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Micronutrient De ciency Conditions:
Global Health Issues
Theodore H Tulchinsky, MD, MPH1
ABSTRACT
Micronutrient de ciency conditions are widespread among 2 billion people in
developing and in developed countries. These are silent epidemics of vitamin and
mineral de ciencies affecting people of all genders and ages, as well as certain risk
groups. They not only cause speci c diseases, but they act as exacerbating factors
in infectious and chronic diseases, greatly impacting morbidity, mortality, and
quality of life. De ciencies in some groups of people at special risk require
supplementation, but the most effective way to meet community health needs safely
is by population based approaches involving food forti cation. These complementary
methods, along with food security, education, and monitoring, are challenges for
public health and for clinical medicine. Micronutrient de ciency conditions relate
to many chronic diseases, such as osteoporosis osteomalacia, thyroid de ciency
colorectal cancer and cardiovascular diseases. Forti cation has a nearly century
long record of success and safety, proven effective for prevention of speci c
diseases, including birth defects. They increase the severity of infectious diseases,
such as measles, HIV/AIDS and tuberculosis. Understanding the pathophysiology
and epidemiology of micronutrient de ciencies, and implementing successful
methods of prevention, both play a key part in the New Public Health as discussed
in this section, citing the examples of folic acid, vitamin B12, and vitamin D.
Key Words: micronutrient de ciency conditions, global health, folic acid, vitamin
D, vitamin B12, de ciency
INTRODUCTION
Micronutrient De ciencies (MNDs) are of great public health and socio-
economic importance worldwide. They affect low-income countries but
are also a signi cant factor in health problems in industrialized societies
withimpacts among wide vulnerable groups in the population, including
women, children, the middle-aged, and the elderly. They affect all populations
1 Braun School of Public Health and Community Medicine. Hebrew University-Hadassah,
Hadassah Ein Karem, Jerusalem, Israel.
Correspondence: Ted Tulchinsky at email tedt@hadassah.org.il or tulchinskyted@hotmail.com
243 Public Health Reviews, Vol. 32, No 1, 243-255
244 Public Health Reviews, Vol. 32, No 1
in Europe and more severely in the transition Countries of Eastern Europe
(CEE), the former Soviet Union, and Countries of Central Asia (CAR).
They signi cantly contribute to chronic diseases as the major causes of
morbidity and mortality in these countries.
The World Health Organization (WHO) considers that more than
2billion people worldwide suffer from vitamin and mineral de ciencies,
primarily iodine, iron, vitamin A and zinc, with important health
consequences.1
In 2006, WHO published a landmark document entitled Guidelines for
Food Forti cation with Micronutrients, and introduced the publication as
follows:
“Interest in micronutrient malnutrition has increased greatly over the
last few years. One of the main reasons for the increased interest is the
realization that micronutrient malnutrition contributes substantially to
the global burden of disease…. In addition to the more obvious clinical
manifestations, micronutrient malnutrition is responsible for a wide
range of non-speci c physiological impairments, leading to reduced
resistance to infections, metabolic disorders, and delayed or impaired
physical and psychomotor development. The public health implications
of micronutrient malnutrition are potentially huge, and are especially
signi cant when it comes to designing strategies for the prevention and
control of diseases such as HIV/AIDS, malaria and tuberculosis, and
diet-related chronic diseases.” 2
This WHO publication goes on to emphasize that micronutrient
malnutrition is not, as was widely assumed, only a problem of developing
countries. WHO de nes food forti cation as the practice of deliberately
increasing the content of an essential micronutrient, i.e., vitamins and
minerals (including trace elements) in a food, in order to improve the
nutritional quality of the food supply and provide a public health bene t
with minimal health risk.
THE GLOBAL SCOPE OF MICRONUTRIENT DEFICIENCY
CONDITIONS
Globally, the problem is enormous. Micronutrient de ciencies are not
always clinically apparent or dependent on food supply and consumption
patterns. They are associated with physiologic effects that can be life-
threatening or more commonly damaging to optimal health and functioning.
