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Status of Micronutrient Nutrition in Zimbabwe: A Review

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More than 65% of the Zimbabwean population live in the rural areas and are food insecure especially due to droughts. The population experiences fluctuating levels of malnutrition including vitamin and mineral malnutrition. This paper constitutes a review of the micronutrient malnutrition status of the Zimbabwean population, focusing on the period from 1980 to 2006, using data from nutrition surveys, the demographic health surveys, sentinel surveillance and monitoring programmes. Data collated from the numerous surveys show that a significant proportion of children under 5 years of age, school children, pregnant and lactating women experience malnutrition. In 1999, 35.8% of children 12-71 months of age were vitamin A deficient (serum retinol <0.70µmol/L). In March 2005, 22.3% of targeted children received vitamin A capsules during routine visits to clinics for growth monitoring and immunisation. However, about 82% of the targeted children received vitamin A capsules during Child Health Days, which is therefore an effective strategy. More than 95% of households in the country have access to iodised salt, while the median urinary iodine in 2005 was about 200µg/L. In 1997, about 9% of the population were found to have less than 10µg/L serum ferritin leading to the conclusion that iron deficiency anaemia was of public health significance in Zimbabwe. About 31% of women of child bearing age were found to be anaemic in a 1999 survey leading to the expansion of iron tablet distribution during ante-natal visits. However, in 2005, 43% of pregnant women were taking iron supplements during pregnancy, with women in urban areas less likely to take iron supplements than women living in rural areas. There is need, therefore, to increase efforts to reduce micronutrient deficiencies in the country. Fortification of vegetable oil with vitamin A is technically feasible and the vitamin is stable for up to 6 months at 23°C. With increasing evidence of other micronutrient deficiencies such as the B-group vitamins, fortification of staple foods, such maize meal, could be a long term strategy of addressing micronutrient deficiencies in Zimbabwe.
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STATUS OF MICRONUTRIENT NUTRITION IN ZIMBABWE: A REVIEW
Gadaga TH1*, Madzima R2 and N Nembaware3,
Tendekayi Gadaga
* Corresponding author: Email: tgadaga@hotmail.com
1Department of Nutrition, National University of Lesotho, P.O. Roma, 180, Lesotho
2Ministry of Health and Child Welfare, P.O. Box CY1122, Causeway, Harare
Zimbabwe
3Helen Keller International, 26 Lomagundi Road, Harare, Zimbabwe
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ABSTRACT
More than 65% of the Zimbabwean population live in the rural areas and are food
insecure especially due to droughts. The population experiences fluctuating levels of
malnutrition including vitamin and mineral malnutrition. This paper constitutes a
review of the micronutrient malnutrition status of the Zimbabwean population,
focusing on the period from 1980 to 2006, using data from nutrition surveys, the
demographic health surveys, sentinel surveillance and monitoring programmes. Data
collated from the numerous surveys show that a significant proportion of children
under 5 years of age, school children, pregnant and lactating women experience
malnutrition. In 1999, 35.8% of children 12-71 months of age were vitamin A
deficient (serum retinol <0.70µmol/L). In March 2005, 22.3% of targeted children
received vitamin A capsules during routine visits to clinics for growth monitoring and
immunisation. However, about 82% of the targeted children received vitamin A
capsules during Child Health Days, which is therefore an effective strategy. More
than 95% of households in the country have access to iodised salt, while the median
urinary iodine in 2005 was about 200µg/L. In 1997, about 9% of the population were
found to have less than 1g/L serum ferritin leading to the conclusion that iron
deficiency anaemia was of public health significance in Zimbabwe. About 31% of
women of child bearing age were found to be anaemic in a 1999 survey leading to the
expansion of iron tablet distribution during ante-natal visits. However, in 2005, 43%
of pregnant women were taking iron supplements during pregnancy, with women in
urban areas less likely to take iron supplements than women living in rural areas.
There is need, therefore, to increase efforts to reduce micronutrient deficiencies in the
country. Fortification of vegetable oil with vitamin A is technically feasible and the
vitamin is stable for up to 6 months at 23oC. With increasing evidence of other
micronutrient deficiencies such as the B-group vitamins, fortification of staple foods,
such maize meal, could be a long term strategy of addressing micronutrient
deficiencies in Zimbabwe.
Key words: Micronutrients, malnutrition, vitamin A, anaemia
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INTRODUCTION
Micronutrient deficiencies impact negatively on the social, economic and intellectual
development of individuals and communities. According to the Global Progress
Report on Vitamin and Mineral deficiency, more than half of the population in Africa,
including many who consume sufficient calories and protein, lack critical vitamins
and minerals [1]. An estimated 350 million women and children in Africa suffer from
deficiencies in iron, vitamin A and folic acid. The WHO estimates that deficiencies in
iron, vitamin A and zinc each rank among the top 10 leading causes of death in
developing countries through disease [2]. Unfortunately, most people affected by
micronutrient deficiencies do not show overt clinical symptoms, nor are they
themselves aware of the deficiency, a phenomenon called “hidden hunger” [3].
