and other areas
where portions of the population are living in poverty, multiple
micronutrient deficiencies coexist (16). It has been noted that
even when females [in Asia] are apparently meeting energy and
protein needs, they may still be at risk of micronutrient malnu-
trition due to lower intakes of more expensive animal foods,
not possible due to an enormous geographic and cultural varia-
tion, even for India.
In Bangladesh, this sex discrimination can actually have an
unexpected impact in that while girls may receive a less favored
diet, this might mean more dark green leafy vegetables so their
of vitamin A deficiency less (43). Research from Mexico, how-
ever, showed no significant sex differences in dietary quality or
quantity in infants and preschoolers even under conditions of
economic and demographic stress (48). Nevertheless, school
girls consumed significantly less energy per day than boys and
less of all micronutrients examined, presumably because of
lower total dietary intake. The authors concluded that the lower
food intakes of girls did not appear to be due to purposeful diet
ing lower activity (48).
SOCIAL AND ECONOMIC COSTS OF
MICRONUTRIENT DEFICIENCIES BY SEX
opment), estimates have been made for several countries. A
recent example is Sierra Leone, where it was concluded that in
the absence of adequate policy and program action to reduce
anemia rates in women, the monetary value of agricultural pro-
over the next 5 y would exceed $94.5 million; the present value
of the future productivity losses associated with the intellectual
impairment resulting from intrauterine iodine deficiency ex-
ceeds $42.5 million; and over 38 000 deaths of Sierra Leonean
children under 5 y of age will be attributable to vitamin A defi-
that the cost of death averted by vitamin A being provided in the
country by Female Community Health Volunteers was $327
(50). Quite apart from the social benefits of empowering these
the incidence and severity of diarrheal diseases and measles,
which in turn reduces the need for Ministry of Health services,
thereby saving the Government of Nepal $1.5 million—which
when cost savings have been factored in, had saved the govern-
studies undertaken on the national vitamin A distribution pro-
grams in Ghana and Zambia found the costs per death averted
were $277 and $162 respectively (51, 52).
There are also major costs of micronutrient deficiencies asso-
ciated with humanitarian crises. Women are typically overrep-
resented in terms of negative impacts of today’s complex emer-
gencies—roughly 70% of refugees and people displaced inside
their own countries by armed conflict are women and children.
Wherever crises have resulted in compromised access to food,
the threat of acute micronutrient deficiencies rises; if a popula-
tion is already deficient in vitamins and minerals when an emer-
had been satisfactory. In Bangladesh, for example, a higher in-
take of vitamin A was associated with a lower risk of severe
malnutrition among children directly affected by floods (53). In
Indonesia, although the drought and economic crisis of the late
1990s did not have a significant impact on child anthropometry
The damage to cognitive development and attained schooling
among these children is likely to be long lasting.
Studies on women’s status and childhood nutritional status,
although not addressing micronutrient status directly, have con-
impacts on the nutritional status of her child. Because women
with higher status (relative to men) have better nutritional status
themselves, they are better cared for and provide higher quality
care to their children (35). Across countries, relative resources
controlled by women tend to increase the share spent on educa-
tion (54). Educated girls and women have fewer children, seek
medical attention sooner for themselves and their children, and
provide better care and nutrition for their children (3).
It has been shown that: (1) micronutrient deficiencies lead to
sible for economic costs at individual, community, and national
effect micronutrient deficiencies, at least in some cultures, and
that where there is a difference it is usually females who are
disadvantaged; and, (5) there are major social and economic
addressing them. What has not been conclusively shown, al-
though the evidence points that way very strongly is that these
costs—both social and economic—are greater for females.
Where it has been demonstrated, it has not been well quantified.
The usual quantitative approaches used in assessing health and
nutrition risk may miss this sort of information, as sex and intra-
household relations, social networks and informal sector activi-
ties are often not uncovered by conventional statistical methods
(34, 43, 54).
The 2003 Human Development report was able to conclude
ity undermines women’s capabilities in education and health”
(3). More attention to the context-specific nature of micronutri-
ent deficiencies is called for as a first step toward more reliable
prevalence estimations and a more rational basis for targeting
public health action. The countries with the worst health and
MICRONUTRIENT DEFICIENCIES AND GENDER
by on September 19, 2009
nutrition conditions, Asia and sub-Saharan Africa, would gain
most from the broad public health benefits of better nutrition
(30). Because it is increasingly accepted that an integrated ap-
proach is required to tackle many vitamin and mineral deficien-
cies (including dietary diversification, fortification and supple-
and malaria, as well as environmental, sanitation, and political
interventions), more attention needs to be paid to the ecological,
tion and absorption of nutrients by sex.
To achieve sustainable improvement of the nutritional status
of children, women’s status should be improved in all regions,
but especially in South Asia, followed by sub-Saharan Africa.
However, women’s health must also be improved for their own
sake so they are able to lead a productive, healthy, and vital role
benefits. One important way of doing this is to ensure that women
and female adolescents and children achieve the various micronu-
trient goals. Investing in female nutrition through long-term, com-
erational cycle of malnutrition, reduce the cost of micronutrient
their households, and ultimately for nations.
The helpful inputs or suggestions of the following people are gratefully
acknowledged: Dr. Victor Aguayo (UNICEF), Dr. Bruce Cogill (FANTA
Project/AED/USAID), Professor Richard Deckelbaum (Columbia Univer-
sity). Dr Rainer Gross, (Chief, Nutrition Section, UNICEF), Professor John
Mason (University of Tulane, USA), Dr. Chizuru Nishida (WHO), Dr. Tina
Sanghvi (BASICS II), Ms Margaret Majuk and Ms. Shannon Fitzgerald
(UNICEF Library services). The collective responsibility for the article is
comprised as follows: conception and outline drafting (IDH and ND); sig-
nificant writing contributions (PW, PWJH, JMH); intellectual contribution
and substantive text editing (MC, MB, MWB) and overall review of article
(BdeB). None of the authors expressed a conflict of interest. The views
expressed are those of the authors, not necessarily their institutions.
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