BINLM Micronutrient Module - Dec 23 2013 PDF

Blended Integrated Nutrition Learning Module (BINLM) By ChimdesaJ.
(MSc)
Micronutrients Module
Author-CHIMDESA JABESA(MSc)
Mar. 2020
BINLM(Chimdesa Jabesa(MSc)) 2020
Series Foreword
The Nutrition Society was first established in 1941, as a result of a group of leading physiologists, biochemists
and medical scientists recognising that the emerging discipline of Nutrition would benefit from its own specific
Learned Society. This was very much driven by concerns about the nutritional status of the Ethiopia population. The
Nutrition Society’s mission was, and still firmly remains, ‘To advance the scientific study of
nutrition and its application to the maintenance of human and animal health’. The Society is the largest Learned
Society for Nutritional Sciences in Europe and has over 2900 members worldwide. More details about the Society
and how to become a member can be found by visiting the Society’s website at www.nutritionsociety.org.
The Society’s first journal, The Proceedings of the Nutrition Society, published in 1944, records the
scientific presentations made to the Society. Shortly afterwards, in 1947, the British Journal of Nutrition
was established to provide a medium for the publication of primary research on all aspects of human and
animal nutrition by scientists from around the world. Recognising the needs of students and their teachers
for authoritative reviews on topical issues in nutrition, the Society began publishing Nutrition Research
Reviews in 1988. The journal Public Health Nutrition, the first international journal dedicated to this important and
growing area, was subsequently launched in 1998. The Society is constantly evolving and has most
recently launched the Journal of Nutritional Science.
This is an international, peer-reviewed, online-only, open access journal.
The Nutrition Society Textbook Series, first established by Professor Michael Gibney (University College
Dublin) in 1998 and now under the direction of the second Editor-in-Chief, Professor Susan Lanham-New
(University of Surrey), continues to be an extraordinarily successful venture for the Society. This series of human
nutrition textbooks is designed for use worldwide and this has been achieved by translating the series into many
different languages, including Spanish, Greek and Portuguese. The sales of the five current textbooks (more
than 55,000 copies) are a tribute to the value placed onthe textbooks both in the UK and worldwide as a core
educational tool.
BINLM is an outstanding second textbook to add to the series. The Editorial Team, led by Professor Julie Lovegrove
(University of Reading), provides the reader with a complete outline of key nutrition methodologies – from basic
and applied statistics, to the fundamentals of measuring dietary intake and nutritional status in individuals and
populations, to the application of some of the newest techniques in nutritional sciences, including the ‘omic’
techniques. The textbook is an absolute must-read for students, nutritionists, dieticians, medics, nursing staff and
other allied health professionals involved in the science of nutrition. It gives me great pleasure to write the Foreword
for this first edition of Nutrition Research Methodologies. I know from my time as the first Chairman of the UK
Food Standards Agency how important high-quality nutrition science is for underpinning sound policies,
both in the Ethiopia and worldwide. This textbook brings together science and the practical application of
methodologies in nutrition and is a most valuable resource to all those working in the field.
Chimdesa Jabesa(MSc in Human Nutrition)
Principal,
Mettu Health Science College,
MHSC
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Blended Integrated Nutrition Learning Module (BINLM)

Micronutrient Nutrition
Introduction
Micronutrients include vitamins and minerals needed in small quantities. They are essential to a
good start in life and robust growth and development. Micronutrients are broadly classified into
minerals and vitamins. Vitamins are groups of related substances present in small amounts in
foodstuffs and are necessary for the body to function normally. Vitamins can further be
categorized as water and fat soluble vitamins. The water-soluble vitamins are vitamin C
(ascorbic acid), vitamin B1 (thiamin), nicotinic acid (niacin) and nicotinamide, riboflavin,
vitamin B6 (pyridoxine), pantothenic acid, biotin, folic acid and vitamin B12 (cyanocobalamin).
The fat-soluble vitamins are vitamin A (retinol), vitamin D (cholecalciferol), vitamin K and
vitamin E (tocopherols). By the same token, minerals are the substances that people need to
ensure the health and correct working of their soft tissues, fluids and their skeleton. Minerals can
be classified into macrominerals and microminerals. The macro minerals include calcium,
phosphorus, magnesium, sodium, potassium and chloride and the micro minerals are iron, zinc,
copper, selenium, chromium, iodine, manganese, molybdenum, and fluoride. The micronutrient
deficiencies of public health significance in Ethiopia are vitamin A deficiency disorders
(VADD), iron deficiency anemia (IDA), iodine deficiency disorders (IDD), folic acid deficiency
and zinc deficiency (ZiD) (table 1).
Table 1: summarizes the impacts of the five micronutrients of public health significance.
Micronutrient Impact through programmes
23% reduction in under-five mortality rates

Vitamin A
70% reduction in childhood blindness
6% reduction in child mortality

Zinc
27% reduction of diarrhoea incidence in children
Iodine 13-point increase in IQ
Iron 20% reduction in maternal mortality
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Folate 50% reduction in severe neural tube birth defects, such as spinal bifida
Source: Investing in the future, united call to action on vitamin and mineral deficiencies: GLOBAL REPORT 2009.
Micronutrient deficiencies are generally associated with poverty and consumption of foods with
low micronutrient content, can be exacerbated by poor health conditions, and have especially
negative consequences during pregnancy and early childhood (figure 1).
Figure 1: Consequences of vitamin and mineral deficiencies during the life-cycle.
Baby
Low Birth Weight

Higher Infant Mortality
Elderly Rate
Risk of chronic disease
Increased morbidity Impaired mental
(osteoporosis, mental development
impairment, etc.)
Increased mortality
Child
Stunted
Micronutrien Reduced mental capacity
t Deficiency Frequent infections
Inadequate catch up
growth
Reduced productivity
Pregnant Women Higher Child Mortality Rate
Increased mortality
Increased prenatal Adult
complications
Reduced productivityReduced productivity
Poor socioeconomic
Adolescent
status
Malnourished
Stunted
Reduced mental capacity
Fatigue
Increased vulnerability to
infection
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The diets of most people in developing countries are primarily composed of starchy staples
which are usually low in vitamin and mineral content. Although consumption of animal products
and fruit and vegetables help improve micronutrient intake of populations, the high costs of such
foods severely limit their regular intake by low income populations who are at highest risk of
vitamin and mineral deficiencies. Less diverse diets not only impede total micronutrient intakes,
but also contain less bioavailable nutrients (e.g. iron from flesh foods is more readily absorbed
than from plant foods, and adequate intake of vitamin C and vitamin A rich fruits and vegetables
help improve iron absorption and metabolism). Moreover, the micronutrient absorption is
compromised by antinutritional factors such as phytates, tannins, polyphenols, goitrogens etc
from foods of plant origin. Normal growth and development do not occur when micronutrient
intake is inadequate. When one or more of the micronutrient requirements are not satisfied,
specific tissue or cell failure will occur. Micronutrient deficiencies often coexist and interact with
each other positively and negatively. Micronutrients significantly contribute to the achievement
of MDGs through reductions in maternal and child morbidity and mortality, improved cognitive
development (IQ) and school attendance and increased productivity.
General objectives
At the end of the training, the trainee will be able to describe micronutrients of public health
significance in Ethiopia, identify deficiency states, administer preventive and therapeutic
supplementations using the national protocol(s) together with individual or population based
intervention strategies to combat micronutrient deficiencies
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Session on Vitamin A
Introduction
Vitamin A is a fat-soluble vitamin which comes in two general forms: preformed as retinol (this
is active vitamin A found in animal products) or provitamin A carotenoids (predominately beta-
carotene) found in plants (this form must be converted by the body into active vitamin A).
Vitamin A is absorbed in small intestine, packaged with other fats, sent to blood for circulation,
delivered to liver if it is being stored or to specialized tissues if being used (1). In Ethiopia, the
proportion of children consuming vitamin A reach foods increases with age from 16% at 6-8
months to 31 percent at 18-23 months. Urban children (38 percent) are more likely than rural
children (24 percent) to consume foods rich in vitamin A. With regards to regions, children
living in Gambella region are most likely to consume foods rich in Vitamin A (48 percent) while
those in Afar region are least likely (11 percent) (2).
Learning Objectives
After the completion of the session, participants will be able to:
 Describe the significance and physiological role of vitamin A

 Identify the food sources and the recommended daily allowance of vitamin A
 Describe the significance of epidemiology of VAD in Ethiopia
 Describe the cause and health effect of VAD
 Identify the clinical manifestations & consequence of VAD
 Describe the strategies for the prevention and control of VAD
 Carry out vitamin A administration following the National guideline
 Perform emergency actions in case of adverse events
 Describe the delivery modalities of VAS, dosage and schedule
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 Explain supportive activities in the prevention and control of VAD

 Describe the assessment method, and indicators of the monitoring and evaluation of
VAD.
Functions of Vitamin A (1)
 Vision- Required by the retina to absorb light and communicate it to the brain; and
required by the cornea to produce mucus and tears which in turn protect the eye from
bacteria, infection, and deterioration and prevent the development of blindness.
 Immune function- Ensures working mucosal cells, membranes, and epithelial layers that
function as the body’s first line of defense against bacteria and viruses; and aids in the
development of lymphocytes and white blood cells (required for proper immune
responses) and improves their fighting capabilities.
 Cellular health and maintenance; growth, reproduction, gene expression, skin
health- Required for cells to grow and divide, particularly the cells of the eye, lungs, and
skin; and to mobilize iron from the liver and produce red blood cells.
 Fetal development- Required for proper fetal development including bones, lungs, heart,
eyes, ears, and growth hormone.
 Antioxidant activity - Carotenoids oxidize free radicals found in the body and prevent
cellular damage that can lead to cancer, aging, and a variety of diseases.
Recommended Daily Allowance
The recommended daily allowance (RDA) for vitamin A is based on amount needed to ensure
adequate stores to support the functions it is responsible for.
Dietary intakes of retinol for children in international units:
Age 0 – 6 mo 7– 12 1 – 3 yr 4 – 8 yr 9 – 13 yr 14 – 18yr 14 – 18yr

mo male Female
RDA 1333 IU 1667 IU 1000 IU 1333 IU 2000 IU 3000 IU 2333 IU
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Sources of Vitamin A (3, 4)

Animal sources
 Breast milk, egg yolks, and organ meats such as liver, whole milk, and milk products,
small fish with liver intact, fish, cod liver oil, butter, and ghee.
 The best food sources of pre-formed active retinol, which is most effectively used by the
body, are animal foods
 The best source of vitamin A for infants is breast milk. Colostrum is the essential first
milk produced for the newborn which is three times richer in vitamin A and ten times
richer in beta-carotene than mature milk
Plant sources
 The best plant sources of vitamin A are dark orange or dark yellow fruits and vegetables
such as papayas, mangos, pumpkins, carrots, and yellow or orange sweet potatoes and
dark green vegetables such as spinach, yabesha gomen, green pepper, salad
 Plants contain beta-carotene that needs to be converted into retinol by the body
Plant sources of vitamin A
Vitamin A Deficiency
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Vitamin A deficiency (VAD) is a disease caused by lack of adequate vitamin A intake. Vitamin
A deficiency has long been known to cause blindness, but more importantly, recent studies
reveal that vitamin A deficiency is closely associated with increased mortality and morbidity
among young children. Studies conducted have shown that vitamin A supplementation reduces
overall child mortality due to infections ailments by 24% (5).
Another cause of vitamin A deficiency and its symptoms is when the ingested vitamin A is not
absorbed by the small intestines or when it is not released by the liver when needed. There are a
large number of conditions that can cause vitamin A to not be absorbed from food sources in the
small intestines. Zinc is needed by the small intestines to absorb vitamin A, therefore a
deficiency in zinc will often lead to a deficiency in vitamin A. Because vitamin A is transported
into the body along with fats, any condition that impairs fat absorption can lead to vitamin A
deficiency. The most common of these is liver disease that results in poor bile quality.
Children 6-59 months of age, and pregnant and lactating women are population at risk for
vitamin A deficiency.
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Clinical manifestations of Vitamin A deficiency

 Poor growth
 Night blindness
 Xerophthalmia,
 permanent blindness (leading cause of preventable blindness in children)
 Increased susceptibility to infection and subsequently death
Before the clinical signs and symptoms occur the person has to go through different sub clinical
vitamin A deficiency states. People with sub-clinical VAD have higher rates of infections like
diarrhea or measles.
A. Ocular
Eye lesions develop insidiously, with an impairment of dark adaptation resulting in night
blindness. This is locally called as “dafint” or “chicken eye” because chickens cannot see at
night. This is the commonest VAD chief complaint the parents tell about the child. Later comes
dryness of the conjunctiva and cornea. The patient may tell he is feeling dryness in the eyes.
1. Dryness of the conjunctiva is called “xerosis conjunctivae”, and
2. Dryness of the cornea is called “xerosis cornea.”
The parents may describe the presence of whitish material in the child’s eye. Clinically it is
called Bitot’s spot. These are foamy and whitish cheese-like tissue spots that develop in the
lateral side of the eyeball. These spots do not affect vision in the daylight. More sever VAD will
lead to corneal ulceration or extensive wrinkling and cloudiness of the cornea called
keratomalacia”. Xerophthalmia is a range of clinical signs secondary to VAD: It icludes night
blindness, Bitot spots, corneal dryness and ulcerations, and finally the occurrence of full-blown
blindness. The parent may notice the following when they compare their child to their peer
group.
 Progress of ocular complication (xerophthelmia)
o Night blindness—Conjunctival xerosis—Bitot’s spot—Corneal ulcer—
Keratomalasia
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 Sign of conjunctival xerosis (conjunctiva becomes dry & looks muddy & wrinkled
(instead of smooth & shiny)
 Bitot’s spot (triangular, pearly-white (or yellowish) foamy spot seen on bulbar
conjunctiva on either side of conjunctiva (frequently bilateral)
 Corneal xerosis and ulcer a serious stage where cornea becomes dry & looks opaque
(instead of smooth & shiny). This is irreversible condition, if it is treated heals with a scar
& affect vision.
 Keratomalasia ( liquidification of cornea, cornea becomes soft and may burst open. If eye
collapse vision is permanently lost. This is a major cause of blindness.
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B. Skin
Dry and scaly skin and follicular hyperkeratosis may be seen on shoulders, buttocks, and
extensor surface of the extremities.
C. Organ Systems.
Epithelial metaplasia in the urinary tract may be associated with infections, reflecte`d by
pyuria and hematuria. Late in the disease state, wide separation of the fontanels and increased
intracranial pressure may occur.
Consequences of Vitamin A Deficiency
Globally, 1.1 million premature child deaths occur a year due to VAD. It is the leading cause of
visual damage and preventable blindness among children; and approximately 350,000 children
become blind each year (1). The latest World Health Organization (WHO) estimates of VAD
prevalence indicate that globally 190 million preschool children suffer from subclinical VAD (no
overt clinical signs) and 5.17 million from clinical VAD (night blindness). Sub-Saharan Africa
25-35% of pregnant women are also estimated to suffer from clinical VAD (5). Vitamin A
deficiency compromises immune systems of 40-60% of children under 5 in the developing
world; even mildly deficient children have a higher incidence of respiratory disease, diarrhea,
and rate of mortality from infectious disease. Absence of vitamin A during critical periods of
fetal development can lead to central nervous system defects (1).
Vitamin A deficiency is a major public health problem in Ethiopia. A national study conducted
in 2005 has shown that the national prevalence rates of 1.7% for Bitot’s spots and 0.8% of night-
blindness among children and 1.8% for night-blindness among mothers. Nationally, 37.7% of
children (95% CI, 35.6% to 39.9%) had deficient serum retinol levels (6).
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Prevention and Control of Vitamin A Deficiency