Iron de ciency is the most prevalent nutrition problem in the world. Folic
Micronutrient de ciency conditions globally 245
acid de ciency remains responsible for excess birth defects, and many
other micronutrient de ciencies are affecting populations at risk of growing
obesity and with poor habits of physical exercise. Vitamin D de ciency,
once pandemic among children in the industrialized countries, is now
found to be extremely widespread, can lead to osteoporosis and bone
fractures and may become life-threatening or leave an elderly person
permanently handicapped, thus reducing length and quality of life.
Individual medical care or nutrition counseling cannot always deal
effectively with micronutrient de ciencies of such widespread proportions.
Some are intrinsic in current dietary patterns and some result from life
situations determined by place of residence, religious practices, and
recreational activities. They can directly impact communicable disease
severity, as in the case of HIV, tuberculosis, and measles, and can greatly
affect quality of life.2
The responses to these challenges as discussed in the section by Harrison
include dietary diversi cation, food forti cation, and direct supplements to
speci c risk groups, such as women, infants, children, middle-aged and
elderly. Policies and programs to address micronutrient de ciencies depend
on public health leadership and understanding of the vital role this issue
plays in the policies of the New Public Health. For example, Recommended
Dietary Intakes based on the Food and Nutrition Board of the US Institute
of Medicine are widely used internationally. The major micronutrient
malnutrition issues affecting populations in developed and developing
countries addressed in the WHO Guidelines are shown in Table 1.
Table 1
Micronutrients De ciency Conditions and Their Worldwide Prevalence
Micronutrient De ciency Prevalence Major De ciency Disorders
Iodine 2 billion at risk Goiter, hypothyroidism, iodine de -
ciency disorders, increased risk of
stillbirth, birth defects infant mortality,
cognitive impairment
Iron 2 billion Iron de ciency, anemia, reduced learning
and work capacity, increased maternal
and infant mortality, low birth weight
Zinc Estimated high in developing
countries
Poor pregnancy outcome, impaired
growth (stunting), genetic disorders,
decreased resistance to infectious
diseases
246 Public Health Reviews, Vol. 32, No 1
Micronutrient De ciency Prevalence Major De ciency Disorders
Vitamin A 254 million preschool children Night blindness, xerophthalmia,
increased risk of mortality in children
and pregnant women
Folate
(Vitamin B6)
Insuf cient data Megaloblastic anemia, neural tube and
other birth defects, heart disease,
stroke, impaired cognitive function,
depression
Cobolamine
(Vitamin B12)
Insuf cient data Megaloblastic anemia (associated with
Helicobacter pylori induced gastric
atrophy)
Thiamine
(Viamin B1)
Insuf cient data, estimated as
common in developing countries
and in famines, displaced persons
Beriberi (cardiac and neurologic),
Wernicke and Korsakov syndromes
(alcoholic confusion and paralysis)
Ribo avin
(Vitamin B2)
Insuf cient data, est. to be common
in developing countries
Non speci c – fatigue, eye changes,
dermatitis, brain dysfunction, impaired
iron absorption
Niacin
(Vitamins B3)
Insuf cient data, estimated as
common in developing countries
and in famines, displaced persons
Pellagra (dermatitis, diarrhea,
dementia, death)
Vitamin B6 Insuf cient data, estimated as
common in developing countries
and in famines, displaced persons
Dermatitis, neurological disorders,
convulsions, anemia, elevated plasma
homocysteine
Vitamin C Common in famines, displaced
persons
Scurvy (fatigue, hemorrhages, low
resistance to infection, anemia)
Vitamin D Widespread in all age groups, low
exposure to ultra violet rays of sun
Rickets, osteomalacia, osteoporosis,
colorectal cancer
Calcium Insuf cient data, estimated to be
widespread
Decreased bone mineralization, rickets,
osteoporosis
Selenium Insuf cient data, common in Asia,
Scandinavia, Siberia
Cardiomyopathy, increased cancer and
cardiovascular risk
Fluoride Widespread Increased dental decay, affects bone
health
Source: Adapted from Allen L et al.: Table 1.2 pp 6-10.2
Micronutrient de ciency conditions globally 247
In this section, we include three articles on the vital topic of the silent
epidemic of micronutrient de ciency conditions and their public health
importance:
● Gail Harrison, on public health interventions to combat micronutrient
de ciency conditions,3
● Michael Holick, on vitamin D de ciency,4
● and Godfrey Oakley, on folic ac id and vitamin B12.5
Other articles in this issue on chronic diseases,6 infectious diseases,7
public health in the US,8 and global health9 also relate issues of micronutrient
de ciencies and their prevention as fundamental to the New Public Health.
