Preliminary Pages: Title Page / Table of Contents / Preface / Foreword / List of Contributors Free

Vol. 70

Editors

Zulfiqar A. Bhutta Karachi, Pakistan

Richard F. Hurrell Zurich, Switzerland

Irwin H. Rosenberg Boston, MA, USA

Nestec Ltd., 55 Avenue Nestlé, CH-1800 Vevey (Switzerland)

Library of Congress Cataloging-in-Publication Data

Meeting micronutrient requirements for health and development/editors, Zulfiqar A. Bhutta, Richard F. Hurrell, Irwin H. Rosenberg.

p.; cm. –– (Nestlé Nutrition Institute workshop series, ISSN 1664-2147 ;v.70)

Includes bibliographical references and index.

ISBN 978-3-318-02111-0 (hard cover: alk. paper) –– ISBN 978-3-318-02112-7 (electronic version)

I. Bhutta, Zulfiqar Ahmed, 1955- II. Hurrell, Richard. III. Rosenberg, Irwin H. IV. Series: Nestlé Nutrition Institute workshop series ;v.70. 1664-2147

[DNLM: 1. Micronutrients––Congresses. 2. Nutritional Requirements––Congresses. 3. Child. 4. Deficiency Diseases––Congresses. W1 NE228D v.70 2012 / WS 130]

572'515––dc23

2012025488

The material contained in this volume was submitted as previously unpublished material, except in the instances in which credit has been given to the source from which some of the illustrative material was derived.

Great care has been taken to maintain the accuracy of the information contained in the volume. However, neither Nestec Ltd. nor S. Karger AG can be held responsible for errors or for any consequences arising from the use of the information contained herein.

© 2012 Nestec Ltd., Vevey (Switzerland) and S. Karger AG, Basel (Switzerland). All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or recording, or otherwise, without the written permission of the publisher.

Printed on acid-free and non-aging paper

ISBN 978-3-318-02111-0

e-ISBN 978-3-318-02112-7

ISSN 1664-2147

e-ISSN 1664-2155

IX Preface

XI Foreword

XIV Contributors

Introduction to Micronutrient Requirements

1 Global Micronutrient Deficiencies in Childhood and Impact on Growth and Survival: Challenges and Opportunities

Imdad, A.; Bhutta, Z.A. (Pakistan)

11 Micronutrients in the Treatment of Stunting and Moderate Malnutrition

Penny, M.E. (Peru)

22 Discussion on Micronutrient Requirements

Solomons, N.W. (Guatemala)

Zinc in Maternal and Child Health

27 Zinc Requirements: Assessment and Population Needs

Hambidge, K.M.; Miller, L.V.; Krebs, N.F. (USA)

37 Role of Zinc in Child Health and Survival

Black, R.E.; Fischer Walker, C. (USA)

43 Discussion on Zinc in Maternal and Child Health

Wasantwisut, E. (Thailand)

Multiple Micronutrient Deficiencies in Pregnancy

49 Global Burden and Significance of Multiple Micronutrient Deficiencies in Pregnancy

Darnton-Hill, I. (Australia/USA)

61 Intervention Strategies to Address Multiple Micronutrient Deficiencies in Pregnancy and Early Childhood

Imdad, A.; Bhutta, Z.A. (Pakistan)

74 Summary on Micronutrient Requirements and Deficiencies in Maternal and Child Nutrition

Bhutta, Z. (Pakistan)

Vitamin A in Childhood: Evidence and Controversy

79 Vitamin A Supplementation, Infectious Disease and Child Mortality: A Summary of the Evidence

Thorne-Lyman, A.; Fawzi, W.W. (USA)

91 Issues and Controversies with Vitamin A in Childhood

Murguía Peniche, M.T. (Mexico)

103 Discussion on Vitamin A Supplementation in Childhood

Bhatia, J. (USA)

Iron

107 Influence of Inflammatory Disorders and Infection on Iron Absorption and Efficacy of Iron-Fortified Foods

Hurrell, R.F. (Switzerland)

117 Safety of Iron Fortification and Supplementation in Malaria-Endemic Areas

Brittenham, G.M. (USA)

128 Discussion on Iron

Lynch, S. (USA)

134 Summary on Vitamin A and Iron

Hurrell, R.F. (Switzerland)

Iodine

137 Are Weaning Infants at Risk of Iodine Deficiency Even in Countries with Established Iodized Salt Programs?

Zimmermann, M.B. (Switzerland)

147 Current Challenges in Meeting Global Iodine Requirements

Eastman, C.J. (Australia); Jooste, P. (South Africa)

Folate, Vitamin B₁₂ and Brain

161 Folate and Vitamin B₁₂: Function and Importance in Cognitive Development

Troen, A.M. (Israel)

172 Discussion on Folate and Vitamin B₁₂ Importance in Cognitive Development

Rosenberg, I.H. (USA)

175 Pros and Cons of Increasing Folic Acid and Vitamin B₁₂ Intake by Fortification

Allen, L.H. (USA)