At the World Summit for Children (1990), world leaders adopted a Declaration on the
Survival, Protection and Development of Children and a Plan of Action for
implementing the Declaration in the 1990s. There was agreement on the need for the
reduction in severe, as well as moderate malnutrition among children under-5 years of
age by half of the 1990 levels, to reduce iron deficiency anaemia in women by one
third of the 1990 levels, virtually eliminate iodine deficiency disorders, and virtually
eliminate vitamin A deficiency and its consequences, including blindness [4].
The International Conference on Nutrition (1992) and the United Nations General
Assembly (2002) sought further commitment to sustainable elimination of iodine
deficiency disorder by 2005 and vitamin A deficiency by 2010, reduce by one third
the prevalence of anaemia, including iron deficiency anaemia by 2010, and accelerate
programs towards reduction of other micronutrient deficiencies through food
fortification and supplementation. Over the past 40 years many developed countries
have dealt with the problem of vitamin and mineral deficiency (VMD) through
fortification, supplementation, dietary diversification, education and disease control.
These are practical and affordable solutions that developing countries can adopt for
the benefit of their populations.
A World Bank Review of micronutrient deficiencies in Zimbabwe showed that there
were recorded incidences of vitamin and mineral deficiencies at health institutions [5].
Recent survey data also showed that vitamin and mineral deficiencies still remain
problems of public health significance in the country. This report reviews progress
made in addressing micronutrient deficiencies in Zimbabwe, focusing on the period
1980 to 2006.
OVERVIEW OF NUTRITION SITUATION IN ZIMBABWE
Over the years, information on the nutritional status of Zimbabweans has been
collected in various national surveys and through child growth monitoring data
recorded at health centres and stored in the National Health Information System
(NHIS). The Zimbabwe Demographic Health Surveys (ZDHS) and Zimbabwe
Vulnerability Assessment (ZimVAC), as well as the Food and Nutrition Surveillance
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(FNS) and the IDD Sentinel surveillance are important sources of nutrition
information for decision makers.
The ZDHS surveys were initiated in 1988, and subsequently done in 1994, 1999, and
2005 [6]. Initially, the ZDHS only reported on the protein-energy nutrition status of
children in the age group 6 – 59 months, namely, prevalence of stunting, wasting and
weight for age, as well as breastfeeding practices. In 1999, ZDHS included several
questions to evaluate the micronutrient status of women and children. As shown in
Figure 1, the nutrition situation of the population has been constantly changing. The
people living in drought prone districts in the southern parts of the country, namely
Matebeleland South, Matebeleland North and Masvingo, are most vulnerable to under
nutrition.
The lack of adequate food intake in general is a major contributing factor in vitamin
and mineral deficiencies, especially iron and vitamin A [7. In other words,
populations that are malnourished are most likely vitamin and mineral deficient, and
malnutrition will generally indicate food insecurity [8]
Figure 1: The prevalence of wasting, stunting and underweight in children
under 5 years of age in Zimbabwe from 1985 to 2006.
0
5
10
15
20
25
30
35
1985
1988
1994
1998
1999
2002
2003
2004
2005
2006
Years
Prevalence (%)
Wasting
Stunting
Underweight
IODINE DEFICIENCY DISORDERS (IDD)
Lack of sufficient intake of iodine in the diet causes the thyroid gland to enlarge
resulting in goitre. However, goitre is only one of the indicators of IDD. Many
disorders begin before birth and persist throughout the life cycle. Infants born to
iodine deficient women, if they survive, may be cretins with short life expectancy,
physically or mentally retarded, deaf or mute and spastic, depending on degree of
iodine deficiency. It is estimated that globally, about 655 million people have goitre,
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while some 43 million are affected by some degree of mental impairment of which 6
million are cretins [9].
Goitre has long been recognized by indigenous Zimbabweans and a number of words
for the condition in local languages exist. In a study done in 1968 in the Chikwaka
area of Goromonzi district, a prevalence of up to 75% endemic goitre was reported.
More than half of those affected had visibly enlarged thyroids [10]. Around the same
time, up to 45% total goitre rate (TGR) and 6.6% visible goitre rate (VGR) were
reported for Omay in Kariba district [11].
The goitre prevalence in 1986 was to some extent similar to what was reported in
1968. A survey of 188 schoolchildren in Chinamhora communal lands reported a
TGR of 44%, while in Wedza district the TGR was 73% [12, 13]. However, it was the
national goitre survey of 1988 that highlighted iodine deficiency to be of public health
significance in Zimbabwe. The survey showed that TGR in Zimbabwe ranged
between 10.8% in Harare and 78.7% in Murehwa district (Table 1), with the
prevalence varying from moderate to severe. Twenty of the 50 districts surveyed had
goitre prevalence rates of more than 50%. The TGR for the provinces varied from
17% in Matebeleland South to 52% in Mashonaland Central. According to these
results, every province in the country could be classified as suffering from at least a
mild level of endemic goitre, with Murehwa district the most affected.
UNIVERSAL SALT IODISATION
A national inter-sectoral committee on iodine deficiency disorders (IDD) was set up
in 1989 with its terms of reference, among others, to monitor the implementation of
an IDD plan of action and facilitate the enacting of legislation for the control of IDD.
