No pills to swallow

  • Micronutrient supplements can be vital short-term measures to reduce anaemia in children
- GIRI RAJ SUBEDI
No pills to swallow

Dec 22, 2014-

According to the World Health Organisation (WHO), approximately two billion people suffer from micronutrient deficiencies globally, and a poor diet is the main culprit. This causes the deaths of 3.5 million mothers and children each year, and millions of children are permanently disabled, physically and mentally, particularly due to a poor diet in the earliest months of life.

The most common deficiencies are those in Vitamin A, iron, zinc, and iodine, which account for 11 percent of the global disease burden. Micronutrient deficiencies are prevalent in poorer countries where people’s diets are limited by economic, cultural, and geographical barriers.

Packed in powders

Micronutrients are the critical building blocks in a child’s body. Lack of micronutrients results in poor development of the body and brain; it affects their hormonal and cognitive functions, physical wellbeing, work and learning capacity, and overall health.

In Nepal, Vitamin A supplementation to children 6-59 months was initiated two decades ago and iodised salt has now reached 80 percent of the Nepali households. However, 69 percent of  young children aged 6-23 months are anaemic, which is critical, considering the WHO threshold of less than 40 percent. Furthermore, 41percent of children are stunted.

Efforts to improve infant and young child feeding practices, particularly, introducing complementary food right after six months, and improving the nutrition quality of diets (frequency and nutrient density, diversity) are currently ongoing. Despite this, only one out four children is fed as per the recommendation.  

After decades of efforts to reverse the tide of anemia among young children, governments in more than 60 countries today are using micronutrient powders (MNP) in complementary food to combat these dietary deficiencies. When mixed with complementary foods, these MNPs provide essential micronutrients in an otherwise poor diet. A WHO study in 2011 on the ‘use of multiple micronutrient powders for home fortification of foods for infants and children under five’ found a reduction in anaemia by 31percent and iron deficiency by 51 percent.

Hailed as a major breakthrough and backed by global and national evidence, both qualitative and quantitative, this intervention is helping rewrite a new chapter in global public health. The present value for a nation’s GNP in earnings is up to $51 ($18-$51) for each dollar spent on the MNP programme.

MNPs in Nepal

In Nepal, the Ministry of Health and Population (MoHP) noticed an alarming relation between critically-high levels of anaemia among young children who also suffered from other micronutrient deficiencies, and felt the need for a concerted strategy to battle both in 2003. Thus, the National Nutrition Policy of 2004 and Anemia Plan of Action 2005 helped develop strategies that sought to overcome poor Infant and Young Child Feeding (IYCF) practices, which revealed that 78 percent of children under two were anemic in 2006.

The need for innovative approaches to address anemia in children and vulnerable groups, and a national plan of action in 2007, endorsed the use of ‘sprinkles’ or ‘Baal Vita’ as an effective and cost-efficient intervention. A feasibility study in two districts paved the way for piloting of the Baal Vita programme in six districts in 2008.

Coupled with improved complementary feeding practices, mothers were also counselled on fortification of staples, diversifying diets, and adding oil or butter, ghee, and peanuts to make it nutrient dense. Hand-washing with soap before preparing food and feeding children was also promoted. Mothers and caregivers were also trained to prepare locally made nutritious complementary foods like ‘poshilo jaulo’ with pulses, rice, and green vegetables cooked in oil or ghee, and ‘lito’, blended and roasted cereal with legume flours. After promising results from the pilot evaluation, the MoHP expanded the IYCF-MNP programme to an additional nine districts in 2012/2013.

Although the MNP programme is being implemented in more than 60 countries, there are some concerns about its feasibility. The first concern is its sustainability, as MNPs are imported; acceptance by families; and the ability to reach targeted populations. Trial production of MNPs by local entrepreneurs has already been successful in Nepal, and this may significantly lower costs. A recent independent assessment by the Nepal Health Research Council also recommended the continuation of the IYCF-MNP programmes in Nepal.  

However, the Ministry recognises MNP approach as a short-term remedy for an unacceptably high rate (69 percent) of anaemia among infants and children under two. A food-based approach alone will not work in the short-term because only 25 percent of Nepali children receive the minimally-accepted diet.

Looking ahead

The Nepali government has recommended four strategies to reduce the level of micronutrient deficiencies.

The first is a long-term strategy to diversify diets by promoting the consumption of foods that are naturally rich in micronutrients. The second is a mid-term strategy of food fortification, where commonly eaten foods, which can be vehicles for one or more micronutrients, can be centrally processed on an economical scale. Some positive examples of food fortification include iodine fortification in salt and fortification of wheat flour with iron, folic acid, and Vitamin A. MNPs are also a food-based approach, as home fortification of commonly-eaten complementary foods.

Supplementation programmes for targeted vulnerable populations is the third short-term strategy, administered through health institutions. Currently, Vitamin A and deworming supplements are provided to children aged 6-59 months, and iron and folic acid supplements are being provided to pregnant and lactating women.

The fourth and continuous long-term strategy involves nutrition education and infection prevention, and is equally crucial because it teaches parents and caretakers about changing and adopting positive behaviours.

These strategies are not mutually exclusive and are being implemented simultaneously. The Multi Sector Nutrition Plan of the government includes interventions for short-, medium- and long-term strategies that address the immediate, underlying, and basic causes of under-nutrition and highlights the role of each relevant ministry. The management of under-nutrition, including micronutrient deficiencies, is one of the key actions being undertaken by the MoHP.

While improved Infant and Young Child Feeding practises, coupled with MNP programmes through the Ministry of Health, will provide quick fixes, long-term interventions should include nutrition sensitive actions from other sectors such as agriculture, water sanitation and hygiene, local development, education, and women and children. The war against micronutrient deficiencies and anaemia can only be won if all interventions by the Health Ministry, other ministries, and partners are planned, coordinated, and implemented in a concerted, efficient and sustainable manner.

Subedi is Chief of the Nutrition Section at Child Health Division, DoHS, Ministry of Health and Population

Published: 23-12-2014 09:18

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