These topics are included in this introductory issue of Public Health
Reviews as they currently receive wide attention in public health with an
array of successful interventions, including forti cation, supplementation
and food based strategies for the alleviation of these conditions as an
essential element of the New Public Health.
BACKGROUND
The earliest recognized clinical trial in micronutrient de ciency was
conducted on sailors on board the HMS Salisbury by James Lind, leading to
his famous report on scurvy in 1753.10 His ndings eventually led to routine
daily lime juice issuance to British sailors, who were then known as “limeys.”
This was followed over the next century by advances in scienti c knowledge
of the importance of iron and iodine nutrient elements in health. In the 1880s,
Kanehiro Takaki demonstrated that dietary changes eradicated beriberi
among Japanese sailors, followed by Christiaan Eijkman (Nobel Prize 1929)
in Java who identi ed dietary factors as a cause of chicken polyneuritis and
neuropathy in humans.11 The term vitamins (derived from “vital amines”)
was initially described in 1912 by Casimir Funk and has become the subject
of great scienti c and public health advances as well as common discussion
and professional controversy ever since.12
In the early decades of the twentieth century, an epidemic of pellagra
was investigated by Joseph Goldberger of the U.S. Public Health Service
(USPHS) and was determined to be a nutritional de cit and not an infectious
disease, as widely thought.13 An epidemic of pellagra in the southern US in
the 1920s cost thousands of lives, and nally disappeared after forti cation
of our with B vitamins was implemented by state law in many southern
states, as dramatically shown in Figure 1.14,
15
248 Public Health Reviews, Vol. 32, No 1
Fig. 1. Number of reported pellagra deaths, by sex of decedent and year – United
States, 1920-1960.
Used by permission. © American Journal of Clinical Nutrition, American Society for Clinical Nutrition.
Source: Centers for Disease Control. Achievements in public health, 1900-1999: Safer and healthier
foods.15
In 1917, many recruits to the U.S. Army were rejected due to goiter and
this led to investigations and the determination that iodizing salt would be
the best approach to address the problem. Forti cation of salt with iodine
was introduced in Switzerland in 1923 to prevent goiter and cretinism, and
in the United States a year later. This strategy was later adopted by the
WHO as a global public health measure of the highest importance.16 Despite
nearly a century of use of iodine to prevent cretinism, goiter and other
manifestation of lack of iodine in soil and basic foods, iodine de ciency is
still widespread in Europe and globally. An estimated 2 billion individuals
have insuf cient iodine intake, and South Asia and sub-Saharan Africa are
particularly affected, while about 50 percent of Europe remains mildly
iodine de cient.17
In 1941, President Franklin D. Roosevelt held a nutrition conference in
the White House, which concluded that forti cation of basic foods was the
best way to prevent silent malnutrition and the recommendations were
implemented throughout the US, as well as in Great Britain and Canada.18,
19
However, in the post war period, this became less well regulated in Canada
and Britain where vitamin forti cation was no longer enforced due to the
seeming disappearance of clinical rickets.
Micronutrient de ciency conditions globally 249
In the 1990s, the issue once again came to the forefront of public health
policy when the UK Medical Research Council determined and con rmed
that folic acid taken before pregnancy prevented the majority of neural tube
birth defects. However, giving supplements to all women capable of
becoming pregnant achieved compliance of no more than one-third of the
population at risk.
20,21 As a result, the U.S. Food and Drug Administration
mandated adding folic acid to the required forti cants in “enriched our”.
Canada (mandatory since 1979), Chile, and many other countries followed
suit with mandatory forti cation of our with folic acid becoming the
common approach.