Improving children’s vitamin A status increases their chance of survival (3):
 Deaths from measles can be reduced by 50%
 Deaths from diarrhea can be reduced by 40%
 Overall mortality can be reduced by 25%
The evidence from eight peer-reviewed published community-based vitamin A intervention trials
that have been carried out across Southern Asia and in Sub-Saharan Africa, including six which
employed large-dose vitamin A supplementation. Based on multiple, independent meta-analyses,
the results of these trials are consistent with an overall 23 to 34 per cent reduction in preschool
child mortality that can be expected from vitamin A programmes reaching children in
undernourished settings (7).
Improving vitamin A status reduces the severity of childhood illnesses:
 Prevents night blindness, xeropthalmia, corneal destruction, and blindness
 Less strain on clinic outpatient services and hospital admissions
 Contributes to the well-being of children and families
Improving vitamin A status also:
 May reduce birth defects
 May prevent epithelial and perhaps other types of cancer
 Prevents Anemia
The main strategies which have been adapted globally to control and eliminate vitamin A
deficiency are:-
 Supplementation of Vitamin A Capsules
 Promote and support optimal breastfeeding
 Food Diversification for Vitamin A
 Food fortification with vitamin A, and
 Infection Control
Supplementation of Vitamin A Capsules
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Vitamin A supplementation program is the main pillar of child survival efforts. When children
receive a twice-annual dose of vitamin A, the child mortality rate drops by a range of 12-23% in
vitamin A deficient populations. It can also reduce child blindness by up to 70%. For this reason,
provision of high-strength vitamin A supplements is recognized as one the most cost-effective
ways to improve child survival. Vitamin A supplements are an important part of an integrated
package of essential services that promote child health and stop preventable deaths. One high-
strength vitamin A capsule every six months can help protect a child from the death and disease
associated with vitamin A deficiency(8). In addition, Eighty five percent coverage of vitamin A
can result in a 90% reduction in the prevalence of severe xerophthalmia.
Universal supplementation with vitamin A capsules is low cost, highly effective strategy for
improving the vitamin A status of children from 6 to 59 months of age. In Ethiopia Vitamin A
supplementation is delivered through three delivery mechanisms:
 EOS campaign: EOS is a vertical campaign-based VAS delivery mechanism conducted
twice yearly. Bi-annual vitamin A supplementation is conducted for children aged 6-59
months in integration with other interventions like de-worming and nutritional screening
of children for the presence of malnutrition.
 Community Health Dsays (CHD): The CHDs are quarterly events that are organized
locally at kebele level by health extension workers. In CHDs vitamin A supplementation
and de-worming are conducted every six months while nutritional screening of children
6-59 months and pregnant and lactating women is conducted every three months.
 Routine Health Service (HEP): The routine HEP modality is a daily service delivery of
VAS which is mainly a mix of facility based, outreach and house to house delivery.
Routine service delivery of VAS is complete integration of VAS delivery into the
existing routine health system (HEP).
Doses and schedules for vitamin A supplements
Vitamin A for prevention:
Age Dose Frequency
Children 6-11 months 100,000 IU (1 capsule of 100,000 IU) Once
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Children 12-59 months 200,000 IU (2 capsules of 100,000 IU) Once every 4 to 6 months
Vitamin therapeutic supplementation: For children with severe acute malnutrition

Age Dose Frequency
Children 6-11 months 100,000 IU (1 capsule of One dose at first contact with health unit
100,000 IU) and then as to the management of severe
Acute malnutrition guideline *
Children 12-59 months 200,000 IU (2 capsules One dose at first contact with health unit
of 100,000 IU) and then as to the management of severe
acute malnutrition guideline *
*Do not give VAS if the child has been supplemented through EOS/CHD/HEP within one
month
Vitamin therapeutic supplementation: For children with diarrhea
Age Dose Frequency
Children 6-11 months 100,000 IU (1 capsule of One dose
100,000 IU)
Children 12-59 months 200,000 IU (2 capsules One dose
of 100,000 IU)
Vitamin therapeutic supplementation: For children with Xerophthalmia or Measles

Schedule Dose in I.U. for children Dose in I.U. for children >1 year
<1 year
Immediately on diagnosis 100,000 IU (1 capsule) 200,000 IU (2 capsules)
Next day 100,000 IU (1 capsule) 200,000 IU (2 capsules)
15 days later 100,000 IU (1 capsule) 200,000 IU (2 capsules)
The new WHO guideline states that Vitamin A supplementation in postpartum women is not
recommended as a public health intervention for the prevention of maternal and infant morbidity
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and mortality (strong recommendation). The quality of the available evidence for maternal
mortality, maternal morbidity and adverse effects was graded as low or very low (9).
Administration of vitamin A supplements (10)
1. Check the age of the child,
2. Ask the caretaker if the child has received vitamin A capsule in the last one month. If
the answer is yes, confirm and do not administer,
3. If the answer is no, ask the caretaker to hold the child firmly, make sure the child is
calm, give the appropriate dose of vitamin A to the child
100,000 IU to child 6-11 months
4. Cut the nipple of the capsule at the middle (not at the tip or bottom) with scissors and
5. immediately squeeze the drops of liquid into the child’s mouth,
6. Check if the child is comfortable after swallowing the drops,
7. Put all capsules that have been used into a plastic bags and
8. Wipe your hands to clean off oil
9. Record the dose on the tally sheet.
When the correct dosage is given, vitamin A is safe and very effective.
• Side effects: occasionally, some children may experience side effects such as headache, loss of
appetite, vomiting or a bulging fontanel (in infants). These symptoms have been investigated by
researchers and confirmed to be minor, harmless and transitory, and require no special treatment.
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• Toxicity: Under normal situations toxicity from vitamin A is not likely to occur if:
 Protocol is followed and proper dose is given
 An interval of at least one month is maintained between high doses
 Proper training is given
 Proper recording is done
 There is adequate supervision
Emergency actions in case of adverse events (10)
In case of choking for infants:
1. Lay the infant on your arm or thigh in a head down position,
2. Give 5 blows to the infant's back with heel of hand,
3. If obstruction persists, turn the infant over and give 5 chest thrusts with 2 fingers, one
fingerbreadth below nipple level in midline.
In case of choking for children:

1. Give 5 blows to the child's back with heel of hand with child sitting, kneeling or lying.
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2. If the obstruction persists, go behind the child and pass your arms around the child's
body; form a fist with one hand immediately below the child's sternum; place the other
hand over the fist and pull upwards into the abdomen; repeat this Heimlich manoeuvre 5
times.
3. If the obstruction persists, check the child's mouth for any obstruction, which can be
removed.
4. If necessary, repeat this sequence with backslaps again.
Management of adverse events

Symptoms Preventable? Action required
Side Headache, loss of appetite, NO, happens with Advise the parent that this is
effects vomiting or a bulging approx. 5% of normal, symptoms will pass
fontanel (in infants) children and no medical treatment is
Not harmful necessary
Overdose Vomiting and YES, if follow Refer for medical treatment
lethargy/listlessness protocol Report
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Only occurs if child takes

multiple doses together
Choking Accidental blocking of YES, if follow Resuscitation
Trachea proper
administration Report
Symptoms Preventable? Action required
Side Headache, loss of appetite, NO, happens with Advise the parent that this is
effects vomiting or a bulging approx. 5% of normal, symptoms will pass
fontanel (in infants) children and no medical treatment is
Not harmful necessary
Overdose Vomiting and YES, if follow Refer for medical treatment
lethargy/listlessness protocol Report
Only occurs if child takes

multiple doses together
Choking Accidental blocking of YES, if follow Resuscitation
Trachea proper
administration Report
Promote and Support Optimal Breast Feeding

In the first six months of life, breast milk protects the infant against infectious diseases that can
deplete vitamin A stores and interfere with vitamin A absorption. Colostrum is the essential first
milk produced for the newborn. Colostrum is three times richer in vitamin A and ten times richer
in beta-carotene (an active precursor form of vitamin A responsible for the yellow color of
colostrum) than mature milk. Because of its high levels of vitamin A, antibodies, and other
protective factors, colostrum is often considered the baby’s first immunization (4).
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Vitamin A in the Breast milk of Infants 0-6 months
Age of Child Sources of Vitamin A
First few days Colostrum is the essential first milk produced for the newborn. Colostrum is
three times richer in vitamin A and ten times richer in beta-carotene (an active
precursor form of vitamin A responsible for the yellow color of colostrum)
than mature milk. Because of its high levels of vitamin A, antibodies, and
other protective factors, colostrum is often considered the baby’s first
immunization.
Around days 5 Transitional breastmilk contains nearly double the vitamin A of mature milk.
to 14 The high vitamin A content of both colostrum and transitional milk matches
the needs of the newborn
Day 14 to six Mature breastmilk in well-nourished mothers contains an average of 250

months international units (IU) of vitamin A per 100 ml. The concentration of vitamin
A in the breast milk of women in developing countries averages about half this
amount. In such cases, providing mothers with a high-dose vitamin A
supplement immediately after delivery can ensure that the supply of vitamin A
in breast milk is adequate to meet the infant’s daily vitamin A requirement and
to build stores.
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Food Diversification for Vitamin A

Food diversification is an important long-term, sustainable strategy for prevention of vitamin A
deficiency. Populations should be encouraged to grow and consume vitamin A rich foods
throughout the country at all times. This requires input from various entities such as the
Ministries of Health, Agriculture, Education, Information and Communication, the Regional
states, donors and NGOs. Relevant regional bureaus must initiate and coordinate the
establishment of horticultural demonstration gardens in health facilities and schools as well as
agricultural extension demonstration plots in farming areas. These horticultural gardens would
serve for demonstration purposes as well as dissemination of information on the use of fruits and
vegetables and distribution of seedlings that could be grown around rural homes. Extension
agents should play a significant role in promoting the introduction of vitamin A rich foods and
improving consumption and storage of such foods (3).
Food Fortification
This would involve adding one or more vitamins and minerals to commonly consumed foods. In
Ethiopia, vegetable oil and wheat flour has been selected as vehicles to fortify vitamin A. With
growing industrialization in Ethiopia at much greater rate than most African countries, refined oil
consumption has increased in the past ten years and this trend is expected to continue in the years
to come hence the need for centrally processed foods such as refined vegetable oil, wheat flour,
sugar and others. Vegetable oil purchase in 2011 was estimated at 38 million people in Ethiopia
and oil fortification is expected to reach wider population at the current urbanization rate of
greater than 18% (2). Vitamin A fortification of palm oil is considered one of the most cost-
effective strategies to address vitamin A deficiency. Fortification of wheat flour with vitamin A
is also considered mainly to improve iron absorption in the flour.
Infection Control
Infection control through the provision of safe drinking water and sanitation, early diagnosis and
treatment, immunizations, health education will reduce excretion of vitamin A. Infections
increase secretion of vitamin A from the body.
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Supportive Activities
 Establishment of a micronutrient committee from concerned sectors and other partners at
all levels (up to woreda levels) to organize and assist program implementation
 Training for health workers and other partners at all levels including pre-service training
of health providers
 Communities mobilized and supported to give due emphasis to production of fruit and
vegetable gardens to improve access to vitamin A rich foods
 Formulate vitamin A/ micronutrient and breastfeeding promotion policies and programs
as an integral part of overall health and nutrition improvement, not as isolated activities
 Promote and support food fortification, giving priority to local products that can be
fortified. Where food aid is used, select vitamin A-fortified foods and provide them to
pregnant and lactating women, as well as to children over six months of age
 Establish and/or provide training to mother support groups and conduct home visits to
share information and experiences on breastfeeding and complementary feeding
 Educate on parasite prevention, treat parasite infections, and follow national guidelines
for the prevention and treatment of iron deficiency anemia
 Development, printing, and dissemination of appropriate IEC/BCC materials to support
public awareness campaigns designed and implemented to increase vitamin A coverage
 Ensure supply of vitamin A capsules and the other necessary logistical materials for
supplementation and fortification
 Quality and safety of service provision (safe VAS and de-worming to avoid chocking and
quality screening and referral)
 Technical and other logistical assistance provided to the food industry (private/public) to
fortify foods
 Monitoring VAS coverage to identify areas of support
Social mobilization
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Social mobilization is a critical in the CHD and routine delivery of vitamin A supplementation
(VAS). The community needs to get clear messages about what are the services; the benefit of
the services: who will receive the services; when the service day for the community will be;
where they should go. The opportunity is also used to increase the community awareness of the
benefits of vitamin A and also to increase demand for health services, particularly routine
delivery of VAS. Health Development Army/Women Development Army plays a critical role in
social mobilization, informing mothers that children 6 – 59 months should get vitamin A every
six months. HEWs may also disseminate the information using the kebele administration,
leaders, iders and village elders that vitamin A is provided in a routine (daily) service in health
facility, house to house visit and outreach services. Social mobilization is important to ensure
high participation and service coverage for the better health & nutrition of the children and
women in the community.
The points that should be mentioned during health education are:
• Importance of a balanced diet
• Vitamin A rich foods
• Since VAD is common in children, lactating and pregnant women, the nutrition of these groups
should be targeted.
Promotion of exclusive breast feeding for the first 6 months, continuing for at least 2 years and
supplementation of mothers with vitamin A in first 6-8 weeks post partum are the important
points to target. Vitamin A deficiency is common in the age groups 6 months to 59 months
which indicates that children in this age are vulnerable due to the improper complementary
feeding and increased demands.
In the prevention and control of VAD the main component should be creating awareness in the
population. This is important because our efforts become successful with community
participation in vitamin A supplementation programs, in dietary modifications and in infection
control. Health education on the consequences of VAD (such as childhood blindness, increased
morbidity and mortality associated with VAD) is important. We should also educate the
community on the early symptoms of VAD (such as night blindness that can be corrected by
vitamin A supplementation before eye disease gets worse).
23
Monitoring and Evaluation

As VAS coverage is an internationally agreed upon indicator to track progress towards the 4th
Millennium Development Goal (MDG) of reducing child mortality, reliable coverage data from
the district level is therefore important to monitor a country’s progress towards achieving
MDG4.
To determine whether the program is going according to plan and whether objectives and
targets are being met, monitoring and evaluation has to be part of the VAS delivery
mechanism.
To improve program performance, effectiveness, efficiency and reduce costs Monitoring
can identify low performing health centers and areas within a district and provide
feedback to those involved in implementing the program and let them know how well
they are doing.
The HMIS system should be strengthened to ensure the necessary information on VAS at all
levels of the health system is collected, analyzed, reported and used to inform decision making.
Regional and district officials should include VAS monitoring in their regular supervisory visits
to track their VAC supply, VAC storage, record keeping, presence of IEC materials and health
worker knowledge about VAS.
Review meetings on the vitamin A program at national, regional and woreda levels have to be
conducted annually or biannually to ensure that VAS coverage is maintained at above 90%.
Periodic reports have to be compiled and analyzed at all levels, including the national level, for
feedback, follow up and fine-tuning of program implementation.
Monitoring surveys
Vitamin A coverage surveys must be carried out at the national/regional levels to evaluate
progress using indicators such as:
- % of children 6- 59 months of age who have received vitamin A within the past six months,
- % of children who are consuming foods rich in vitamin A
24
Periodic surveys
The impact of vitamin A activities, especially supplementation, on infant and child mortality
must be evaluated, though this requires more effective and rigorous surveys. Periodic food
consumption surveys, assessment of retinol levels and other clinical signs in target groups will be
used to estimate prevalence, and to monitor and measure program impact.
Cut-off values for public health significance of VAD (11).
Indicator Prevalence cut-off values for public

health significance
Serum or plasma retinol ≤ 1.9: No public health problem

< 0.70 μmol/l in preschool-age children ≥ 2%-< 10%: Mild
≥ 10%-< 20%: Moderate
≥ 20%: Severe
Night blindness (XN) in pregnant women ≥ 5: Moderate
Source: WHO, Nutrition Landscape Information System (NLIS), Country profile Indicators, 2010.
Identification of Vitamin A Deficiency in Population
Vitamin A deficiency sign/symptoms WHO cut-off levels