The committee came up with a national plan of action in 1991, with the objective of
eliminating iodine deficiency disorders by the year 2000. It recommended universal
salt iodisation (USI) as the main strategy, while distribution of iodised oil capsules
was suggested as an interim strategy in severely affected areas. In 1992, universal salt
iodisation was adopted but the legislation was only put in place in 1995. The Food
and Food Standards (Condiments) (Amendment) Regulations, 1995 (Statutory
Instrument 69 of 1995) set the iodisation level at between 30 and 90 mg/kg (ppm).
Following reported cases of hyperthyroidism, this regulation was amended and
replaced by the Food and Food Standards (Condiments) (Amendment) Regulations,
2000 (Statutory Instrument 44 of 2000), which now requires that all salt manufactured
or sold for human consumption in Zimbabwe, including crude salt, table salt,
flavoured salt or in other forms, shall be iodised with potassium or sodium iodate and
contain the equivalent of not less than 25mg or more than 55 mg of iodine per
kilogram of salt.
Universal salt iodisation (USI) was successful in Zimbabwe mainly because virtually
all of the country’s salt requirements were imported with very insignificant local
small-scale production. The quality of the imported salt could be easily monitored. By
1994 only eight companies handled almost 80% of all salt imports with the bulk of the
salt coming from Botswana. Salt was sold to consumers packed in 0.5, 1 and 2 kg
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bags. However, the number of salt traders/importers has since increased, with some of
the new players not aware of the IDD control programme. Some importers have been
suspected of bringing in inappropriately iodised salt. Although there are some areas in
Zimbabwe with potential salt deposits such as the Hot Springs, Gonarezhou National
Park, Zambezi Basin and Chipinge, the deposits are insignificant for commercial
exploitation. The local deposits are mostly utilized for household consumption and
very little if any, is sold commercially.
PROGRESS IN ELIMINATING IDD
Since the introduction of USI there have been significant changes in the iodine status
of the population as shown by the decrease in prevalence of visible and palpable
goitre. For example, in 1996, the TGR in Chinamora district, determined by palpation
in primary school children (n=329) of both sexes aged 6–14 years, was found to be
9%. Before the introduction of USI this rate was 44%. The median urinary iodine
level was about 450µg/L, double the upper limit of normal [14]. Only 5% of the
samples were below 100µg/L.
In 1999, a National Micronutrient survey was conducted which showed that 97.8% of
households in Zimbabwe were consuming iodised salt. Urine iodine levels of primary
schoolchildren showed that only 8.5% had <100µg/L, indicating a normalization of
iodine nutrition in the population [15]. Unfortunately, at that time, several cases of
hyperthyroidism were reported that indicated excess iodine in the diet [16]. About 12
deaths solely due to thyrotoxicosis were reported at Parirenyatwa Hospital in Harare
between 1993 and 1995 [16]. It was then suggested that the quality of iodised salt
should be constantly monitored. The level of iodisation which had initially been
recommended at 30–90 mg/kg was revised to 25-55mg/kg. The Ministry of Health
and Child Welfare, through the Environmental Health officers now continuously
monitors the IDD situation in the country by routine sampling of salt at retail level,
and through biannual IDD sentinel surveillance in 12 districts of the country.
IDD SENTINEL SURVEILLANCE
The IDD sentinel surveillance is regularly conducted in 12 districts: Harare,
Bulawayo, Chitungwiza, Nyanga, Chimanimani, Centenary, Murehwa, Matobo,
Shurugwi, Chegutu, Bikita and Binga. In each district 3 schools are chosen at random
and in each of these schools about 50 pupils are chosen using systematic random
sampling for collection of spot urine specimens. Goitre surveys are conducted at the
same time. Salt samples for titration are also collected from households (brought by
schoolchildren) and retail outlets in the catchment area of the 3 schools. The first such
surveillance was done in 1992. However, the surveys have not been held biannually as
scheduled and after 1992, the surveys were only done in 2002 and then in 2005.
In the 2005 IDD sentinel surveillance exercise, more than 1800 salt samples were
tested for iodine. About 54% of the iodised samples had levels of iodine within the
recommended range of 25-55 mg/kg. Another 39% of the samples had iodine levels
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below 25 mg/kg and the remaining 7% had levels above 55 mg/kg (Table 2). Binga
had the highest proportion of salt with iodine levels in the recommended range,
probably indicating a uniform source for their salt. In total, 99.7% of the salt samples
tested contained iodine.
Iodine deficiency disorders monitoring was also integrated into the Food and
Nutrition Surveillance (FNS) programme. However, some of the districts among the
10 sentinel districts used during FNS are different from those of the IDD sentinel
surveillance (Table 3), and therefore results may not be directly comparable. From the
November 2004 Food and Nutrition Surveillance data, 90% of households
interviewed used iodised salt, while about 7% were using un-iodised salt. About 3%
had no salt at all at the time of sampling (Table 3). Centenary district had the highest
number of households with un-iodised salt and also those without salt at the time of
sampling. By comparison, in June 2005 Zimbabwe Vulnerability Assessment
Committee (ZimVAC) reported that on average 95% of households were using
iodised salt. However, sub-optimal levels of iodine were detected in some salt
samples. Mashonaland East, Masvingo, Mashonaland West, Midlands and
Matebeleland South had 25%, 24%, 16%, 11% and 3% of the households,
respectively, using un-iodised salt, indicating that the IDD monitoring programme
needed strengthening. The results also suggest that some communities in the country
could be having access to salt obtained from other sources other than Botswana Ash
and other recommended suppliers. Centenary (67% iodised salt), Bulilimamangwe
(80.2%), Kwekwe (85.7%) and Kariba (86.7%) seem to be worst affected [17].