The US Centers for Disease Control and Prevention reported in 2008
that the number of countries practicing our forti cation rose from 33 in
2004 to 54 in 2007. Most countries fortify with iron and folic acid but many
include thiamin, ribo avin, and niacin as well, increasing the number of
protected persons by 540 million in just three years. Regionally, this breaks
down to 97 percent of the population in the Americas, an increase from 5 to
44 percent in the Middle East, from 26 to 31 percent in the African Region,
and from 16 to 21 percent in the Southeast Asia Region. However, as
of 2007, only 6 percent of the population in the European Region and
4percent in the Western Paci c Region were protected by a combination of
forti cants.22
Discussion of food forti cation as an important public health issue in
Europe is limited by national and European Union free trade complexities.23,24
Folic acid forti cation, although practiced on a voluntary basis by some
food manufacturers, has not been made mandatory in any European country
as of November 2009.25 The United Kingdom Food Standards Agency
(UKFSA) recommended mandatory forti cation of our in 2007, but this
was delayed by the Chief Medical Of cer with instruction to review the
evidence. The UKFSA renewed its recommendation in October 2009,26 but
the matter has been referred to the political level and there has not been a
decision as yet.
During the past decade, much attention has been given to vitamin D
de ciency in the nutrition, medical, and public health professional
literature. A growing body of evidence points to vitamin D de ciency in
high percentages of the world population, and is associated with increased
risk of osteoporosis, cardiovascular diseases, cancer, and other chronic
conditions such as asthma. Speci c de ciency conditions are becoming
commonly re ected in the emergence of clinical rickets among breastfed
infants of dark skinned migrants living in northern latitudes, and de ciency
among youngsters spending more and more time in front of computer
250 Public Health Reviews, Vol. 32, No 1
screens instead of outside on soccer elds.3 In 2008, the American Academy
of Pediatrics (AAP) reviewed with concern the growing body of evidence
of widespread vitamin D de ciency among infants, children, and
adolescents despite longstanding forti cation of milk with vitamin D. They
recommended an increase of the levels of vitamin D supplements to 400
International Units per day, and widened the recommendation to include all
infants, children, and adolescents based on historical evidence of
effectiveness of supplementation and its safety.27
Dietary Reference Intakes (DRI) are the most recent set of dietary
recommendations established by the Food and Nutrition Board of the
Institute of Medicine, 1997-2001.28,29 These standards are under continuing
review and periodic revision as the cumulative evidence base and body of
knowledge evolves. The issues in food forti cation are complex, often
politically charged and under continuing surveillance. Resistance to food
forti cation continues, claiming that it is costly, interferes with individual
choice, and could potentially overdose the population with possibly harmful
substances. The long delay of adaption of folic acid forti cation of our in
Europe is a case in point.
Vitamin supplementation is needed for infants, children up to
adolescence, women in the age of fertility (iron, folic acid), middle-aged
women (vitamin D), the elderly (vitamin D), patients in chronic care
facilities (vitamin D), and patients with chronic diseases (e.g., HIV/AIDS)
among others.30 Food supplements and forti cation are used to supplement
dietary intake and ensure adequate amounts of nutrients vital to a healthy
life.
31
Common foods that are frequently forti ed are shown in Table 2,
adapted from the US Dietary Supplement Fact Sheet of the Of ce of
Dietary Supplements of the National Institutes of Health.32
This section on micronutrient de ciency conditions presents authoritative
reviews with recommendations on public health nutrition policies, and the
cases of folic acid, vitamin B12 and vitamin D. These issues are important
for policy makers, as well as public health teachers and practitioners, and
most certainly for students.
Micronutrient de ciency conditions globally 251
Table 2
Widely Used Forti ed Foods
Food Vehicle Fortifying agent
Salt Iodine, iron
Wheat and corn ours, bread. pasta, rice Vitamin B complex, iron, folic acid, vitamin
B12
Milk, margarine, yoghurts, soft cheeses Vitamins A and D
Sugar, monosodium glutamate, tea Vitamin A
Infant formulas, cookies Iron, vitamins B1 and B2, niacin, vitamin K,
folic acid, zinc
Vegetable mixtures amino acids, proteins Vitamins and minerals
Soy milk, orange juice Calcium
Juices and substitute drinks Vitamin C
Ready-to-eat breakfast cereals Vitamins and minerals
Diet beverages Vitamins and minerals
Enteral and parenteral solutions Vitamins and minerals
Adapted from: Of ce of Dietary Supplements, National Institutes of Health. Vitamin D and
healthful diets. Dietary Supplement Fact Sheet. Available from URL: http://dietary-supplements.
info.nih.gov/factsheets/vitamind.asp (Updated 13 November, 2009 and accessed 9 March, 2010).