184 Discussion on Vitamin B₁₂ and Folic Acid Fortification

Rosenberg, I.H. (USA)

187 Summary on Iodine Folate and Vitamin B₁₂

Rosenberg, I.H. (USA)

191 Subject Index

For more information on related publications, please consult the NNI website: www.nestlenutrition-institute.org

In the past two decades, micronutrients have been recognized as having a more prominent position in the global effort to control and overcome hunger and malnutrition. The three micronutrients whose deficiencies have the greatest prevalence and have attracted the greatest attention from international agencies and as well as institutions and not-for-profit agencies are vitamin A, iodine and iron. Recently, zinc has received much attention for its role in the treatment of diarrhea and its preventive potential for childhood diarrhea and pneumonia. Even with this increased attention and enhanced research, a number of important questions remain. What is the importance of these micronutrients and others, including folate and vitamin B₁₂, as limiting nutrients in growth and development and their potential for preventing stunting and global malnutrition? What are the forms and doses of these micronutrients that may be required for the prevention of stunting and malnutrition or the treatment of moderate and severe malnutrition? What are the effective interventions including individual or multiple micronutrient interventions, and what are the effective methods of addition of these micronutrients to the food supply and in the form of fortification?In which form are these micronutrients most effective and most appropriately or most effectively absorbed and bioavailable? Are there any potential safety concerns? Do interactions restrict potential coadministration? And perhaps most importantly, what are the appropriate target populations for interventions in treatment or prevention?

To address the current knowledge in these and other related questions, Nestlé Nutrition Institute invited three nutrition scientists to organize a symposium with other leading scientists knowledgeable and active in the field of micronutrient nutrition. These scientists were invited to give their presentations at the meeting in Cebu, Philippines, in April 2011, along with an invited group of knowledgeable leaders in the fields of pediatric nutrition and micronutrient nutrition from all parts of the world. The papers that were presented at this meeting and a summary of the discussions form the substance of this publication and report. We hope that this publication is another milestone in the path towards a better understanding of the importance of micronutrients in nutrition and development, and that it willcontribute to the growing urgency for the control of childhood malnutrition.

Zulfiqar A. Bhutta

Richard F. Hurrell

Irwin H. Rosenberg

Meeting macro- and micronutrient requirements during pregnancy and early childhood (‘the first 1,000 days’) is crucial for short- and long-term health and cognitive function. Recent surveys on the timing of growth retardation and stunting indicate that the onset is maternal under nutrition before and during pregnancy. Inappropriate weaning food and frequent infections hamper growth and development during the ‘critical window’ of the first 24 months after birth. Stunting (178 million children world wide) and severe acute malnutrition (wasting -19 million) are associated with micronutrient deficiencies. Epidemiology indicates that the most common micronutrient deficiencies – vitamin A, iron, zinc, and iodine – could be related to an estimated 1 million child deaths per year and 9% of global childhood DALYs [1]. Meta-analyses confirm that supplementation or fortification of food with the ‘big four’ is efficacious to reduce risk of infectious disease, improves growth and cognitive outcome. More recently, folate and vitamin B₁₂ deficiencies during pregnancy have been shown to be associated with poor neurodevelopmental outcome and childhood obesity. Because of the high prevalence of micronutrient deficiencies in populations from developing countries, the challenge is to develop the right intervention strategies. Governmental agencies and international non-governmental organizations need strong support from scientific institutions, and industry should cooperate with all relevant stakeholders.

The 70th Nestlé Nutrition Institute Workshop, which took place in March 2011 in Cebu, Philippines, was the third to address micronutrient needs. Two previous NNI workshops addressed the needs during the first months of life (NNIW 52) and the weaning period (NNIW 54). It became clear during the last years and was addressed at this workshop that maternal and fetal deficiencies can induce inadequate metabolic programming in the offspring with increased risk for non-communicable diseases later in life. In order to answer questions and lead scientific discussions, we asked world-renowned experts in the area of health science and nutrition to clarify the pathogenesis of micronutrient deficiencies in pregnancy and childhood, preventive methods and strategies, and opportunities for treatment.

To discuss the most recent findings and outcome strategies, leading experts in the fields of epidemiology and nutritional intervention met with those in genetics, epigenetics, and metabolic outcome. We would like to warmly acknowledge the excellent program conceived by the chairpersons – Prof. Zulfiqar A. Bhutta, Pakistan, Prof. Richard F. Hurrell, Switzerland, and Prof. Irwin H. Rosenberg, USA. We are also indebted to all the renowned speakers giving the presentations, and discussants leading the debates of this important topic. We thank all experts who came from across the globe to review and discuss the importance of the micronutrients in child life and the opportunity to meet them.

Finally, we wish to thank Dr. Marco Turini and Dr. Grace L. Uy with their teams from the Nestlé Nutrition Institutes in South East Asia – Philippines for excellent logistic support and hospitality which allowed the participants to enjoy both the scientific program and the wonderful cultural spirit of Cebu.