Urine iodine levels also confirm that there has been a reduction in IDD prevalence in
Zimbabwe (Table 4). In 1992 urinary iodine levels in schoolchildren were well below
100µg/L but a sharp rise in urinary iodine levels was observed in a few districts in
1993. A further increase was noted in 1995 with quite a number of districts recording
urine iodine levels above 300µg/L, which coincided with the time iodine induced
hyperthyroidism (IIH) was observed in some parts of the country. The urine iodine
levels showed a major reduction from the 1995 highest levels of 600 µg/L to 220 µg/L
in 2005, indicating a stabilization of the iodine intake in the population. However, in
Nkayi and Shurugwi districts the median urinary iodine levels were still above
600µg/L in 2005. The observed reduction could be linked to the amendment of the
Food Regulations in 2000. As the IDD prevention programme progresses, goitre rates
become less useful indicators and urinary iodine level progressively becomes the
elimination criteria. [14].
VITAMIN A DEFICIENCY
Vitamin A deficiency (VAD) can lead to visual malfunctions such as night blindness
and xerophthalmia and can reduce immune responsiveness causing increased
incidence and severity of respiratory infections, gastrointestinal infections and
measles. Vitamin A deficiency is not only the cause of childhood blindness across
developing countries, its effects on children’s immune system directly results in
around 10.8 million deaths each year. According to UNICEF, eradicating VAD would
cut child deaths due to measles by 50% [17]. Maternal VAD may contribute to mother
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to child transmission of HIV and contribute to increased infant mortality [18].
Vitamin A can be obtained from food either as preformed vitamin A in animal
products or as provitamin A carotenoids, for example α-carotene, β-carotene and β-
cryptoxanthin in plant products.
Prior to 1999, the vitamin A deficiency status in Zimbabwe was not completely
known except for a few limited studies. For example, McManus investigated about
250 cases of xerophthalmia in rural Matebeleland North and South [19]. Most of these
cases were observed following measles infection, while some were associated with
protein energy malnutrition (PEM) and some with dysentery. Most cases were seen
from May to December when milk is less available and green vegetables are
consumed dry. In a separate study, Decker studied 988 cases of hospitalized children
in Lupane and found that ocular lesions from measles were much more severe among
black children with low vitamin A intake [20]. However, in 1983, findings from the
World Bank Population Health and Nutrition Sector review seemed to indicate that
vitamin A deficiency was uncommon in Zimbabwe [5].
A study conducted in Matebeleland North in 1991 recorded the prevalence of Bitot’s
spots at 0.17% and that of vitamin A related corneal scars at 0.03%, well below the
0.5% WHO criteria for VAD of public health significance [21]. The National
Micronutrient Survey, however, showed a more detailed picture of the vitamin A
deficiency prevalence in Zimbabwe [15]. The survey showed that 35.8% (n=346) of
children 12-71 months had vitamin A deficiency, with serum retinol levels below
0.70µmol/L. Among schoolchildren of 6-14 years age group VAD prevalence was
18% (n=657). In women of child bearing age, 15-49years, VAD prevalence was 6.9%
(n=804) [15]. At the same time, however, the ZDHS (1999) showed that 3 in 4
children under 3 years of age received food rich in vitamin A. Unfortunately the types
of foods given were not recorded [6].
All this information pointed to the need for Zimbabwe to take measures to adequately
and continuously address VAD in the population. Several approaches are documented
in literature including distribution of high dose oral supplements, food fortification,
and education to increase the consumption of foods naturally rich in vitamin A [22].
Zimbabwe has been pursuing all three strategies with different results to date.
VITAMIN A SUPPLEMENTATION
Targeted vitamin A capsule distribution in Zimbabwe was initiated through UNICEF
funding in 2002 and was integrated with the Expanded Programme on Immunisation
(EPI) in the same year. In the programme, vitamin A capsules are given to children
under 5 years of age every 6 months. The vitamin A capsules were also distributed in
areas severely affected by the drought in 2002/2003. The National Nutrition and EPI
Survey done in 2003 found that the vitamin A capsules distributed through the routine
EPI programme only reached 46% of the targeted population in the country.
In November 2004, the Food and Nutrition Surveillance observed that 23% of the
children assessed had received vitamin A in the previous 6 months, while 69% had
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not, and the status of 8% of them was not known [23]. Vitamin A capsule distribution
coverage was particularly low in Centenary, Mudzi, Kariba, Gutu, Tsholotsho,
Bulilimamangwe and Kwekwe, the worst affected being Centenary (94% without) and
Kariba (90%). In the 12-23 and 24-59 months age groups, over 60% had not received
vitamin A in the previous 6 months. Among the 10 provinces, Bulawayo had the best
coverage of about 40% (verified by a Health card).
In March 2005, the vitamin A supplementation coverage had further decreased
compared to November 2004 [23]. During this time an average 22.3% of the children
in the sentinel districts had received vitamin A, 70.5% had not received while the
status of 7% was not known. However, Bulawayo still had the best coverage with
over 50% of children having received vitamin A and verified with a health card.