CONCLUSIONS
Public health nutrition addresses individual and population health
needsincluding those of groups at high risk for micronutrient de ciency
conditions. A comprehensive food policy includes food security and
distribution with special emphasis on the elderly and low-income
populations. Food forti cation is necessary for developed and developing
countries to ensure essential nutrients in processed foods, improving their
suitability for human nutrition. In conjunction with this, regulation of
forti cation is important to avoid risks due to “promiscuous” forti cation.
Vitamin and mineral forti cation and supplementation policies need to
be promoted as the epidemiologic, nutritional, and sociological scienti c
basis of human nutrition expands, speci cally addressing widespread
de ciencies of micronutrients essential for individual and population
252 Public Health Reviews, Vol. 32, No 1
health. Use of other strategies such as preventive supplementation and
foods suitable for forti cation should be mandated under governmental
responsibility for safe and healthful food products. These should be
regulated and sometimes subsidized to prevent micronutrient de ciencies
for many groups at special risk for such de ciencies and their associated
negative health and societal effects.
From these conclusions, a number of recommendations arise for national
governments and international agencies, as well as for public health
practitioners, teachers, and policy makers. Their importance is measured
by the potential positive impact on a nation’s health with safety and low
cost, and should be integral to active governmental leadership in a wider
context of public health nutrition policies including agricultural practices
and subsidies, widely promoted and involving food industries, as well as
manufacturing, processing and marketing of food. Food forti cation and
vitamin/mineral supplementation have a long tradition in public health
practice, and as the scienti c and evidence base grows, these will continue
to evolve as a vital element of the New Public Health in the 21st century33
including:
1. Adoption of Food Forti cation Recommended Guidelines by WHO
member states with implementation recommendations adopted by
international bodies and aid agencies, particularly addressing iodized
salt, our forti cation (iron, vitamin B complex, folic acid, and vitamin
B12), milk with vitamin D, and others according to local conditions of
appropriate common food sources to raise individual and population
levels of essential micronutrients.
2. Regulation and incentives, both technical and possibly nancial, provided
to food producers, manufacturers and marketers to implement, promote
and monitor food forti cation policies and their public acceptance.
3. Encouragement of national health systems to adopt and nance vitamin
and mineral supplementation policies for vulnerable groups, especially
for women in age of fertility, pregnant women, infants, toddlers,
children and adolescents, as well as the middle-aged and elderly.
4. Promotion of low fat foods in the food industry, marketing, and
consumer education.
5. Regulation to ban use of transfats and high salt content in manufactured
foods and incorporation of nutritional educational measures.
6. Promotion of unsweetened drinks and reduction of high sugar and salt
content in food particularly in schools, institutions, as well as national
and community organizations.
Micronutrient de ciency conditions globally 253
7. Promotion of national food security and nutrition advisory boards
to link ministries of health, industry, and agriculture with food
manufacturers’ associations and academic and public representatives to
monitor implementation of nutritional status, the evolving science of
nutrition, epidemiology and health, health food laws and their regulation,
and implementation.
8. Monitoring of nutrition status in the population with technical and
nancial assistance by national ministries of health in periodic national
nutrition and health surveys.
9. Implementation and promotion by national and international agencies
of nutrition strategies with monitoring and review mechanisms.
10. Promotion of nutrition education in school systems, professional
education and training programs for physicians, nurses, and other health
professionals, among other social and educational professions, as well
as for the general public.
Recognition and attention to micronutrient de ciencies as a group of
important public health issues are vital to preventing diseases and promoting
health. The science and epidemiology of the key role of micronutrients and
their hidden effects are continuously evolving but their central role should be
very clear in research, teaching, practice, and policy in the New Public Health.
Con icts of interest: None declared.
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