Children Clinical
Night blindness >1%
Bitot’s Spots >0.5%
Conjunctival xerosis/ulceration/ keratomalacia >0.01%
Corneal scar >0.05%
Pregnant women
Night blindness during recent pregnancy >5%
25
Biochemical levels
Serum retinol levels <0. 35 μ mol/L or 10 μ g/dl >5%
Serum retinol levels of 0.7μ mol/L or <20 μ g/dl >15%
Checklist for administer vitamin A following safety measures

1. Check the age of the child,
2. Ask the caretaker if the child has received vitamin A capsule in the last one month. If the
answer is yes, confirm and do not administer,
3. If the answer is no, ask the caretaker to hold the child firmly, make sure the child is
calm, give the appropriate dose of vitamin A to the child
4. Hold capsule gently the index and thumb finger, then cut the nipple of the capsule at the
middle (not at the tip or bottom) with scissors and immediately squeeze the drops of
liquid into the child’s mouth,
5. Check if the child is comfortable after swallowing the drops,
6. Put all capsules that have been used into a plastic bags and
7. Wipe your hands to clean off oil
8. Record the dose on the tally sheet.
Checklist for the management of emergency actions in case of adverse events following
VAS
A. In case of choking for infants:

1. Lay the infant on your arm or thigh in a head down position,
2. Give 5 blows to the infant's back with heel of hand,
3. If obstruction persists, turn the infant over and give 5 chest thrusts with 2 fingers, one
fingerbreadth below nipple level in midline.
B. In case of choking for children:

26
1. Give 5 blows to the child's back with heel of hand with child sitting, kneeling or lying.
2. If the obstruction persists, go behind the child and pass your arms around the child's
body; form a fist with one hand immediately below the child's sternum; place the other
hand over the fist and pull upwards into the abdomen; repeat this Heimlich manoeuvre 5
times.
3. If the obstruction persists, check the child's mouth for any obstruction, which can be
removed.
4. If necessary, repeat this sequence with backslaps again.
Assessment questions for the vitamin A
1. Which of the following vitamin A form is found in plants?

A. Retinol
B. Beta-carotene
C. A and B
D. None of the above
2. Which of the following best describes the function of vitamin A?
A. Prevent the development of blindness.
27
B. Required for proper immune responses

C. Proper fetal development
D. All of the above
E. None of the above
3. Which community group has the greatest risk of developing VAD?
A. Children from 6-59months of age
B. Pregnant women
C. Lactating women
D. All of the above
4. How much percent of childhood mortality can be reduced by correcting Vitamin A
deficiency?
A about 5%
B about 5-10%
C about 23-34%
D All of the above
E None of the above
5. Which of the following are symptoms of VAD?
A. Poor growth
B. Night blindness
C. Xerophthalmia,
D. permanent blindness
E. All of the above
6. Improving vitamin A status helps in
A. Reducing birth defects
B. Improving resistance to infection
C. Reducing anemia through its action on cell maturation
D. All of the above
28
7. Which of the following could precipitate VAD?

A. Persistent diarrhea
B. Recurrent ARI
C. Measles
D. All of the above
8. The main strategies in the prevention and control of VAD includes
A. Supplementation of Vitamin A Capsules
B. Promote and support of optimal breastfeeding
C. Food diversification and fortification with vitamin A
D. A and B
E. All of the above
9. What is your assessment if community ‘x’ has >0.5% Bitot’s spot prevalence?
A. VAD is considered as public health problem
B. VAD isn’t considered as public health problem
C. There is insignificant numbers of people who have VAD
D. All of the above
10. Social mobilization is important to ensure high participation and service coverage for
VAS
A. False B. True
References
1. Project Health Child: Overview of Vitamin A, Training Module

2. Ethiopia Demographic Health Survey 2011: Central Statistical Authority , March 2012
29
3. National Guideline for Control and Prevention of Micronutrient Deficiencies, FMOH,

2004
4. LINKAGES, Breast milk: A Critical Source of Vitamin A for Infants and Young Children
UNICEF, 1997. State of the World’s Children
5. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global
database on vitamin A deficiency. Geneva, World Health Organization,
2009(http://whqlibdoc.who.int/publications/2009/9789241598019_eng.pdf, accessed 21
May 2011).
6. Demissie T, Ali A, Mekonen Y, Haider J, Umeta M Food Nutr Bull. 2010 Jun;31(2):234-
41
7. World Nutrition. Journal of the World Public Health Nutrition Association.
www.wphna.org Volume 1, Number 5, October 2010
8. Micronutrient Initiative. Vitamin A: the scope of the problem. Ottawa, Micronutrient
Initiative, 2011(www.micronutrient.org/English/View.asp?x=577&id=440, accessed 17
December 2013).
9. WHO. Guideline: Vitamin A supplementation in infants and children 6–59 months of age.
Geneva, World Health Organization, 2011.
10. Enhanced Outreach Strategy for Child Survival: FMOH, March 2006
11. WHO, Nutrition Landscape Information System (NLIS), Country profile Indicators, 2010.
Session on Iodine
30
Introduction
Iodine is essential for the normal development of the brain of the fetus during pregnancy, infancy
and early childhood. Iodine deficient pregnant women are more likely to give birth to mentally
retarded children. In communities affected by iodine deficiency, the average IQ of children on a
scale of 100 points is 13.5 IQ points lower than that of children living in communities without
iodine deficiency (1). Children of iodine deficient pregnant women are more likely to have
scores in the lowest quartile for verbal IQ (60% higher risk), reading accuracy (69% higher risk)
and reading comprehension (54% higher risk) than those of sufficient mothers (2). Children born
to deficient mothers had reductions of 10% in spelling, 8% in grammar and 6% in English-
literacy compared with children whose mothers were iodine sufficient during pregnancy (3).
Hence countries with IDD are encouraged to prevent and control the problem without delay.
General objectives
At the end of the training, the trainee will be able to describe micronutrients of public health
significance in Ethiopia, identify deficiency states, administer preventive and therapeutic
supplementations using the national protocol(s) together with individual or population based
intervention strategies to combat micronutrient deficiencies.
Specific objectives
After completing this module/session, the trainee will be able to
 Describe the physiologic functions of iodine
 Describe the iodine requirements during pregnancy and lactation, infancy and childhood,
adolescence, adults and elderly.
 List the common food sources of iodine
 Describe the public health significance of IDD in Ethiopia
 Describe iodine deficiency disorders.
 Identify the causes of IDDs
 Identify clinical manifestations consequences of iodine deficiency
 Describe the economic consequences of IDDs
31
 Describe the methods used to assess IDDs

 Describe the intervention strategies of IDDs
 Describe indicators for M&E
 Examine and grade goiters
 Conduct qualitative test to monitor iodization
 Administer iodized oil capsules
Prevalence of IDD
IDD is still a public health problem in Ethiopia. According to recent survey findings, the
prevalence of goiter in children 6 -12 years of age was 40% and nearly 46% of the children had
median urinary Iodine excretion levels below 20 µg/l (4). Similarly a community-based cross-
sectional study among 15-49 years old Ethiopian women revealed a total goiter prevalence of
35.8% with 24.3% palpable and 11.5% visible goiter (4). Ethiopia was identified as the first of
the top ten iodine-deficient countries (based on national median UIC <100 µg/L) with the
greatest numbers of school-age children with insufficient iodine intake in 2011 (5).
32
Figure 1: The top ten iodine-deficient countries (based on national median UIC <100 µg/L) with
the greatest numbers of school-age children with insufficient iodine intake in 2011.
Physiologic role of iodine
Iodine is an essential micronutrient for the biosynthesis of thyroid hormones, triiodothyronine

(T3) and thyroxine (T4), produced by the thyroid gland (6). These hormones are needed for
physical development, brain development, reproductive functioning and metabolism (7). With
the help of the brain’s hypothalamus and pituitary gland, the thyroid gland ‘traps’ iodine from
the blood in order to create thyroid hormones. Triiodothyronine is required for the development
of the central nervous system. It is critical during periods of rapid brain growth, particularly in
utero up to three years of age, but can have impacts through adulthood. Inadequate amounts
during periods of rapid growth lead to irreversible brain damage. As a result, maternal iodine
33
sufficiency is critical as a child receives iodine in utero from the mother and after birth via breast
milk. A lack of iodine can lead to an underactive thyroid gland. An underactive thyroid slows the
body’s metabolic rate since thyroid hormones are needed to convert food into energy. Iodine is
needed through the production of various hormones for the normal functioning of reproductive
organs such as the ovaries, prostate, and breast.
Health Effects of Inadequate and Excess Intakes of Iodine
Consequences of iodine deficiency disorders
The most damaging effect of inadequate intake of iodine is on the developing brain. A meta
analysis of 20 studies has shown that iodine deficiency alone lowered mean IQ scores by 0.9 SD
or 13.5 IQ. In addition to its impact on brain and intellectual development, iodine deficiency can
induce goiter (thyroid enlargement) at any period in life. It is estimated that 3% of babies born to
iodine deficient women suffer from cretinism and 10% suffer from severe mental retardation (8).
Moreover, it can cause impaired reproductive outcomes (9) and a high degree of apathy and
reduced work productivity (10) in the adult population living in severely iodine deficient areas,
leading to economic stagnation of communities. The consequences of IDD at different stages of
life are summarized in the table below.
In pregnant women, fetuses In infants, children and In adults

and newborns Adolescents
Decreased fertility Hypothyroidism Goitre and its complications
Spontaneous abortion Impaired coordination Hypothyroidism
Stillbirths, congenital Impaired mental function Impaired mental
Abnormalities Function
Neonatal mortality IQ 13.5 points lower Lower energy, poor motivation
for work and
Productivity
Cretinism Retarded mental and
34
physical development
Psychomotor defects Diminished school
Performance
There are a number of reasons why an urgent action against iodine deficiency is critical in
Ethiopia. To site few
 Universal salt iodization (USI) can lead to an increase of the average intelligence of the
entire school age population by as much as 13.5 points
 Salt iodization will improve the physical and mental development of millions of
Ethiopian people
 The intellectual and cognitive development of whole generations of Ethiopian children
will be reduced by around 10% unless adequate iodine is provided
Human and economic cost of major micronutrient deficiencies
IDD and MDGs
The control of IDD addresses four of the eight MDGs as indicated in the following table.
MDG goal Relevance of iodine nutrition

MDG 1: Eradicate extreme poverty Reducing IDD reduces underweight
and hunger prevalence among preschoolers
MDG 2: Achieve universal primary Iodine deficiency disorder reduces
education mental capacity and academic
achievement of children.
MDG4: Child mortality Reduces perinatal mortality (abortions
and still births)
MDG5: Maternal health Reduces maternal hyperthyroidism
Development stages most at risk for IDD
Pregnant women / Prenatal development

35
The individuals most at risk for IDD are pregnant and lactating women, fetus and infants. The
fetus must obtain all required iodine from the mother. Fetal iodine deficiency is caused by
maternal iodine deficiency, which can lead to congenital hypothyroidism (a deficiency of thyroid
gland activity in the newborn infant). Severe cases can lead to cretinism (stunting of the body’s
physical and mental growth). This occurs when maternal iodine deficiency affects the fetus
before the fetus’ own thyroid is functional. Moreover, iodine deficiency during pregnancy has
been associated with increased incidence of miscarriage and stillbirth.
Lactating women / Newborns and infants
Sufficient intake of iodine during infancy continues to be critical due to the rapid growth of the
brain during this time. Adequate maternal levels of iodine in breast milk are key. Additionally,
iodine deficiency has been found to increase infant mortality with findings indicating an increase
in childhood survival upon correction of the iodine deficiency.
Children and adolescents
It is generally during childhood and adolescence that an iodine deficiency can manifest itself as a
goiter. The incidence of goiter peaks in adolescence and is more common in girls. Iodine-
deficient school children perform poorly in school, have a higher incidence of learning
disabilities, and lower IQs.
Adults
It has been found that iodine deficient adults demonstrate slower response times and impaired
mental function. Other symptoms include fatigue, weight gain, cold intolerance, and
constipation.
Human and economic loss due to IDD
Beyond its effect on mental development, IDD significantly impacts the economy. The 2006
Ethiopian Profiles analysis estimated that if the levels of iodine deficiency in pregnant Ethiopian
women remain unchanged, over 4.5 million newborns will suffer some form of intellectual
36
disability and GDP loss of more than 64 billion Birr between 2006 and 2015 necessitating the
need for an urgent action against iodine deficiency in the country.
Food sources and daily requirements of iodine for various age groups
Dietary sources of iodine
The richest dietary sources of iodine are sea foods (e.g, fish), seaweeds and iodized salt. Foods of
animal origin including meat and milk can also constitute a significant source of iodine if
animals have grazed on iodine sufficient soils. Similarly, crops from iodine sufficient soils may
supply some dietary iodine. Iodine fortified foods are also significant sources of dietary iodine.
Breast milk is an important source for infants and is affected by maternal iodine nutrition status.
Moreover, breast milk is an important source of iodine for the infant. The breast actively
concentrates iodine into breast milk for the benefit of the developing infant. In Ethiopia, where
the staple diets are mostly of plant origin and marine foods are rarely consumed, the use of
iodized salt for cooking and at the table constitutes a viable source of iodine.
Recommended Dietary Allowances (RDA)
The populations at risk of iodine are people of all ages and sexes. More at risk are the fetus,
young children, pregnant women, and lactating mothers. An unborn child needs a healthy and
well-nourished mother to grow properly. Therefore, babies born to mothers with iodine
deficiency are at risk of suffering from some degree of learning disability. Thus, iodine is one of
the many nutrients required in increased amounts during pregnancy and lactation. The daily
requirements of iodine do vary by age, sex and physiological status as indicated in the following
table.
Life stage Recommended Dietary Allowances (RDA) for Iodine

Age Males (µg/day) Females (µg/day)
Infants 0 – 6 months 110 (AI) 110 (AI)
Infants 7 – 12 months 130 (AI) 130(AI)
37
Children 1 – 3 years 90 90
Adolescents 14 – 18 years 150 150
Adults 19 years and older 150 150
Pregnancy All ages 220
Breastfeeding All ages 290
Toxicity from excess intake of iodine
Getting high levels of iodine (above the tolerable upper limit for a sustained period of time) can
cause some of the same symptoms as iodine deficiency, including goiter due to overstimulation
of the thyroid gland. However, instead of being due to hypothyroidism (not enough thyroid
hormone made), it’s due to hyperthyroidism (the thyroid makes too much thyroid hormone)
caused by too much iodine. The safe upper limits for iodine are listed in the table below.
Tolerable Upper Limit (UL)
Age group UL (µg/day)