Again Centenary (96.9%), Bulilimamangwe (89.8%), Gutu (81.9%) and Kariba
(83.4%) had the highest number of children who had not received vitamin A in the
previous 6 months (Figure 2). These districts are therefore a cause for concern. The
highest number of children (9.2%) who had received vitamin A without
documentation was from Mudzi.
In November 2005, the third FNS reported that an average of more than 50% of the
children assessed had received vitamin A in the previous 6 months and this was
verifiable by child health card. About 12% received vitamin A supplementation but it
was not recorded in the child health card, while 33.5% did not receive vitamin A
supplementation at all. This was an improvement over the previous 12 months.
However, it was clear that vitamin A capsule distribution strategy needed to be
modified. There were suggestions to combine the capsule distribution programme
with other programmes such as mosquito net distribution or national Child Health
Days. Recent data show that during the Child Health Days in June 2005, 82% of the
targeted children received vitamin A capsules [24]. Figure 3 shows the trend in
vitamin capsule distribution from 2003 to 2005.
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Figure 2: Vitamin A supplementation coverage in Zimbabwe in the 6
months before March 2005. (Chc=child health card)
0
20
40
60
80
100
120
Bulawayo
Harare
Chimanimani
Centenary
Mudzi
Kariba
Gutu
Tsholotsho
Bulilima
Kwekwe
Province
Coverage %
not received
received with chc
received no chc
Some stakeholders believe that there is further need to formulate additional strategies
for sustainable vitamin A capsule distribution and train staff involved in the
implementation of the programme. For example, National Vitamin A days backed by
vigorous information and education campaigns would help the parents to understand
the need for their children to receive vitamin A supplements [23]. While the annual
vitamin A capsule distribution campaigns together with the routine EPI should
continue, more information should be given to mothers on the importance of this
exercise. In addition, the staff involved should be well trained and motivated with
sufficient supervision so that all the necessary details about the programme are
recorded.
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Figure 3: The coverage of vitamin A capsule distribution in Zimbabwe
from 2003 to 2005. [2005a = March 2005; 2005b = November
2005]
0
10
20
30
40
50
60
2003 2004 2005a 2005b
Sampling period
%
Covera
ge
DIETARY DIVERSIFICATION
Dietary diversification leads to consumption of foods rich in pro-vitamin A. This is a
sustainable and cost effective long-term strategy. However, recent studies showed that
the efficiency of conversion of pro-vitamins in plant foods to retinol is variable. De
Pee et al.[25] and Bulux et al.[26] suggested that there is little or no vitamin A
nutritional benefit from increased consumption of dark green vegetables, highlighting
the need to investigate this relationship further. While many Zimbabweans produce
vegetables in their home gardens, there is insufficient documented information on
consumption and preparation methods. In addition many people in the drier parts of
the country do not have access to fresh vegetables throughout the year. Mandatory
fortification of some staple foods, therefore, will help improve the nutritional status of
consumers.
FORTIFICATION OF FOOD WITH VITAMIN A
Fortification of foods with vitamin A is technically feasible and can be a cost-
effective method of providing adequate vitamin A to high risk groups [27]. According
to current Zimbabwe laws [Food and Food Standards (Edible Fats and Oils)
(Amendment Number 3) Regulations, 1990], vegetable oil is currently not required to
be fortified with vitamin A. However, some food processing companies have
voluntarily fortified vegetable oil with vitamin A. On the other hand, margarine is
required to contain not less than 27 IU and not more than 33 IU of vitamin A [Food
and Food Standards (Margarine) Regulations, 1973]. However, monitoring of these
regulatory provisions is not very efficient as the central laboratories often do not have
all the necessary materials (equipment and analytical reagents) and trained people to
test for vitamin A in food. The laboratories, therefore, need to be well equipped to
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conduct these tests because fortification of vegetable oil and margarine are an
efficient way of providing vitamin A to the consumers. Retention of vitamin A in
vegetable oil has been reported to be as high as 83-100% after 6 months storage at
23oC [22].
Stability tests on vitamin A in maize meal and wheat flour have shown significant
losses during storage and cooking [28]. For example, almost 32% of vitamin A added
to maize meal was lost during 12 weeks storage at 45oC. Fortifying dry products such
as cereal flours also requires a process of converting vitamin A to a water soluble
compound and then drying it, which may increase fortification costs. Fortification of
vegetable oil, therefore, seems to be the viable option in Zimbabwe and may result in
sustained elimination of VAD in the country.
IRON DEFICIENCY ANAEMIA
Iron deficiency is one of the most widely prevalent micronutrient deficiencies in the
world, affecting at least half of all pregnant women and young children in developing
countries [3, 9]. Children under 24 months are especially at risk, resulting in stunting
and reduced ability to resist common childhood illnesses [3]. In older children the
ability to concentrate and perform well in school is lowered [29]. Anaemia is a serious
risk to mothers with many women dying in childbirth because of severe anaemia. Iron
deficiency anaemia in pregnant women reduces the oxygen supply to the foetus,
causing intrauterine growth retardation and increased risk of premature delivery and
reduced birth weight. Using results from the 1999 ZDHS, Mishra et al. [30] observed
that supplementation of mothers with iron during pregnancy had a strong positive
effect on child’s birth weight. When iron deficiency is compounded by other vitamin
and mineral deficiencies, the economic impact can be significant, yet iron can be
obtained from animal products such as red meat and in vegetables, grains and
legumes.
Chinyanga [31] measured the haemoglobin (Hb) levels in both goitrous and non-
goitrous pregnant women in a survey done in Harare, Wedza and Nyanga. The study
revealed that 11.4 % of the women in Harare had Hb levels less than 11g/dL, with 33
% in Wedza and 10.9 % in Nyanga. Folate levels of less than 2µg/mL in 7.8% of all
the women assessed were also recorded. The Ministry of Health and Child Welfare
also carried out an iron deficiency prevalence survey in 1997. Samples were collected
in 4 provinces, namely, Mashonaland Central, Midlands, Matebeleland North and
Matebeleland South. Haemoglobin and serum ferritin levels were measured in pre-
school children, pregnant women, lactating mothers and adult males. It was observed
that 33 % of pregnant women, 29.6 % of lactating women, 17.6 % of pre-school
children and 16.5 % of adult males had Hb levels between 9 and 11g/dL. About 9 %
of the population had depleted iron stores (serum ferritin <10µg/L), concluding that
iron deficiency anaemia was of public health significance in Zimbabwe. It was
suggested that future studies should examine the prevalence of parasitic infections and
the HIV status of respondents in order to correct for their confounding effect.
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In a survey of 505 rural Zimbabweans in Matebeleland North province, iron overload
was found almost exclusively among men who consumed traditional beer brewed in
steel drums [32]. The study also reported high serum ferritin and a transferrin
saturation of over 70%, raising concerns over possible high risk of liver disease.
Maternal anaemia is a common cause of both maternal and neonatal mortality. The
National Micronutrient Survey (1999) found that 31% of women of child-bearing age
were anaemic, followed by children below the age of 6 years (27.4%) and children
between 6 and 14 years (19.3%) [15]. Because of this, women in Zimbabwe are given
iron supplements during pregnancy. Iron supplements distribution has been integrated
with antenatal and postnatal health programme. Over 90% of pregnant women in
Zimbabwe have at least one antenatal contact with the health services where they are
expected to receive a four week supply of prophylactic iron sulphate and folate
tablets. However, ZDHS (1999) recorded less than 6% of pregnant women had taken
more than 90 iron tablets during their pregnancy [6]. Less than 5% of mothers in
Mashonaland Central, Mashonaland East, Mashonaland West, Matebeleland North
and Matebeleland South took 90 or more iron tablets during their pregnancy. In
Harare, only 1% of mothers took 90 or more iron tablets during pregnancy.
Zimbabwe Demographic and Health Survey (ZDHS) (2005/06) data also showed that
in the five years preceding the survey, less than half (43%) of pregnant women
received iron supplements. Women in urban areas were less likely to receive iron
supplements than women living in rural areas (41 and 44%, respectively). Pregnant
women in Harare are least likely to receive the supplements (29%). This is
paradoxical considering the high number of pregnant women who have access to ante-
natal care. Iron deficiency anaemia, therefore, continues to unnecessarily hamper
national productivity.
OTHER MICRONUTRIENT DEFICIENCIES
Seasonal niacin deficiency and cases of pellagra have been reported in Zimbabwe,
increasing during severe drought. Niacin deficiency is associated with a maize based
diet. Surveillance reports from Mashonaland Central indicated high incidence of
pellagra in 1995 [33]. Data from the NHIS shows that pellagra cases have been on the
increase since 2000, with 5538 cases reported in 2005 compared to 3832 in 2000.
Vitamin B12 levels were reportedly low in some pregnant women in Zimbabwe [31].
There is, therefore, need to address these micronutrients in the broader strategy to
reduce VMD.
STAPLE FOOD FORTIFICATION IN ZIMBABWE
The objective of national micronutrient programmes is to ensure that needed
micronutrients are available and consumed in adequate quantities by vulnerable
groups.
The micronutrient deficiencies described above highlight the inadequacy of the diet to
provide adequate amounts of the micronutrients. Household food insecurity forces
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515
people to consume the little food that is available with very little scope for
diversification. From the consumption studies previously done in Zimbabwe, it is
apparent that mandatory fortification of staple foods such as maize meal, wheat flour,
sugar, cooking oil and salt, which are commonly consumed by vulnerable groups in
the population may help to reduce and eventually eliminate most of the micronutrient
deficiencies in Zimbabwe [34, 35, 36]. Fortification of salt with iodine has been a
major success with more than 95% of the population now using iodised salt. The
fortification of maize meal or flour with iron and folate is feasible, inexpensive, safe
and likely to be beneficial, while the fortification of vegetable oil with vitamin A has
been done elsewhere with great success [37]. Vitamin A fortification of sugar is
currently being done in Zambia and Nigeria. However, experience with sugar
fortification in Zambia shows that sugar processors are likely to pass on the cost of
fortification to the consumer and that imported sugar has to meet the fortification
requirement. The size of sugar granules also affects the efficiency of fortification,
hence the need to assess feasibility for specific countries.
THE WAY FORWARD
According to WHO criteria for elimination of IDD, Zimbabwe achieved Universal
Salt Iodisation (USI), with repeated surveys since 1995 indicating that more than 90%
of the households in Zimbabwe use iodised salt. Salt monitoring and surveillance
should be done on a continuous basis.