Infants 0 -12 months Not established
Children 1 – 3 years 200 µg/day
Adolescents 14 – 18 years 900 µg/day
Adults 19 years and above 1,100 µg/day (1.1 mg/day)
Major causes or risk factors of micronutrient deficiencies
Major causes of IDD
38
The major causes of iodine deficiency disorders are inadequate iodine intakes (reduction in use
of iodized salt, iodine supplements and iodine fortified foods), geography (regions where top soil
has been lost due to deforestation, erosion and flooding), goitrogens in cassava, kale, etc in the
diet (block absorption or utilization of iodine and hence reduce uptake of iodine into the thyroid)
and coexisting iron, selenium or vitamin A deficiencies.
Population-level strategies for prevention and control of micronutrient deficiencies
Strategies for the prevention and control of iodine deficiency
The main strategies to control and eliminate iodine deficiency are the following:
Fortification (Universal Salt Iodization)
Fortification of salt is widely used to avert consequences associated with IDD. Significant
progress has been made in reducing the number of countries whose populations suffer mild to
severe iodine deficiency. Iodine deficiency disorder can be eliminated by the daily consumption
of iodized salt which is both a preventive and corrective measure for iodine deficiency.
Fortification or Universal salt iodization (USI) is the most effective, low-cost and long-term
solution to IDD.
The correct type and level of iodine in salt

The iodine content in salt is expressed as either ppm (or mg/kg) of iodine or ppm (mg/kg) of
KIO3. In Ethiopia, usually potassium iodate (KIO3) is used for salt iodization because of its
relative stability over potassium iodide (KI) under unfavorable conditions. Potassium iodate
(KIO3) is more convenient than iodides for salt iodation. Iodates (such as KIO3) are resistant to
oxidation and do not require the addition of stabilizers. Iodates are less soluble than iodides and
are less prone to migrate out of the salt when the fabric of the container absorbs the moisture of
the salt. The standard for salt iodization in Ethiopia is 34-66 ppm in the form of potassium
iodate( KIO3) or 20-40 ppm as Iodine. The KIO3 content in salt is the same as the iodine content
times 1.68, i.e., KIO3 = I x 1.68. In Ethiopia, an iodine content of 34 - 66 ppm is required as
KIO3 at the port of entry or at the processing and packaging plant.
39
Handling of Iodated Salt

In any salt iodization program, it is important to ensure that salt contains the specified amount of
iodine at the time of consumption. The retention of iodine in salt depends on the iodine
compound used, the type of packaging, the exposure of the package to prevailing climatic
conditions and the period of time between iodization and consumption. To ensure that iodized
salt ultimately reaches the consumer with the specified level of iodine, the following precautions
must be taken into consideration by the responsible authorities where climatic and storage
conditions could result in a large amount of iodine loss:
 Iodized salt shall be packed in air tight bags of either high density polyethylene or
polyethylene bags.
 Bulk packing units shall not exceed 50kg to avoid the use of hooks to lift the bags
 Bags already used for packing other articles shall not be reused for packing iodized salt
 The distribution network shall be streamlined so as to reduce the interval between
iodization and consumption of salt
 Iodized salt shall not be exposed to rain, excessive humidity or direct sunlight and
oxidizing contaminants in particular ferric ions at any stage of storage and transportation
necessitating the avoidance of iron tins as containers.
 Bags of iodized salt shall be stored only in covered rooms or warehouse that have
adequate ventilation
 The consumer shall be similarly advised to store iodized salt in such a manner as to
protect from direct exposure to moisture, heat and sunlight.
The required amount of iodine in iodated salt is maintained only when the following conditions
are avoided.
 Sprinkle salt at the end of cooking
 Washing salt before use not recommended
 Storage for more than recommended time
Supplementation
40
There are two main approaches to giving supplementary iodine: either on a daily basis, typically
using potassium iodide, or on an annual basis, using a slowly released iodine preparation such as
iodized oil. As a short-term strategy in highly endemic areas, Lipiodol (iodized oil capsules)
should be distributed to targeted high risk groups once annually. Iodine capsule supplementation
is costly, not universally accessible and consequently not a sustainable intervention measure.
Achieving sufficient iodine nutrition in the population through USI and other dietary means
would eliminate the need for specific iodine supplementation during pregnancy and lactation.
Alternative interventions are needed only when USI is impractical or delayed. The supplements
must be sufficient in amounts to prevent brain damage or thyroid function disorders due to an
iodine deficiency during pregnancy, lactation and the first 2 years of life. WHO-recommended
dosages of daily and annual iodine supplementation are given below (11).
Population group Daily dose of iodine Single annual dose of iodized

supplement (µg/d) oil supplement (mg/y)
Pregnant women 250 µg/d 400 mg/y
Lactating women 250 µg/d 400 mg/y
Women of reproductive age (15 – 49 yrs) 150 µg/d 400 mg/y
Children < 2 yearsa,b 90 µg/d 200 mg/y
a
For children 0-6 months of age, iodine supplementation should be given through breast milk.
This implies that the child is exclusively breastfed and that the lactating mother received iodine
supplementation as indicated above.
b
These figures for iodine supplements are given in situations where complementary food fortified
with iodine is not available, in which case iodine supplementation is required for children of 7-24
months of age.
Nutrition education
The nutrition education sessions should emphasize on the mental (IQ loss of 13.5 and reduced
learning capacity of children) and economic consequences (more than 64 billion birr in ten years)
of IDD, consumption of iodized salt at every life stage, increased consumption of sea foods e.g.
fish, iodization of foods consumed by animals (animals like humans suffer from IDD), decreased
41
consumption of goitrogenous foods and proper food processing methods able to detoxify
goitrogens and improved handling of iodized salt including at the household level. In any salt
iodization program, it is important to ensure that salt contains the specified amount of iodine at
the time of consumption. The retention of iodine in salt depends on the iodine compound used,
the type of packaging, the exposure of the package to prevailing climatic conditions and the
period of time between iodization and consumption.
Breastfeeding
Exclusive breast feeding for the first six months and continued breastfeeding up to two years and
beyond should be promoted to improve iodine nutrition in children. For children 0-6 months of
age, iodine supplementation should be given through breast milk. This implies that the child is
exclusively breastfed and that the lactating mother received iodine supplementation/nutrition.
With sustained breastfeeding, children 7–24 months of age should be given additional iodine
through complementary foods fortified with iodine.
Dietary Diversification and Modification

Dietary diversification is an important long term and sustainable strategy for the prevention of
micronutrient deficiencies. Through dietary diversification, communities should be encouraged
and get educated to grow and consume nutrient dense locally available fruits and vegetables,
increase consumption of iodized salt, increase consumption of sea foods and decreased
consumption of gotrigenous foods.
Other supportive measures in preventing and controlling IDD

Among the notable supportive measures in preventing and controlling IDD are strengthened
political commitment and support, strengthened enforcement of salt legislation and quality
control. As part of the quality control, periodic checking of the iodine content of salts available at
wholesale/retail outlets and quality check at the household level using salt iodine test kit is
critical.
Assessment methods for IDD
42
Various methods are available to assess iodine deficiency but thyroid stimulating hormone
(TSH), total goiter rate (TGR), thyroglobulin (Tg) and urinary iodine excretion (UIE) are
generally recommended. TSH provides an indirect measure of iodine status. An elevated
concentration of TSH reflects an insufficient supply of maternal and/or foetal thyroid hormone to
the developing brain and indicates a risk of irreversible brain damage. Goiter rate reflects chronic
(months to years) suboptimal iodine nutrition and Tg is a good indicator for an intermediate
response (weeks to months). UIE is a sensitive marker of recent iodine intake (days) as more
than 90% of dietary iodine is excreted through urine (12). UIE can be measured in spot urine
samples of children or adults provided that a sufficient number of specimens are collected (13).
Monitoring and evaluation of IDD prevention and control programs
Monitoring
Monitoring of IDD prevention and control programs is crucial in order to ensure that additional
iodine intake is effective in reducing the deficiency while preventing excessive intake that may
lead to adverse health consequences. The monitoring process should include the assessment of
coverage and iodine nutrition status (14).
Indicators to assess iodine nutrition status

Goiter
Goiter is a swelling on the neck and is the only visible sign of iodine deficiency. Although
thyroid-size palpitations have been used in the past to gauge iodine deficiency in a population,
this technique lacks sensitivity to acute changes in iodine intake and is, therefore, of limited
usefulness. The criteria for assessing the public health severity of iodine deficiency among
school-age children (>6 years) is depicted in the following table.
Severity of public Indicator

health problem
Median urinary iodine (µg/l) Total goiter prevalence (%)

Mild 50-99 5.0-19.9
43
Moderate 20-49 20-29.9

Severe <20 >30
Urinary Iodine Excretion (UIE)

The WHO has designated Urinary Iodine Excretion (UIE) as the most useful indicator of
population level iodine status since it reflects current intake of iodine in the diet. Most of the
iodine absorbed by the body is eventually excreted in the urine, although there may be small
losses in feces. Although the concentration of iodine in the urine of an individual can vary
diurnally and from day-today, the concentration of iodine in spot or casual samples of urine
taken from an adequate sample of schoolchildren has been shown to be a reliable biochemical
marker of recent dietary intake by the general population of the same area when measured using
recommended methods. A low median UI concentration indicates that a population is at risk of
developing thyroid disorders. UIE levels among pregnant women of less than 150 µg/l are
considered indicative of iodine deficiency. Similarly, for school-age children, UIE levels less
than 100 mcg/l indicate deficiency. For lactating women and children <2 years of age a median
urinary iodine concentration of 100 μg/l can be used to define adequate iodine intake. This is true
for lactating women since a significant amount is lost via breast milk. Levels above 300µg/l in
children and 500µg/l in adults are considered excessive and could cause risk of iodine-induced
hyperthyroidism.
Table x: WHO criteria for assessing iodine nutrition in a population based on median/range of
UIC in school-aged children.
Median UIE (μg/L) Iodine intake Iodine status

School age children
< 20 Insufficient Severe iodine deficiency
20-49 Insufficient Moderate iodine deficiency
50-99 Insufficient Mild iodine deficiency
100-199 Adequate Optimal
44
200-299 More than adequate Risk of iodine-induced hyperthyroidism

≥ 300 Excessive Risk of adverse health consequences
Pregnant women
<150 Insufficient
150-249 Adequate
250-499 Above requirement
>500 Excessive
Monitoring Quality of Iodated Salt at various levels

IDD control program based on salt iodization clearly cannot succeed unless all salt for human
consumption is being adequately iodized. Therefore, the most important indicator to monitor is
salt iodine content, and the most important place to monitor salt is at the site of production and
importation. If all salt leaving production facilities and imported salt is properly iodized,
packaged, and labeled, populations consuming this salt are likely to have their iodine
requirements met.
Monitoring salt iodine at the production site and port of entry

Monitoring salt iodine at the production site and port of entry is required to ensure adequate
iodization of the salt i.e. according to the level required by the law of the country. Salt
monitoring at the site of production is the responsibility of both the salt producer (internal
monitoring) as well as governmental food inspectors (external monitoring).
Monitoring salt at the wholesale and retail levels

Monitoring the iodine in salt at the retailer level is essential to ensure the availability of iodized
salt to the consumer. Monitoring at this level yields a quick and easy indication of whether or not
iodized salt is available in the marketplace, and the degree to which non-iodized salt is
competing for household use.
Monitoring salt at the household level
45
Monitoring the iodine in salt at the household level is required to determine the percentage of
households using salt at any iodine concentration and the percentage of households using salt
that is within an acceptable range of iodine concentration. This information indicates what is
actually used in households on a national basis and provides important information about the
successful delivery of iodized salt to the consumer as well as about use of non-iodized salt
obtained from unconventional marketing sources.
Impact Evaluation
Iodine status is the most immediate measure of whether the thyroid gland has adequate iodine to
function normally and protect the individual from the manifestations of iodine deficiency. The
median urinary iodine concentration reflects population status and is the indicator most
commonly assessed. The most commonly used impact indicators for IDD are percent of children
with clinical and sub clinical IDD and UIE level of >100 µg/l in target population (school age
children, 6-12 yrs).
Linkage between iodine nutrition and other nutrition sensitive sectors

Recognizing the extent of iodine deficiency in the country and the disorders that could emanate
from it, the FMoH has engaged itself in the overall coordination of the production and
distribution of iodized salt. But, this is sending the wrong message that responsibility for salt
iodization solely lies with the Ministry of Health. It is obvious the health sector plays a pivotal
role but several other sectors including private sector can significantly contribute to the success
of the USI program in Ethiopia. A mandatory salt regulation # 204/2011 was enacted by the
Council of Ministers in March 2011.The regulation makes it mandatory that all salt for human
consumption must be iodized according to the country’s’ specification prescribed by the
appropriate authority. Ethiopian Food, Medicine and Health Care Administration and Control
Authority established by proclamation NO. 661/2009 is the main regulatory agency. But, the
roles of the agriculture, education, trade and industry, the media and other nutrition sensitive
sectors is essential.
46
Assessment questions for iodine nutrition
1. IDD is still one of the public health problems in Ethiopia.

a. False
b. True
2. The average IQ of children reduced due to IDD is
a. 25 IQ points
b. 13.5 IQ points
c. 35 IQ points
d. None
47
3. Iodine is an essential for the biosynthesis of

a. Thyroid hormones
b. Triiodothyronine (T3)
c. Thyroxine (T4)
d. All
4. Which of the following is not a consequence of IDD?
a. Stillbirth
b. Impaired mental function
c. Goiter
d. None
5. Which one of the following is clinical signs/symptoms of iodine deficiency?
a. Pallor
b. Bitot’s spots
c. Bilateral pitting edema
d. None
6. Which of the following are not population groups at risk for IDD?
a. Pregnant women
b. Children
c. Adolescents
d. None
7. Rapid test kit is used to know that the salt we are using is adequately iodized.
a. False
b. True
8. To compensate loss of iodine during distribution, storage and cooking, higher levels of
iodine are added at the production stage.
a. False
b. True
9. One is not a cause for iodine deficiency disorders
a. Inadequate iodine intakes
48
b. Goitrogens
c. Coexisting iron, selenium or vitamin A deficiencies
d. None
10. Why is iodine added to common salt?
a. Salt is an ideal vehicle for addition of iodine as it is usually needed in fairly
constant daily amounts
b. The technique for iodization is simple and well established
c. The added iodine doesn’t affect the appearance and taste of salt
d. All
11. What is the importance of iodine for pregnant women to have sufficient iodine in her
diet?
a. A fetus needs a steady supply of iodine for the normal growth and development of
its brain and body
b. Iodine deficiency during pregnancy may also result in abortion or stillbirth
c. The critical period for brain growth is from conception to three years of life
d. All
12. What is the national iodization standard for Ethiopia?
a. 34-66 ppm for potassium iodate
b. 20-40 ppm of KI
c. Both
d. None
13. Which of the following is not a strategy to control and eliminate iodine deficiency?
a. Universal salt iodization
b. Supplementation
c. Dietary diversification
d. None
14. The sensitive marker of recent iodine intake (days) is
a. Goiter
b. Urinary iodine excretion
49
c. Thyroid stimulating hormone

d. None
15. The median urinary iodine concentration used to define iodine intake is
a. 50 μg/l
b. 100 μg/l
c. 300 μg/l
d. 500 μg/l
References
50
1. Hetzel BS. The story of iodine deficiency. An intellectual challenge in nutrition. New
York. Oxford Medical Publications, 1989.
2. Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their

children: results from the Avon Longitudinal Study of Parents and Children. SC Bath, et
al. Lancet 2013.
3. Mild iodine deficiency during pregnancy is associated with reduced educational

outcomes in the offspring: 9-Year Follow-up of the Gestational Iodine Cohort. KL Hynes,
et al. J Clin Endocrinol Metab 98: 1954–1962, 2013.
4. Abuye C, Berhane Y (2007). The goitre rate, its association with reproductive failure, and
the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: cross-
section community based study. BMC Public Health 7, 316.
5. Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and

trends over the past decade. J Nutr Epub Feb 29, 2012.
6. Zimmermann MB (2009). Iodine Deficiency. Endocrine Reviews 30, 376-408.
7. Ristic-Medic D, Piskackova Z, Hooper L, Ruprich J, Casgrain A, Ashton K, Pavlovic M,