The country should also pursue mandatory fortification of edible oils. Available food
consumption data show that more than 60% of the population consume vegetable oils
almost every day. In addition, mandatory fortification of wheat flour with iron and
folic acid is also feasible with the bulk of the flour being produced by five big
companies. However, many small millers have emerged as key suppliers of maize
meal and flour and have to be considered in any strategy for food fortification. Flour
and maize meal can also be fortified with B-group vitamins.
The Food and Nutrition Surveillance is a good tool to monitor the progress towards
eliminating VMD. It is recommended, however, that a more representative sampling
frame be used so that a better estimate of the micronutrient status in the country is
readily available. The IDD Sentinel surveillance should be integrated into the Food
and Nutrition Surveillance in order to maximise the use of resources. The National
Micronutrient Surveys should also be held timely to allow for effective intervention.
CONCLUSION
Although the country has recorded significant progress in reducing malnutrition,
significant setbacks have been observed in the last 5 years, especially due to drought
induced food shortages. This has also impacted the micronutrient nutrition status of
the population. However, the control of IDD in Zimbabwe seems to have been
successful. The national total goitre rates have been decreasing since 1988 and up to
95% of households in Zimbabwe used iodised salt and the median urinary iodine
levels are about 220 µg/L. On the other hand the main strategy against vitamin A
Volume 9 No. 1 2009
January 2009
516
deficiency has been vitamin A capsule distribution during routine visits to clinics for
growth monitoring and immunisation. A national coverage of 22.3% by March 2005
suggests that the programme may not be achieving its intended goal. Vitamin A
capsule distribution during Child Health days, however, seems to be more effective as
up to 90% of the targeted children are reached. The impact of other micronutrients
such as vitamin B group and zinc have not been thoroughly investigated and there is
need for the country to strengthen the micronutrient intervention programmes in order
to achieve some of the Millennium Development Goals [38].
ACKNOWLEDGEMENT
This review was made possible with funding from Helen Keller International under
CIDA purchase order 7036919. The views in the paper do not reflect opinions of
either HKI or CIDA.
Volume 9 No. 1 2009
January 2009
517
Table 1: The prevalence of goitre in Zimbabwe in after the 1988 National
Goitre survey
Province %Total Goitre
Rate
%Visible Goitre
Rate
Manicaland 49.1 4.7
Mashonaland Central 51.8 4.9
Mashonaland East 54.9 10.0
Mashonaland West 40.8 1.2
Masvingo 51 5.3
Matebeleland North 39.6 1.6
Matebeleland South 16.8 0.7
Midlands 44.7 4.4
Harare 10.8 0.2
Bulawayo 19.3 0.4
National 44.1 3.9
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518
Table 2: The level of iodisation of salt samples collected from retail
outlets during the 2005 IDD sentinel surveillance
District % salt samples with iodine content
<25 ppm 25–55 ppm >55ppm
Bikita 48 48 4
Binga 12.5 81.5 6.3
Bulawayo 40 57.1 3.3
Centenary 28 64 7.15
Chegutu 33.3 53.3 13.3
Chitungwiza 44 50 6
Harare 54 47 0
Kwekwe* NA NA NA
Matobo 27.6 58.6 13.8
Murehwa 56 44 0
Nyanga 55 30 15
Shurugwi 30 65 5
National 38.7 54.4 6.7
Source: IDD Sentinel Site Surveillance, May 2005. *NA = Not Available
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519
Table 3: The use of iodised salt at household level in 10 sentinel districts
in Zimbabwe according to the 2005 Food and Nutrition
Surveillance programme
Iodine status
District %Iodized %Un-iodized
% with no
salt
Bulawayo (n=368) 100 0 0
Harare (n=323) 99.4 0.6 0
Chimanimani (n=291) 97.3 2.3 0.3
Centenary (n=211) 67.4 23.3 9.3
Mudzi (n=296) 94 4.1 1.9
Kariba (n=306) 86.7 7.4 5.9
Gutu (n=362) 94.5 2.9 2.6
Tsholotsho (n=376) 94.5 4 1.5
Bulilimamangwe (n=299) 80.2 15 4.8
Kwekwe (n=353) 85.7 13.6 0.7
TOTAL (n=3185) 90 7.3 2.7
Table 4: Changes in median urinary iodine concentration after
introduction of universal salt iodisation in Zimbabwe
Year Median urinary iodine concentration (ug/L)
1991-92 20 - 80
1993-94 200 – 500
1995 290 – 560
2005 ca. 220
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You can access the full text on this World Bank website: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/1994/06/01/000009265_3970128113943/Rendered/PDF/multi0page.pdf
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The stability of vitamin A in foods subjected to transportation and storage conditions of child feeding programs in India was investigated. Pails of fortified soybean and bags of corn soy blend (CSB) were tracked from U.S. production and packaging sites to their point of distribution in Indian villages. Vitamin A levels found in different batches of CSB arriving in India varied 10-fold. An estimated 35 to 45% loss occured in vitamin A activity in CSB and equalled approximately 0-30% in oil. The study found no settling out of fortificant from oil. Cost calculations suggest significant savings in using oil as the vehicle for vitamin A instead of CSB.