Glibetic M (2009). Methods of assessment of iodine status in humans: a systematic
review. Am J Clin Nutr 89, 2052S-2069S.
8. Clugston GA,Dulberg EM,Pandav CS,Tiden RL Iodine Deficiency Disorders in

Southeast Asia. In: Hetzel BS, Dunn JT, Stanbury JB, eds. The Prevention and Control of
Iodine Deficiency Disorders. New York: Elsevier, 1987: 65-84.
9. Pharoah P, Buttfield IH, BS Hetzel (1971). Neurological damage to the fetus resulting
from severe iodine deficiency during pregnancy. Lancet 1, 308-310.
10. Hetzel B (1983). Iodine deficiency disorders (IDD) and their eradication. Lancet 2, 1126-
1129.
51
11. WHO. Prevention and control of iodine deficiency in pregnant and lactating women and
in children less than two years old. World Health Organization. Geneva.
12. Vought R, London W (1967). Iodine intake, excretion and thyroidal accumulation in
healthy subjects. J Clin Endocrinol Metab 27, 913-919.
13. WHO (2007). WHO, UNICEF and ICCIDD. Assessment of iodine deficiency disorders
and monitoring their elimination. Geneva: World Health Organization.
14. WHO/UNICEF/ICCIDD. Assessment of IDD and Monitoring their Elimination. World

Health Organization, Geneva, 2001.
52
53
Session plan for skill competencies of IDD
Date: December 21, 2013 Venue: Kereyu Resort, Adama Session: Iodine Duration: 45 minutes
Title: Determination of the iodine content of salt at the household/retail level using Rapid Test Kit (RTK).
Session objective
At the end of the session, the participant will be able to
 Perform qualitative test to determine the level of iodine in salt using RTK
Methods and activities Materials/Resources
Introduction (10 min)  Rapid test kits for salt iodine determination
 IDD  Iodized and non iodized salt
 USI
 Flipchart papers, markers and masking tape
 Quality control measures
 Procedures of RTK written on flip chart
 Review objectives
Body (20 minutes)  Needle or pin
 Demonstrate the determination of the iodine content in salt using RTK
 Re-demonstrate the determination of the iodine content in salt using RTK
 Coaching
Summary (5 minutes)
 The need for quality monitoring of salt
 Need for representativeness of salt sample from the unit of packaging
material
Evaluation
 Check participants performance using the checklist
Review (10 minutes)
 What worked well and what did not?
 Likely modifications for future practices
 Future actions (follow up, report writing and communication to the next higher level)
55
Checklist for the determination of the iodine content of salt at the
household/retail level using Rapid Test Kit (RTK)
RN Skill No Yes
01 Check the expiry date, contents of RTK if it includes a bottle of starch

solution, recheck and a color chart for qualitatively determining the level
of iodine and the presence of needle or pin.
02 Record the expiry date, brand name, manufacturer of the salt and whether
the package is labeled as iodized or not.
03 Collect/get salt samples and make sure that salt sample is representative of
the unit of packaging material
04 Shake the contents of the test solution before use
05 Puncture the cover of the test solution when open for the first time
06 Drop one to two drops of the starch solution (white) on a sample of salt
collected
07 Observe for a color change in about 1 minute.
08 Compare the color changes with the color chart in the test kit. The color
intensity of the spot indicates the iodine content of the salt collected from
the household/retail shop.
09 If no color change is observed, apply up to five drops of the recheck

solution followed by another two drops of the starch solution. If no color
change is still observed, report that the salt is non-iodized.
10 Store the RTK contents closed tightly after use.

Iron Nutrition
Introduction
Iron is a mineral substance essential to most life forms and to normal human physiology. Iron is
an integral part of many proteins and enzymes that maintain good health. Our body only requires
very small amounts hence it is essential micronutrient. Iron deficiency is the commonest cause
of nutritional anemia.
Learning objectives
After completing this session, the trainee will be able to:
1. Describe the physiological roles of iron
2. Describe the food sources and daily requirements of iron for various age groups and
physiologic states
3. Describe public health significance of Iron deficiency and its epidemiology
4. Explain the major causes Iron deficiencies and iron deficiency anemia
5. Describe the health effects and clinical manifestations of both inadequate and excess
intakes of iron
6. Describe the human and economic cost of Iron deficiencies and iron deficiency anemia
7. Explain common assessment methods to identify anemia
8. Outline individual and population based intervention strategies to prevent and control
Iron deficiencies and iron deficiency anemia
9. Describe the indicators for monitoring and evaluation of IDA prevention and control
programs
Physiological roles of iron

In humans, iron is an essential component of proteins involved in oxygen transport. It is also
essential for the regulation of cell growth and differentiation. A deficiency of iron limits oxygen
delivery to cells, resulting in fatigue, poor work performance, and decreased immunity. On the
other hand, excess amounts of iron can result in toxicity and even death (table 3.1).
57
Table 3.1: Physiologic role Functions of iron

Oxygen transport and  Part of hemoglobin found in red blood cells responsible for
storage carrying oxygen throughout the body. Without iron,
hemoglobin can't do its job: provide body tissues, organs and
systems with oxygen. Every tissue in the body requires iron.
 Part of myoglobin responsible for carrying oxygen to muscles.

Without iron, muscles don't get the oxygen they need and we
get fatigued.
Cognitive development  Due to iron’s role in neural tissues, nerve myelination, and
neurotransmitter synthesis.
 Anemic children interact less with surrounding environment,
which may affect cognitive development.
Energy metabolism and  Iron makes up the core of cytochromes, which are responsible
storage, detoxification, for these functions.
neurotransmitter and
hormone synthesis, and
cellular regulation
Immune functioning  Required for T-lymphocytes to divide ensuring the body’s
ability to mount an immune response.
Antioxidant activity  Required to break down toxic oxygen species in the body but
can also cause the creation of free radicals if iron roams free
outside the cellular system.
DNA synthesis  Required for DNA synthesis; therefore plays a role in basic
human physiology: growth, reproduction.
What foods provide iron?

There are two forms of dietary iron: heme and non-heme.
58
- Heme iron obtained from animal sources and it is absorbed better than non-heme iron.
- Non-heme iron obtained from plant source foods. Non-heme iron accounts for most
dietary iron but it is less bio-available because it and very influenced by dietary factors.
Diets of poor people are often low in animal products (which contain iron that is more readily
absorbed), low in fruit (which can enhance iron absorption) and high in some cereals (which
contain phytate which hinders absorption). Infection and poor sanitation (hence infection with
hookworm) also exacerbate iron deficiency (See session: dietary diversification and
modification).
Table 2: Selected coomon Iron Rich Food Sources

Plant sources (non-heme iron) Animal sources(heme iron)
 Legumes: Chickpea, Soya bean, Lentil  Breast milk
 Vegetables & fruits: Onion stalks,  blood
Spinach, Pumpkin, watermelon,  Dark red & organ meat- liver, kidney, lean red
Fenugreek leaves meat (especially beef), lamb, pork, shellfish
 Whole grain: (teff, millet, sorghum),  poultry, eggs (especially egg yolks)
amaranthus
In breast milk, iron remains relatively stable regardless of the mother’s status and readily
absorbable (50%).
Annex (pictures of common sources)
What is the recommended intake for iron?

Dietary iron requirements are highest in the second and third trimesters of pregnancy and in the
rapidly growing infant between 6 and 18 months of age. The next high risk period for nutritional
iron deficiency is the adolescent growth spurt and the onset of menstruation in girls (Table 3).
The needs of women of childbearing age are much higher than those of men, but quite variable
because of the wide range in monthly menstrual blood loss.
59
Table3: Daily Recommended Dietary Allowances for Iron (RDA1)
Age and sex Males (mg) Females (mg)

0 to 6 months (AI*) 0.27 0.27
7 to 12 months 11 11
1 to 3 years 7 7
4 to 8 years 10 10
9 to 13 years 8 8
14 to 18 years 11 15
19 to 50 years 8 18
Pregnant women - 27
Lactating < 19 - 10
Lactating 19 – 50 - 9
51+ years 8 8
* Recommended iron intake for 0 -6 months is based on an Adequate Intake (AI) that reflects the
average iron intake of healthy infants fed breast milk.
Public health significance of Iron deficiency and its epidemiology

Deficiency state: Iron deficiency and iron deficiency anemia
Three general stages of deficiency:
 Storage iron deficiency: stored iron is used up but circulating iron is not affected. Hb
levels remain normal.
 Early iron deficiency: stored iron is used up and circulating iron is now tapped for use
causing a problem in creating enough red blood cells. However, Hb levels still normal.
 Iron deficiency anemia: stores and circulating iron are both affected and are not sufficient
for the body’s needs. Hb levels are now affected.
1
Recommended Dietary Allowances (RDA) - recommends the average daily intake that is sufficient to meet the nutrient
requirements of nearly all (97–98%) healthy individuals in each age and gender group
60
Note: The terms anemia, iron deficiency, and iron deficiency anemia often are used
interchangeably. But, they are not equivalent.
Iron deficiency affects one in three of the world’s population, and severe deficiency (which can
cause death of mothers and their newborns) remains a problem. Unlike other types of nutritional
deficiencies anemia often only presents with subtle symptoms and often remains undetected
except in its severe form. The global prevalence of anemia is estimated to be 43% (273 million)
in children, 38% (32 million) in pregnant women and 29% (496 million) in non-pregnant
women. Iron deficiency is the leading nutritional cause anemia that contributes to approximately
one half of anemia cases worldwide2.
WHO: Classification of Anemia as problem of Public Health

Significance
Prevalence of anemia (%) Category of Public Health Significance
<4.9 No public health problem

5.0 - 19.9 Mild public health Problem
10.0 - 39.9 Moderate public health Problem
> 40 Sever public health Problem
Population at risk of iron deficiency and causes of deficiency

The population groups most vulnerable to developing iron deficiency are
 Pregnant women- Nutrient requirements increase during pregnancy to support fetal
growth and maternal health. Iron requirements of pregnant women are approximately
double that of non-pregnant women because of increased blood volume during
pregnancy, increased needs of the fetus, and blood losses that occur during delivery
 Preterm infants do not benefit from iron stores since these iron stores are built up during
the last trimester. In a full term infant, stored iron is enough for 6 months.
2
Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, Peña-Rosas JP, Bhutta ZA, Ezzati M. Global, regional, and national
trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a
systematic analysis of population-representative data. Lancet Global Health July, 2013; 1: e16-e25.
61
 Children 6 – 59 months: after 6 months, infant stores are depleted and other dietary
sources are needed. Unfortunately, traditional weaning foods in developing countries are
often poor sources of bioavailable iron.
 The adolescent girls: growth spurt and the onset of menstruation increases their iron
demand
 Women of childbearing age, especially those with heavy menstrual losses
In addition, People with renal failure, especially those undergoing routine dialysis; people with
gastrointestinal disorders who do not absorb iron normally
It can be noted from the table below that the prevalence of anemia, nationally, decreasing.
However, the EDHS reports indicate that the prevalence is higher in Afar, Somalia and Dire
Dawa. The 2011 EDHS estimated the prevalence of anemia among adult men age 15 – 59 is
12%.
Table: Prevalence of Anemia in Ethiopia among children and

women, 2005 & 2011
Population Years Mild Moderate Sever Total
groups
children (6 -59 2005 21.40% 28.30% 3.90% 53.60%
months) 2011 21% 20% 3% 44.00%
Pregnant 2005 14.70% 13.00% 3% 30.70%
women 2011 12.20% 8.70% 1.20% 22.10%
Breast feeding 2005 20.20% 8.30% 1.30% 29.80%
women 2011 14.80% 3% 0.60% 18.40%
WRA 2005 16% 6.80% 1% 23.80%
2011 12.30% 2.20% 0.50% 15.00%
Health and economic consequences of Iron deficiency

62
 Anemia during pregnancy is a major contributing factor to low birth weight babies and
maternal mortality. Maternal anemia almost always leads to infant anemia with serious
consequences for infant health, survival and development. More specifically, Iron
deficiency is a concern because it can:
 Iron deficiency can delay normal infant motor function (normal activity and movement)
or mental function (normal thinking and processing skills).
 Iron deficiency anemia during pregnancy can increase risk for small or early (preterm)
babies. Small or early babies are more likely to have health problems or die in the first
year of life than infants who are born full term and are not small.
 Iron deficiency can cause fatigue that impairs the ability to do physical work in adults.
Iron deficiency may also affect memory or other mental function in teens.
Multiple causes of iron deficiency and iron deficiency anemia include:
 Increased requirements of iron: during pregnancy and during rapid growth periods (
infants and toddlers)
 Repeated pregnancies and poor birth spacing,
 Insufficient intake of bioavailability/absorbable iron; low socioeconomic status to access
anemia source food, and dietary habit (vegetarians, extended fasting)
 Increased blood loss - heavy menstrual bleeding, heavy bleed during childbirth, internal
bleeding (like GI bleeding), major surgery,
 Repeated infections, such as worms (hookworm, malaria, schistosomiasis, trichuriasis),
chronic diarrhea and dysentery
 Extreme physical exercise (endurance athletes)
 those deficient in vitamin A
 hemoglobinopathies such as or thalassemias and
Clinical manifestation of Iron deficiency:
Early stage iron deficiency can exist without overt anemia, but with other non-hematological
symptoms
63
Clinical symptoms Clinical signs