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This review updates a previous (1982) report using information covering the period from independence to 1992. It finds that Zimbabwe has successfully reduced the high levels of preschool child malnutrition evident at the time of the last report, but that new threats have emerged, including the crises brought about by the 91-92 drought and HIV infection. Other nutritional problems and their causes are discussed, and the emerging institutional framework for tackling them is outlined. Recommendations include a greater focus on school-age children, a renewed emphasis on the benefits of breastfeeding, and the expansion of the community based growth monitoring program. -M.Amos
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he Millennium Development Goals are of central concern to the international community. The year 2005 is a year of benchmarks for the Millennium Development Goals - the questions commonly asked are, are we on target? Will the world achieve the Millennium Development Goals (MDGs) by 2015? One can make a distinction between the achievability versus the adequacy of the MDGs. It seems to me that the adequacy question needs to be answered before the achievability question. So I would like to address the issue of adequacy of the MDGs first and then briefly assess the likelihood of achieving the MDGs by 2015. Let me say by way of preamble that analysis of the MDGs has been a great preoccupation for the North-South Institute. We brought out three publications in 2005 that deal with the MDGs. One is about Canada's international policy, the second is our annual flagship publication: the Canadian Development Report, which emerged in September just before the Millennium Review Summit, and the third publication is entitled, We the Peoples 2005 - Special Report, The UN Millennium Declaration and Beyond - Mobilizing for Change, Messages from Civil Society. Some of my comments will be based on the findings of this last report, which is the fourth in a series of surveys we have commissioned or undertaken canvassing some 450 civil society organi- sations all over the world, 60 percent of whom are from the South. In this report, we try to ascertain their knowledge of and engagement with the Millennium Development Goals and the Millennium Declaration. T
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There is little evidence to support the general assumption that dietary carotenoids can improve vitamin A status. We investigated in Bogor District, West Java, Indonesia, the effect of an additional daily portion of dark-green leafy vegetables on vitamin A and iron status in women with low haemoglobin concentrations (Every day for 12 weeks one group (n=57) received stirfried vegetables, a second (n=62) received a wafer enriched with β-carotene, iron, vitamin C, and folic acid, and a third (n=56) received a non-enriched wafer to control for additional energy intake. The vegetable supplement and the enriched wafer contained 3·5 mg β-carotene, 5·2 mg and 4·8 mg iron, and 7·8 g and 4·4 g fat, respectively. Assignment to vegetable or wafer groups was by village. Wafers were distributed double-masked. In the enriched-wafer group there were increases in serum retinol (mean increase 0·32 [95% Cl 0·23-0·40] μmol/L), breastmilk retinol (0·59 [0·35-0·84] μmol/L), and serum β-carotene (0·73 [0·59-0·88] μmol/L). These changes differed significantly from those in the other two groups, in which the only significant changes were small increases in breastmilk retinol in the control-wafer group (0·16 [0·02-0·30] μmol/L) and in serum β-carotene in the vegetable group (0·03 [0-0·06] μmol/L). Changes in iron status were similar in all three groups.An additional daily portion of dark-green leafy vegetables did not improve vitamin A status, whereas a similar amount of β-carotene from a simpler matrix produced a strong improvement. These results suggest that the approach to combating vitamin A deficiency by increases in the consumption of provitamin A carotenoids from vegetables should be re-examined.
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The pattern of food consumption among the people of Mutambara was studied during periods in December/January, May, and August. A total of 146 food items were consumed. The largest number of meals missed, mainly lunches, was in May. Home grown foods were consumed to a greater extent in May and August than in the December/January period. Wild and semi-wild vegetables and insects were consumed only in December/January when they were available.
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The purpose of the study was to investigate the iodine status of the population and the possible role of goitregens (that are metabolised to thiocyanate), in two endemic goitre areas of Zimbabwe. This was done through estimation of iodine (I) and thiocyanate (SCN) levels in spot urine samples collected from goitrous and non-goitrous subjects. Mean and median urine iodine concentrations respectively for Wedza (n = 50) were 1.4 micrograms/dl and 1.0 micrograms/dl and for Chiweshe (n = 60) were 2.1 micrograms/dl and 1.65 micrograms/dl. The differences between the two districts are significant (P = 0.005) and mirror the overall differences in goitre rates found. Urine I levels were generally lower in goitrous than non-goitrous subjects, but the difference was not significant. Mean urine SCN concentrations and mean I/SCN ratios respectively for Wedza were 0.5 micrograms/dl and 2.9 micrograms/dl and for Chiweshe were 0.7 micrograms/dl and 3.4 micrograms/dl. These results indicate that the populations studied are affected by severe iodine deficiency, but that thiocyanate does not have a significant goitrogenic effect. The implications of the results, and the reasons for the discrepancies between them and ones obtained in earlier studies, are discussed.
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Goitre prevalence surveys were carried out in 1986 in five primary schools in Wedza District and the results compared with those obtained from the same schools in 1968. Overall, goitre prevalence was 73 percent and there had been no significant change since 1968. In 1986 the visible goitre rate was 14 percent. Goitre was more common in girls on both occasions. Evidence (though not conclusive) of milder forms of endemic cretinism was found. The need for a nationwide iodination programme is emphasised.