 Light headedness/Dizziness or  Pale fingernails (often with vertical
fainting lines)
 Easy fatigue and loss of  whitish/pale conjunctiva
energy/tiredness
 Headache  Pale tongue
 Confusion or loss of concentration Sever cases
 Soreness of the mouth with cracks at
the corners
 Dyspnoea (Shortness of breath)  lusterless, brittle and upward
especially on exertion curvature of the nails (spoon-shaped(
(koilonychias)
 Palpitations (uncomfortable  Tachycardia: Pulse rate
awareness of one’s hear beat) >100beat/minute
especially on exertion
 Pica - a desire to eat non-food  inflamed tongue
items, such as clay, ice
Image/slides on clinical signs of
anemia
Children:
 tiredness,
 restlessness and irritability
 attention-deficit/hyperactivity disorder (ADHD),
 growth retardation,
 cognitive and intellectual impairment.
Laboratory Examination:
64
• Measure hemoglobin - can be easily measured in a blood sample obtained by finger-

prick.
• hematocrit - the percentage of red blood cells in your blood by volume
In addition: -
 Blood film for malaria
 Complete blood count (to look at the number and volume of the red blood cells)
 Peripheral blood morphology
 Stool examination for hookworm and schistosomiasis
 Urinalysis
 Pregnancy test
Table : Hemoglobin and hematocrit cutoffs used to define anemia in people living at sea level and Stages
of anemia
Age or Sex group Hemoglobin below (g/dl) Hematocri
Normal Mild Moderate Sever Anemia t%
Anemia Anemia
6 months - 5years > 11.0 10.0 - 10.9 7.0 - 9.9 < 7.0 33%
5 - 11 years > 11.5 11.0 - 11.4 8.0 - 10.9 < 8.0 34%
12 -14 years > 12.0 11.0 - 11.9 8.0 - 10.9 < 8.0 36%
Non-pregnant females >15 > 12.0 11.0 - 11.9 8.0 - 10.9 < 8.0 36%
years
Men >15 years > 13.0 11.0 - 12.9 8.0 - 10.9 < 8.0 39%
65
Pregnant
First Trimester > 11.0 10.0 - 10.9 7.0 - 9.9 < 7.0 33%
Second Trimester > 10.5 10.0 - 10.4 7.0 - 9.9 < 7.0 32%
Third Trimester > 11.0 10.0 - 10.9 7.0 - 9.9 < 7.0 33%
Source: WHO/UNICEF/UNU (2001). Iron deficiency anaemia. Assessment prevention and
control. A guide for programme managers. Geneva, WHO/UNICEF/UNU.
Hemoglobin values change with altitude, so the hemoglobin values need to be adjusted for
altitudes to define anemia. Decrease the Hemoglobin measured by the amount corresponding to
the altitude of the client/ patient residence
Altitude Adjustment
< 1000 m 0.0 g/dl
1000 m 0.1 g/dl
1500 m 0.4 g/dl
2000 m 0.7 g/dl
2500 m 1.2 g/dl
3000 m 1.8 g/dl
3500 m 2.6 g/dl
Iron supplementation during the latter part of pregnancy may benefit the infant even if the
mother is neither iron deficient nor anemic at 20 weeks of gestation
Strategies to address Iron Deficiency and Iron deficiency Anemia

Public health interventions to reduce the burden of iron deficiency anemia should address locally
important determinants of IDA. Main strategies for correcting iron deficiency in populations
exist, alone or in combination:
1. Nutrition education combined with dietary modification or diversification, or both, to
improve iron intake and bioavailability;
2. iron supplementation
66
3. Food fortification – large scale industrial food fortification or home fortification of

complementary food of infant & young children
4. Public health measures and other interventions -
o delayed cord clamping, control of parasites (helemthiasis, malaria and
schistosomais),
o Improvements in access to health care, food security, and socioeconomic status
are important factors.
It is worth important combine different interventional strategies as iron deficiency is not the only
cause of anemia.
Iron-folic acid supplementation

Iron supplementation has long been advocated for the control of anaemia. Oral iron is widely
available as a single micronutrient supplement in liquid and tablet formulations, as iron with
folic acid, or in multiple micronutrient preparations. Different iron compounds have varying
bioavailability, effect and cost. A daily protocol of iron supplementation is recommended for
treatment and prevention in the priority target groups. Numerous studies have evaluated whether
the frequency of iron supplementation can be reduced from daily to twice or once per week
without compromising the efficacy of supplementation. The evidence is promising.
Consuming folic acid along with iron supplements has also been promoted. Supplementation
with 400µg of folic acid around the time of conception significantly reduces the incidence of
neural tube defects, a group of severe birth defects. Folic acid supplementation that is initiated
after the first trimester of pregnancy is too late to prevent birth defects. A daily dose of 400 µg
folic acid is a safe and healthy intake for women during pregnancy and lactation but is more than
the amount required to produce an optimal haemoglobin response in pregnant women.
Nevertheless, if iron supplements containing 400µg folic acid are available, their use in
supplementation programs is recommended. If such supplements are not available, the currently
available iron supplement containing 250 µg folic acid should be used until higher folic acid
formulations can be obtained.
67
Iron and folic acid supplementation in pregnant women

WHO recommends pregnant women take daily oral iron and folic acid supplements as part of the
antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency3. A
formulation containing 30 - 60 mg elemental iron and 400 µg folic acid is recommended. The
suggested scheme is present in Table 1. The lower dose (30 mg) may be considered in areas
where the prevalence of anaemia is lower than 40%. This lower dose may promote adherence by
reducing the side-effects and unnecessarily high hemoglobin level (above 130 g/L) 4.
In areas where the prevalence of anaemia among pregnant women is lower than 20%, non-
anaemic pregnant women may choose intermittent iron and folic acid supplementation as an
alternative to the daily regimen. Weekly supplementation of iron and folic acid for non-anaemic
pregnant women may be used to prevent the development of anaemia and to improve gestational
outcomes5. A suggested scheme for intermittent iron and folic acid supplementation in non-
anaemic pregnant women is presented in Table 2.
Table 1: Daily iron and folic acid supplementation in pregnant women.

Supplement composition Iron: 30–60 mg of elemental iron*
Folic acid: 400μg (0.4 mg)
Frequency One supplement daily
Duration Throughout pregnancy. Iron and folic acid
supplementation should begin as early as possible
Target group All pregnant adolescents and adult women
Settings All settings
* 30 mg of elemental iron equals 150 mg of ferrous sulfate heptahydrate, 90 mg of ferrous
fumarate or 250 mg of ferrous gluconate.
Program Tips
3 WHO. Guideline: Daily iron and folic acid supplementation in pregnant women .Geneva, World Health Organization, 2012.
4 30 mg of elemental iron equals 150 mg of ferrous sulfate heptahydrate, 90 mg of ferrous fumarate or 250 mg of ferrous gluconate.
5 WHO. Guideline: Intermittent iron and folic acid supplementation in non-anaemic pregnant women. Geneva, World Health Organization, 2012.
68
a. Encourage women to book for ANC service within 3 months of pregnancy and to get at least
4 ANC visits. In doing so, involve the Health Development Army to identify, refer and trace
pregnant women for ANC service.
b. All pregnant women shall be given a comprehensive education & counseling on causes and
consequences of maternal anaemia; benefits of IFA supplement consumption, possible side
effects related to the intake and ways to mitigate side effect if happened and thereby
improve adherence to supplement.
 Every pregnant woman should be given: 1 IFA tablet of per a day for at least 6
months even during the postpartum period.
 Clearly inform the schedule for next visit and give adequate number of IFA tablets
until next visit.
 Advice the women to take the IFA tablets at the same time each day to avoid missing
any & do not take two doses together to make up for a forgotten dose.
 Link IFA-taking behavior to normal daily routine activities.
 Assess adherence level in subsequent visits and reward for high adherence.
 Reassure that all side effects are temporary and will disappear through time.
 If the woman encountered heartburn advice to take the tablet during meal but not with
dairy products and anti-acid drugs that inhibits absorption. In addition, provide advice
reducing the intake of spicy foods, tea and coffee that aggravates gastric discomfort.
In addition:
 Encouraged to intake of a variety of foods, according to local availability and
accessibility, in adequate amounts in order to meet their nutritional requirements.
 In addition to the regular three meals, women should be counseled to eat at least one
extra meal (snack) per day while pregnant and two extra meals per day while breast
feeding, to meet the daily energy requirements of pregnancy and lactation respectively.
 The intake of iron and folate before conception helps to provide adequate reserves that
help to prevent anemia later during pregnancy.
69
Intermittent supplementation
Intermittent use of oral iron supplements (i.e. once, twice or three times a week on non-
consecutive days) has also been proposed as an effective alternative to daily iron
supplementation to prevent anaemia (8, 9). Intestinal cells turn over every 5–6 days and have
limited iron absorptive capacity, thereby weekly provision of iron exposes only the new cells to
iron, which may improve its absorption (Viteri et al 1995). An intermittent regimen, such as
weekly supplementation, may also be more acceptable to women and therefore increase
compliant with supplementation programmes (12, 13).
WHO recommends intermittent iron and folic acid supplementation for menstruating women in
populations where the prevalence of anaemia among non-pregnant women of reproductive age is
20% or higher in order to improve their haemoglobin concentrations and iron status and reduce
their risk for anaemia6. A suggested scheme for intermittent iron and folic acid supplementation
in menstruating women is presented in Table 3. Use of these regimens should improve women’s
iron and folate status prior to pregnancy, thereby helping to prevent both anaemia and neural
tube defects.
Table: Suggested scheme for intermittent iron and folic acid supplementation in
menstruating women
Supplement composition Iron: 60 mg of elemental iron*

Folic acid: 2800 μg (2.8 mg)
Frequency One supplement per week
Duration and time interval 3 months of supplementation followed by 3 months of no
between periods of supplementation after which the provision of supplements should
supplementation restart.
If feasible, intermittent supplements could be given throughout the
6
WHO. Guideline: Intermittent iron and folic acid supplementation in menstruating women. Geneva, World Health
Organization, 2011.
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school or calendar year

Target group All menstruating adolescent girls and adult women
Settings Populations where the prevalence of anaemia among non-pregnant
women of reproductive age is 20% or higher
* 60 mg of elemental iron equals 300 mg of ferrous sulfate heptahydrate, 180 mg of ferrous
fumarate or 500 mg of ferrous gluconate.
Iron supplementation for Children 6 -24 Months of Age

Infants need a relatively high iron intake because they are growing very rapidly. Infants are
normally born with plenty of iron. However, beyond 6 months of age, iron content of milk is not
sufficient to meet many infants requirements and complementary foods are usually low in iron.
Low-birth-weight infants (less than 2500 g) are born with fewer iron stores and are at high risk
of deficiency after 2 months. Where iron-fortified complementary foods are not widely and
regularly consumed by young children, infants should routinely receive iron supplements in the
first year of life (Table 5). Where the prevalence of anemia in young children (6.24 months) is
40% or more, supplementation should continue through the second year of life.
Guidelines for iron supplementation to children 6 - 24 months of age

Dosage Birth-weight category Duration
Normal 6 -24 months of age
12.5 mg iron + 50 µg folic acid daily Low birth weight (<2500 g) 2 -24 months of age
Note:
o If the prevalence of anemia in children 6.24 months is not known, assume it is similar to
the prevalence of anemia in pregnant women in the same population.
o Iron dosage is based on 2 mg iron/kg body weight/day.
Food based approach to prevent iron deficiency anaemia

A food-based strategy is long-term, sustainable and cost-effective strategy that has the goal
preventing iron deficiency and iron deficiency anaemia in the general public through increasing
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the availability and consumption of iron rich foods. Pertaining to prevention and control of iron
deficiency anaemia, the food-based strategy comprises two approaches, namely dietary
diversification and food fortification with iron.
Dietary diversification and modification includes interventions that aim to

1. Increase the production, availability and access to foods high in iron;
2. Increase the consumption of iron rich foods; or
3. Increase the bioavailability of iron in the diet; that is, the amount of iron that can be
absorbed and utilized by the body.
Forms of iron in the food
- Heme iron (from animal products; accounts for the least amount of iron in the diet but is
the most bioavailable form)
- Non-heme iron (from non-animal and animal products; must be converted by the body
into heme; accounts for most dietary iron but is less bioavailable and very influenced by
dietary factors)
Common iron rich foods

Plant sources Animal sources
 Legumes: Chickpea, Soya bean, Lentil  Breast milk
 Vegetables & fruits: Onion stalks,  blood
Spinach, Pumpkin, watermelon,  Dark red & organ meat- liver, kidney, lean red
Fenugreek leaves meat (especially beef), lamb, pork, shellfish
 Whole grain: (teff, millet, sorghum),  poultry, eggs (especially egg yolks)
amaranthus
In breast milk, iron remains relatively stable regardless of the mother’s status (which is true for
folate, vitamin D, calcium and zinc too)
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Recommended dietary modifications for the prevention and control of iron deficiency and Iron
deficiency anaemia are aimed at promoting the consumption of iron rich foods and improving the
bioavailability, particularly of plant source iron, by promoting nutrition practices that reduces
anti-nutrition factors.
 Increase the intake of germinated seeds, fermented cereals, heat-processed cereals
 Add small amounts of meat, poultry, or fish to cereal-based staple foods
 Promote the consumption of fruits and vegetables rich in vitamin C (e.g. oranges,
tangerines, mangoes, tomatoes, green peppers)
 Discourage the consumption of tea, coffee, chocolate, or herbal teas just before, during
and shortly after meals containing iron.
Enhancers and inhibitors of iron absorption

Enhancers Inhibitors
 Haem iron, present in meat, poultry,  Phytates, present in cereal bran, cereal grains,
fish, and seafood; high-extraction flour, legumes, nuts, and seeds;
 ascorbic acid or vitamin C, present in  tea, coffee, cocoa, herbal infusions in general,
fruits, juices, potatoes and some other certain spices (e.g. oregano), and some
tubers, and other vegetables such as vegetables; and
green leaves, cauliflower, and cabbage;  Calcium, particularly from milk and milk
and products.
 Some fermented or germinated food
Nutrition education and counseling programs

 Should address the issue of iron deficiency within different population groups with
varying dietary habits, socio-economic situations and nutritional and health status
 Simple and practical message has to be delivered to the community on how to manage
the issue of enhancers and inhibitors with in diets through food preparation and diet
modification
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 It should address the promotion of increased access to iron rich foods
Note: Dietary modification and diversification is the most sustainable approach, however,
change of dietary practices and preferences is difficult, and foods that provide highly
bioavailable iron (such as meat) are expensive
Fortification: large scale and point of use

Large scale/industrial food fortification is adding small amounts of vitamins and minerals to
industrially processed appropriate foods to enhance their nutrient content. This is appropriate
where micronutrient intake could not be met through dietary diversification, which is a general
truth all over the world. In the world, fortifying industrially milled wheat and maize with iron
and other nutrients like folic acid, is a most common a sustainable measure being practiced to
prevent iron deficiency and iron deficiency anemia. These staple are widely and regularly
consumed, and mostly processed in large industrial mills with established distribution and
marketing networks which deliver the products to urban and rural populations in many countries.
Ethiopia has plan to fortify XXX % industrially wheat flour that could cover XXX%
Processed foods such as noodles (pasta, macaroni) and breakfast cereals are increasingly being
fortified on a voluntary basis. Fortified weaning foods for children are also becoming popular.
An appropriate food vehicle is one which is widely consumed an adequate amounts by the target
populations, where the micronutrient added does not adversely affect consumer acceptability of
the product, where food processing is sufficiently centralized that fortification is feasible and
with adequate quality assurance and control procedures and enforcement, etc.
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Role of the nutritionist:

1. Food processing industries
presupposes the existence of some local system of quality assurance, as well as local laboratories
capable of doing simple tests. With appropriate support and diligence, national food safety and
quality control systems could be strengthened.
Fortification: Iron fortification is probably the most practical, sustainable, and cost-effective
long-term solution to control iron deficiency at the national level.
So far access to fortified food is very limited. Industrially processed complementary food and
food aid distributed through Special targeted Supplemental Nutrition Program , particularly in
humanitarian emergencies.
Fortify foods at home. Complementary foods prepared at home can be fortified during
preparation with powders (“sprinkles”), spreads, “foodlets” (a crushable nutrient-rich tablet that
dissolves in water), and other preparations that contain iron and other micronutrients. Many
suitable products are on the market or being tested, but their affordability and availability are
limited.
Home fortification of home prepared complementary foods and improving vitamin and mineral
intakes, particularly for improving the nutrient intake of infant & young children who do not
have access to commercially marketed infant foods. They are labeled as complementary food
supplements. The supplements are available as water‐dispersible or crushable tablets, sprinkles
or spreads or lipid based that can be added to complementary foods just before feeding infants
and young children.
They are designed to provide 1 to 2 EARs (Estimated Average Requirements) of vitamins and
minerals in a small volume and are easily integrated into existing food practices.
Food fortification is a complementary strategy for improving micronutrient status.
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Helminth Control
Where hookworm infection is endemic (prevalence 20-30% or higher) and anemia is very
prevalent, hookworm infection (Necator americanus and Ancylostoma duodenale) is likely to be
an important cause of anemia, especially moderate-to-severe anemia. Hookworms cause
intestinal blood loss by feeding on the intestinal mucosa. The amount of blood lost is directly
proportional to the number of worms infecting the host. A moderate infection of hookworms
approximately doubles the iron losses of a child or menstruating woman.
During Focused antenatal care visits, anthelminthic therapy combined with iron and folate
supplementation enhances the hemoglobin response to iron supplementation.
 Either Albendazil 400mg or Mebendazole 500mg may safely be administered to pregnant

women after the first trimester.
 Biannual deworming to children 6 -59 months is provided through EOS/CHD or through
routine health services
 School aged children and adolescent girls could be de-wormed bi-annually through the
School Health and Nutrition program
Malaria Control
Plasmodium falciparum malaria causes a profound anemia during and after acute infection. The
anemia is caused by hemolysis of red cells combined with suppression of erythropoiesis.
Consequently body iron is shifted from hemoglobin to storage forms.
 Where P. falciparum malaria is endemic, the use of insecticide-impregnated bednets in
communities decreases the prevalence of severe anemia in young children.
 Malaria prophylaxis during pregnancy in malaria endemic areas is not practiced in
Ethiopia.
Reproductive and obstetric strategies
I. Prevent adolescent pregnancies, reduce the total number of pregnancies and increase the
time between pregnancies
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II. Delay cord clamping: After delivery of the baby more blood cells are transferred from
the placenta to the newly born infant if the umbilical cord is not clamped and ligated
until it stops pulsating. By holding the newborn on the mother’s abdomen, continued
blood flow to the newborn .This increases the body iron content of the infant which
will help to prevent iron deficiency in later infancy
Promote exclusive breastfeeding

The promotion of exclusive breastfeeding for about 6 months followed by breastfeeding with
complementary feeding into the second year of life which contribute to the control of iron
deficiency anemia
Anemia Prevention and control through Continuum of Care
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Maternal mortality
Low Birth Weight
Neonatal and child mortality
Altered development and behavior
Constrained productivity
Pre-conception
Adolescent & NPW
Pregnancy Neonate Infant & children
SHN Focused ANC Delivery IYCN

FP/RH and
Newborn Care Increase iron intake
Increase iron intake Increase Iron intake Exclusive Breast Feeding
Fortification Daily IFA Home fortification of
Weekly IFA De-worming -2nd /3rd Delayed Cord Clamping complementary food -MNP
De-worming &WASH trimester Colostrum feeding ITN for malaria
ITN for malaria ITN for malaria De-worming> 24 months
WASH
Decreased maternal and childhood morbidity and mortality

Improved cognition, growth, and Cycomoter developmental outcomes
Increased work capacity and productivity

Economic development
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Counseling skill exercise
Case Scenarios for role play & group case study
Case 1
Abebech was a married women living in a rural village in your Keble. She was pregnant with her
third child. She had never attended antenatal care. She is illiterate and her husband a farmer;
both have no awareness the need to visit health professional while women got pregnancy. She
considers pregnancy a normal experience for every woman. Her husband also believes that
pregnancy as a woman issue. They were not aware of pregnancy related life threaten
experiences. Her mother- in- law also mostly reassured any event during pregnancy as evil spirit
possession while she insisted to visit health institutions like other pregnant women do.
Around the 2nd months of her pregnancy she started to have headache and repeated vomiting as
the previous two pregnancies of her. She reassured herself that these are normal phenomena.
Her husband also decided to ignore it as the previous pregnancies. Once morning while she was
attending coffee ceremony with her neighbors, she heard about the need to visit the Keble health
post. She was highly motivated and decided to discuss with her husband. During the night she
discussed with her husband what the women team leader explained for her during coffee
ceremony.
At her 3rd months of pregnancy she had her first ANC visit at nearby Keble health post. Since
then she has started to take IFA supplement daily. Due to the multiple tasks at home, she has
forgotten taking the tablet for number of days. However she tried to compensate the missing days
by taking two tablets at a time.
1. What is your assessment (How do you explain Abebech knowledge and motivation
pertaining to ANC)?
2. What are the key issues the health provider focus during counseling session with
Abebech and her husband?
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3. List the focused antenatal care service components should the health service provider
give to Abebech for this visit.
Case 2
Lemlem was an 18 years old women living in rural village near to the health post. She has
completed grade 8. She married a farmer, who able to read and write, last year. She worried
about her condition because she did not see menstruation for two months. She has had vomiting
and nausea every morning since the amenorrhea. One night she explained her condition to her
husband that her doubt about being pregnant with her first child.
She decided to visit health institutions in order to check her situation. She has the knowledge
about pregnancy risks and the need to visit health institutions during pregnancy. Her husband
was also eager about having child. He insisted her to visit the health extension worker at nearby
health post.
Next month, 3rd months of pregnancy, she attended her initial antenatal care visit. When she
started taking medicine every morning following the visit, her mother in-law reassured her not to
take any medicine during pregnancy. The mother-in law explained that taking such drug during
pregnancy will enlarge the fetus and she will encounter difficulty during labor. She was
occasionally having heart burn but get worse since very recently. She doubted it could be from
the IFA tablets.
A week later, when the health extension worker perform home visit to Lemlem’s family,
Lemlem was not taking the daily IFS supplement from about a week.
1. How do you explain Lemlem knowledge and motivation pertaining to IFS?

2. What are the key issues the health extension worker will focus during counseling session
with Lemlem and her husband?
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Case 3
W/ro Alemaz was a married women living in rural village far from the Keble health post. She
was pregnant with her 5th child. She had attended two ANC follow up visits in one of her
pregnancy. Since she has had normal pregnancy experience previously, she hardly believes
the need to visit health institution during pregnancy. She considers visiting health post
during pregnancy as time wastage because of her past uncomplicated pregnancy history.
W/ro Genet, a women team leader inform W/ro Alemaz to visit health post. W/ro Genet
explained for her that she would be able to have a check-up for safety of her baby and her
healthy conditions. However Alemaz refused to do so. She was vaccinated during one of her
previous pregnancy. Currently, the child is moving nicely and she considers no need of
manipulation by health professionals. Following the information from the women team
leader, the health extension worker came to visit W/ro Alemaz family at 5th month of her
pregnancy.
1. How do you explain W/ro Alemaz knowledge and motivation pertaining to ANC?
2. What are the key issues the health extension worker focus during counseling session
with Alemaz?
3. List the focused antenatal care service components should the health extension
worker would give to Alemaz on this session.
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Case 4
Yeshewawork is a 29 year old woman who lives in a small rural village. She is a mother of child
and now she has 5 month pregnancy. She did attend antenatal care neither for her previous
pregnancy period nor during her current pregnancy; and gave birth at home her previous
delivery. From her village it is almost 20 minutes walk to the nearest health post and two hours
walk to the nearest health centre.
Yeshewawork is unmarried and her previous and current pregnancy is out of wedlock. People
around her have ashamed her of being pregnant without formal marriage. She became shy to go
out to public, avoided church, market, health facility & uses unusual time to fetch water from the
nearby spring, prefer to stay roaming around her compound.
Those women attending ANC services from Yeshewawork’s community beliefs & reflects that
the “will of God” and the influence of “evil spirits” that determines the outcome of pregnancy&
health status of an individual. So, the community often chooses to go to traditional healers.
Moreover, women in the community including Yeshewawork do not usually dare and converse
with unknown persons (health professionals delivering the service).
The health extension worker in that Keble heard about Yeshewawork from the women team
leader in that village; and she decided to visit her. The next day HEW observed that
Yeshewawork looks unhappy & tired and doubted that she looks pregnant (big belly).
1. How do you explain Yeshewawork knowledge and motivation pertaining to ANC?

2. What are the key issues the health extension worker focus during counseling session
with Yeshewawork?
3. List the focused antenatal care service components should the health extension
worker would give to Yeshewawork on this session.
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Case 5
Alemitu & Zeynabe are strong HEWs who always strive to reach every corner of the kebele.
The kebele is has challenging topography & harbor about 9000 population. Both are involved in
a number of community development projects in the Keble on top of their routine duties. They
are hardly & infrequently supervised by the HC & the WoHO. There HP less organized,
registers forms and tables are undusted. They have posted encourage performance report in most
of their planned activities. However, they are a bit worried that PW are not coming for ANC
service to their HP. Even though they are proud about the rest HEP program performance, their
performance on ANC program related interventions like TT, IFAS, PMTCT… are unexpectedly
low & they don’t feel comfortable about it. There have been complains that they are not usually
available at HP, informed that the recently inauguration HC at the woreda center provides
marvelous services & lab investigations.
 What are the challenges of Alamitu & Zynabe?

 Indicate the strategies & actions to be taken address these challenge?
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Assessment Questions on Iron Nutrition
1. What are the basic causes of anemia?

a. Inadequate dietary intake of iron and other micronutrients like
b. Excessive RBC destruction
c. Inadequate RBC production
d. Parasites (Hookworm, Malaria, schistosomiasis)
e. All of the above
2. In the clinical work up of anemia what laboratory investigations can be done in a routine
laboratory setup?
a. Hemoglobin determination
b. Stained red blood cell morphology assessment
c. Stool examination for ova of parasites
d. Reticulocyte (RBC) count
e. All of the above
3. Which complementary public health intervention may help to reduce anaemia? Circle the
correct answer.
a. Utilization of Insecticide treated bed nets
b. De-worming medication in school children
c. Improved sanitation
d. All of the above
4. Which once is the following is the national IFA supplementation protocol for pregnant
woman?
a. 1 tablet 30 - 60mg elemental iron & 0.4mg folate tablet per day, at least for 6 months
b. 1 tablet 30 - 60mg elemental iron & 0.4mg folate tablet per day, at least for 2 months
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c. 2 tablet 30 - 60mg elemental iron & 0.4mg folate tablet per day, at least for 2 months
d. 3 tablet 30 - 60mg elemental iron & 0.4mg folate tablet , at least for 3 months
e. Depending on sign & symptoms of anemia
5. Which one of the following important information should be communicated to a client during
prescribing IFA tablet?
a. benefits of taking/adhering the tablet
b. the daily dose – the number the tablet & time to take to be taken
c. the total duration of the supplement
d. the common side effects
e. all
6. At what month should a PW be given de-worming medicine?

a. first 3 months of pregnancy
b. second ANC follow up visit
c. anytime
d. Should not be given at all
7. Which of the following are not signs of anemia?
a. Pallor: paleness inside eyelids, palms of the hands, fingernails and gums.
b. Rapid breathing
c. Fast pulse
d. Low Blood pressure less than 120/80 mmhg
e. All
8. If the pregnant mother is anemic, how will it affect the child she is expecting?
a. Child may be born small than expected (low birth weight).
b. Child will be born healthy.
c. Child will be of heavier weight.
d. Will have no effect.
Say true or false.
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True False
9 Iron deficiency is the most common MND in world
10 Fruits & vegetables are rich sources of heme Iron
A pregnant woman may not need to sleep under ITN if her home is
10 sprayed with Indoor Residual Spray
11 IFA supplement is not recommended for healthy Pregnant women
12 Low Blood Pressure measurement indicates the presence of anaemia
Question for Managers: Imagine that the total number of people in one community is exactly
5,000. Calculate how many pregnant women are likely to be eligible for antenatal care services
in this community in one year (use expected number of pregnant women = 4% of the total
population). (5 points)
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Folic Acid Nutrition
Introduction
Folic acid sometimes referred to as foliate is a water soluble B vitamin (B9). Folic acid is
involved in producing the genetic material called DNA and in numerous other bodily functions.
Folic acid is used for preventing and treating low blood levels of folic acid (folic acid
deficiency), as well as its complications, including “tired blood” (anemia) and the inability of the
bowel to absorb nutrients properly. Folic acid is also used for other conditions commonly
associated with folic acid deficiency, including ulcerative colitis, liver disease, alcoholism, and
kidney dialysis.
Women who are pregnant or might become pregnant need folic acid to prevent miscarriage and
“neural tube defects,” birth defects such as spina bifida that occur when the fetus’s spine and
back don’t close during development. Having a healthy baby means making sure you're healthy,
too. One of the most important things you can do to help prevent serious birth defects in your
baby is to get enough folic acid every day — especially before conception and during early
pregnancy.
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General objectives
At the end of the training, the trainee will be able to describe folic acid, identify deficiency
states, administer preventive and therapeutic supplementations using the national protocol(s)
together with individual or population based intervention strategies to combat folic acid
deficiency.
Specific objectives

 Describe the physiologic functions of folic acid
 Describe folic acid requirements during pregnancy, lactation, infancy and childhood,
adolescence, adults and elderly.
 List the common food sources of folic acid
 Describe the public health significance of folic acid
 Describe folic acid deficiency
 Identify the causes of folic acid deficiency
 Identify clinical manifestations and consequences of folic acid deficiency
 Public health significance of folic acid
 Describe the intervention strategies of folic acid deficency
 Administer folic acid tablets
 Describe indicators for M&E
Food Sources
Foods that are naturally high in folic acid include leafy vegetables (such as spinach, broccoli, and
lettuce), fruits (such as bananas, melons, and lemons), beans, mushrooms, meat (such as beef
liver and kidney), orange juice, and tomato juice.
Folic acid deficiency

Folic acid deficiency is a low level of folic acid in the body. Deficiency of foliate can occur
when the body's need for foliate is increased, when dietary intake of floated is inadequate, or
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when the body excretes (or loses) more foliate than usual. Medications that interfere with the
body's ability to use foliate may also increase the need for this vitamins (1-6).
Adequate foliate should be present in a person's diet. Signs of Foliate deficiency are often subtle.
Anemia is a late finding in foliate deficiency. Megaloblastic anemia is the term given for this
medical condition.
What are the causes of folic acid deficiency?

1. Inadequate intake: Not eating enough foods containing folic acid (foliate) is the most
common cause.
2. Pregnancy causes reserves of folic acid in your body to be used by the growing baby.
You are at risk of becoming low in folic acid during the later stages of pregnancy,
particularly if you do not eat well during pregnancy.
3. Malabsorption some uncommon conditions of the gut may cause poor absorption of folic
acid - for example, celiac disease.
4. Disease conditions : Some blood disorders can lead to a very high turnover of red blood
cells - for example, sickle cell disease and thalassaemia. Normal amounts of folic acid in
the diet may then not be enough and supplements may need to be taken.
Symptoms of folic acid deficiency

 Women with folate deficiency who become pregnant are more likely to give birth to low
birth weight and premature infants, and infants with neural tube defects.
 In infants and children, folate deficiency can slow growth rate.
 In adults, anemia (macrocytic, megaloblastic anemia) can be a sign of advanced folate
deficiency.
Folic acid and pregnancy

Extra folic acid (folate) is advised for at least the first 12 weeks of pregnancy for all women -
even if healthy and have a good diet. If y extra folic acid is taken in early pregnancy there will be
less chance of having a baby born with a spinal cord problem such as spina bifida. It is best to
90
start taking the extra folic acid before becoming pregnant. If the pregnancy is unplanned then
start taking folic acid as soon as pregnancy is known.
Interventions for the prevention and control of folic acid deficiency

Dietary Diversification and Modification
Educate /counsel households and communities to
 Diversify food to include foods rich in folic acid (DGLVs, fruits , cereals and legumes)
 Consume fortified foods (wheat flour)
 Advice soak to germination
 Cook for short time or steam foods to preserve the folic acid in foods
Supplementation
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Provide folic acid tabs or group vitamin supplements particularly to high risk groups (pregnant
and to be pregnant women) near the time of conception and during the first month of pregnancy
to decree the risk of neural tube Defects (NTDs).
For most women the dose is 400 micrograms (0.4 mg) a day according to the national protocol.
 If your risk of having a child with a spinal cord problem is increased then the dose is
higher (5 mg a day - you need a prescription for this higher dose). That is, if:
o You have already had a previous baby with a spinal cord problem.
o You, your partner or a first-degree relative have a spinal cord problem.
o You have celiac disease, diabetes…...
o You are obese - especially if your body mass index (BMI) is 30 or more
Treatment for folic acid deficiency

Treatment is easy and is by taking a tablet of folic acid (foliate) each day. You need to take this
until the anemia is corrected and the folic acid stores in the body are built up (usually for about
four months). You may need advice on diet to stay well and the tablets can be stopped if your
diet improves. You may need to continue with treatment if a poor diet was not the cause of folic
acid deficiency. For example, if you have sickle cell disease you may need a folic acid tablet
each day indefinitely.
Assessment Questions on Folic Acid Nutrition
SN Question/Statement True False

1 Folic acid belongs to the B-group vitamins T
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2 Folic acid is sometimes referred to as foliate T

3 All women critically need folic acid F
4 Folic acid requirement can be fully met from routine diets F
5 Folic acid supplementation should be included as an essential T
component of ante-natal care
6 Spina bifida is one of the negative health effects of folic acid T
deficiency
7 Folic acid deficiency is closely associated with anemia T
8 According to the national protocol, the daily dose of folic acid
supplementation for pregnant women is 400 mg/day
9 For best outcomes folic acid supplementation need to be carried T
out around conception or early gestation
10 Pregnancy depletes folic acid stores of the mother and hence F
undermines additional intake of folic acid naturally or
artificially.
References
1. Pol Merkur Lekarski 26 (152): 136–41. PMID 19388520.
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2. Oakley GP Jr, Adams MJ, Dickinson CM (1996). "More folic acid for everyone, now".
Journal of Nutrition 126 (3): 751S–755S. PMID 8598560.
3. McNulty H (1995). "Folate requirements for health in different population groups".
British Journal of Biomedical Science 52 (2): 110–9. PMID 8520248.
4. Stolzenberg R (1994). "Possible folate deficiency with postsurgical infection". Nutrition
in Clinical Practice 9 (6): 247–50. doi:10.1177/0115426594009006247. PMID 7476802.
5. Pietrzik KF and Thorand B (1997). "Folate economy in pregnancy". Nutrition 13 (11–
12): 975–7. doi:10.1016/S0899-9007(97)00340-7. PMID 9433714.
6. Kelly GS (1998). "Folates: Supplemental forms and therapeutic applications". Altern Med
Rev 3 (3): 208–20. PMID 9630738.
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Zinc Nutrition
Introduction
Zinc deficiency is among the most important causes of morbidity in developing-country settings
including Ethiopia. There is an urgent need to begin to identify areas or regions that are at
increased risk for zinc deficiency and to quantify the number of individuals at risk on a national
scale. To date, there are very limited data available at the country level on the risk of zinc
deficiency. In part, the assessment of zinc status may be hindered by the lack of standard,
accepted guidelines on which indicators to use, how to carry out the assessment, and how to
interpret the results.
General objective
The general objective of the session is to provide the reader or trainee with a comprehensive look
in zinc to ensure a detailed understanding of zinc nutrition and zinc nutrition interventions.
Specific objective
o Describe the physiologic functions of zinc
o Describe the zinc requirements during pregnancy and lactation, infancy and
childhood, adolescence, adults and elderly.
o Identify the common food sources of zinc
o Describe the public health significance of ZiD in Ethiopia
o Identify the causes of ZiDs
o Identify clinical manifestations consequences of zinc deficiency
o Describe the economic consequences of ZiDs
o Describe the methods used to assess ZiDs
o Describe the intervention strategies of ZiDs
o Administer zinc supplements during acute and persistent diarrhea
o Describe indicators for M&E of ZiDs
Public health significance
The significance of zinc in human nutrition and public health was recognized in the 1960s, when
the consumption of diets with low zinc bioavailability was associated with "adolescent
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hypogonadism and nutritional dwarfism" from the Middle East (1). Zinc supplementation studies
proved that zinc deficiency is a worldwide problem (2). It is noteworthy that although newborn,
children, pregnant women and old people are considered the main risk groups, zinc deficiency
may affect the whole population (3). Supplementary zinc benefits children with diarrhea. Zinc
supplementation given during an episode of acute diarrhea reduce the duration and severity of
the episode (4, 5). A meta-analysis of studies evaluating the impact of zinc supplementation to
prevent diarrhea had concluded that zinc supplementation given for 10-14 days lowered the
incidence of diarrhea in the following 2-3 months. It was also estimated that the inclusion of zinc
in the management of diarrhea could prevent 300 000 children from dying each year (6). Zinc
supplementation reduced the mean duration of acute diarrhea by approximately 20%, and
persistent diarrhea by 15–30% implying a significant beneficial impact on the clinical course of
acute and persistent diarrhea (7).
Prevalence of ZiD
Ethiopia is one of the five countries contributing to many of the global child deaths attributable
to zinc deficiency (8). Though the prevalence of zinc deficiency and its consequences are yet to
be established, the limited available reports indicate that zinc deficiency is of public health
concern in Ethiopian children (9). Nearly 44% of the Ethiopian children under-five years old are
stunted (10). Stunting in children is considered as an indirect indicator of zinc nutritional status
(11) as zinc has a particular role in physical growth (12) and stunted children respond to zinc
supplementation with rapid increases in growth (13). Zinc deficiency is not affecting children
only. Pregnant and nonpregnant women are also affected by zinc deficiency. A study by Kassu
and colleagues (14) showed that 66.7% of pregnant women from Gonder, Northwest Ethiopia
were zinc deficient and Haidar and colleagues (15) reported a prevalence rate of 11.3% for
marginal zinc deficiency in lactating women from Metropolitan, Addis Ababa. Recently, high
prevalence rates of zinc deficiency (74%) among women in their third trimester have also been
reported from Southern Ethiopia (9).
Physiologic role of zinc
96
Zinc is an essential trace element for all forms of life. It is involved in a number of metabolic
actions in biological systems including growth, immunity, reduction in morbidity, pregnancy,
reproduction, appetite, protection of structural and functional integrity of biological membranes,
behavior and brain function and gene expression and protein synthesis.
Health Effects of Inadequate and Excess Intakes of Zinc
Consequences of zinc deficiency
The adverse consequences of zinc deficiency include the following:
 Impaired immunocompetence and increased prevalence and incidence of childhood
infections, such as diarrhea and pneumonia, which may result in increased rates of
mortality
 Impaired growth and development of infants, children and adolescents
 Impaired maternal health and pregnancy outcomes (16).
Diarrhea
Zinc supplementation reduces the incidence and duration of acute and persistent diarrhea in
children. Supplemental zinc leads to an 18% reduction in the incidence of diarrhea and a 25%
reduction in diarrheal prevalence (17). It is noteworthy that the impact of supplemental zinc on
reducing diarrheal morbidity is comparable to that observed in programs to improve water
quality, water availability, and excreta disposal (18).
Toxicity from excess intake of zinc

Individuals may be exposed to high intakes of zinc, either through supplemental zinc or by
contact with environmental zinc. Overt toxicity symptoms, such as nausea, vomiting, epigastric
pain, diarrhea, lethargy and fatigue, may occur with acute, high zinc intakes (19). Approximately
225–450 mg zinc is known to produce immediate vomiting in adults. Short-term exposure to
very high levels of contaminant zinc (> 300 ppm) from the improper storage of food or
beverages in galvanized vessels has caused acute gastroenteritis (19). Chronic overdosage of
zinc, in the range of 100–300 mg zinc/day for adults, may induce copper deficiency (20) and
alterations in the immune response and serum lipoprotein levels (21).
Population subgroups at increased risk of zinc deficiency
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Population subgroups with particularly high risks of zinc deficiency can be identified on the
basis of their age and physiologic status or the presence of particular pathologic conditions, as
described in the following sections.
Infants and young children
Theoretical estimates of zinc requirements suggest that exclusively breastfed infants of mothers
with adequate zinc nutriture can satisfy their zinc requirements for the first 5–6 months of life
(22). However, after approximately six months of age, it is unlikely that breastmilk alone can
supply sufficient zinc to meet infants’ needs (22). Therefore, if the introduction of
complementary foods to breastfed infants is delayed until after six months of age, or if the
complementary foods introduced contain inadequate amounts of absorbable zinc, infants will be
at increased risk of zinc deficiency. In many lower-income countries, cereals or starchy roots or
tubers are used as the basis for complementary foods and these foods often have a low content of
total or absorbable zinc. Thus, the complementary diet fails to meet the estimated needs for zinc
(23). Conversely, the premature introduction of other food sources will reduce net zinc
absorption if these foods displace breastmilk, have a lower concentration of absorbable zinc than
breastmilk, and/or contain substances like phytate, which may interfere with absorption of zinc
from breastmilk (24).
Adolescents
Given its role in growth, particularly growth retardation (25), deficiency of zinc can pose serious
physiologic challenges during adolescence. Physiologic requirements for zinc peak during
adolescence at the time of the pubertal growth spurt. Even when the growth spurt has ceased,
adolescents may require additional zinc to replete tissue zinc pools depleted during puberty (26).
Pregnant and lactating women
Increased nutritional demands during pregnancy and lactation predispose women to developing
zinc deficiency. These demands are greater for lactation than for pregnancy (27). Studies have
indicated that iron supplements reduce the absorption of zinc. Where dietary intakes of zinc are
low, supplemental iron, in dosages as low as 60 mg/day, may prevent women from meeting their
increased needs for zinc during pregnancy and lactation (28).
98
Elderly
A number of factors may contribute to the risk of poor zinc nutrition among the elderly,
including reductions in total food intake due to reduced mobility, decreased energy needs, and
possibly depression, and low intakes of zinc-rich foods, such as meat, poultry, or fish due to
poverty or physical disabilities (e.g., swallowing and dental problems).
Low-birth weight infants
Low-birth weight infants have a reduced size at birth, and hence a smaller content of hepatic zinc
metallothionein, which reportedly acts as a zinc reserve in young infants (29). For low-
birthweight infants born prematurely, their body zinc content at birth will be further
compromised because more than two-thirds of the zinc is transferred during the last trimester of
pregnancy (30). Moreover, preterm infants may have reduced absorption because of their
immature gastrointestinal tract. These impairments result in elevated zinc requirements during
the neonatal period.
Malnourished infants and children

The dietary requirements for zinc in malnourished children are markedly higher than those
estimated for healthy children, presumably due to prior zinc depletion, the need for zinc for
tissue synthesis, problems of malabsorption due to changes in the intestinal tract, and possibly
increased losses due to diarrhea.
Zinc deficiency and the Millennium Development Goals
Zinc intervention programs can help to achieve three of the four health related MDGs:
MDG Contribution of zinc
MDG 4: Reduce child Zinc deficiency contributes substantially to diarrhea and
mortality pneumonia, which are the most common causes of death among
children in developing countries. Therefore, intervention to
enhance the zinc intake of children is a useful strategy to reducing
child mortality rates.
MDG 5: Reduce maternal Zinc deficiency can result in protracted labor, which increases
mortality maternal mortality rates and adversely affects the fetus. Therefore,
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improving the zinc intake of women before and during pregnancy

may help to reduce maternal mortality and benefit infant growth
and survival.
MDG 6: Combat There is evidence that zinc supplementation may reduce the
HIV/AIDS, malaria, and severity of malaria. In addition, zinc supplementation reduces the
other diseases risk of both diarrhea and pneumonia, which frequently complicate
HIV infections. Therefore, zinc supplementation may reduce
fatalities from these diseases.
Food sources and daily requirements of zinc for various age groups
Dietary sources of zinc
The rich sources of zinc are diets of animal origin, particularly those containing lean red meat,
and plant-based diets including whole-grain cereals, pulses and legumes. Among the modest
sources of zinc are fish, roots and tubers, green leafy vegetables and fruits. The absorption of
zinc depends on a number of dietary factors as potential enhancers or antagonists. Soluble low
molecular weight organic substances such as amino acids and hydroxyl acids facilitate zinc
absorption and organic compounds such as phytates, which form stable and poorly soluble
complexes with zinc, impair absorption.
Recommended Dietary Allowances (RDA)
The IZiNCG derived RDAs for dietary zinc intakes are presented in the following table for each
sex and life-stage group.
Table x: Revised recommended dietary allowances (RDAs) for zinc, by life stage and diet type,
as suggested by IZiNCG (International Zinc Nutrition Consultative Group).
Age Sex Reference RDA for zinc as suggested by IZiNCG (mg/d)
body weight Mixed or refined Unrefined cereal based
(kg) vegetarian diets diets
6-11 months M, F 9 4 5
1 – 3 yrs M, F 12 3 3
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4 – 8 yrs M, F 21 4 5
9 – 13 yrs M, F 38 6 9
14 – 18 yrs M 64 10 14
14 – 18 yrs F 56 9 11
Pregnancy F - 11 15
Lactation F - 10 11
>= 19 yrs M 65 13 19
>= 19 yrs F 55 8 9
Pregnancy F - 10 13
Lactation F - 9 10
Causes of zinc deficiency and groups at high risk
Zinc deficiency causes are classified in to two namely metabolic or genetic malfunctions and
nutrition causes. Alternatively, development of zinc deficiency can be attributed to at least five
general causes occurring either in isolation or in combination. These include inadequate intake,
increased requirements, malabsorption, increased losses and impaired utilization.
Inadequate intake
Inadequate dietary intake of absorbable zinc is likely to be the primary cause of zinc deficiency
in most situations. This may result from a combination of low total dietary intake, heavy reliance
on foods with low zinc content and/or with zinc that is poorly absorbable. Several estimates of
dietary zinc intakes indicate that inadequacy of intakes is widespread, occurring across a wide
variety of geographical areas and dietary patterns.
Increased requirements
Low intakes of absorbable zinc are further exacerbated by physiologic or pathological conditions
that lead to greater requirements for zinc (per kg body weight). The physiologic and pathologic
conditions associated with elevated zinc requirements place individuals in these subgroups at an
increased risk of zinc deficiency.
Malabsorption
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Malabsorption of zinc may result from a number of different conditions. For example,
acrodermatitis enteropathica is a rare genetic defect that specifically affects zinc absorption.
Certain disease states, such as malabsorption syndromes and inflammatory diseases of the bowel,
may result in poor absorption and/or losses of zinc from the body. Hence, these conditions may
precipitate secondary zinc deficiency states, particularly in the presence of marginal dietary zinc
intakes.
Increased losses
Certain disease states or conditions that result in increased losses of endogenous zinc from the
body include chronic renal disease, trauma, prolonged bed rest, and other conditions associated
with bone or muscle atrophy. As the secretion and re-absorption of endogenous zinc in the
intestine are key mechanisms in maintaining zinc homeostasis, conditions that perturb intestinal
function or the integrity of the intestinal mucosa may have profound effects on the body’s ability
to maintain zinc status. For example, fecal zinc excretion is elevated during acute diarrhea.
Because diarrheal disease is a common infection in many lower-income countries including
Ethiopia, the possible effects of diarrhea on endogenous zinc depletion worth addressing. Not
only does zinc deficiency appear to augment the susceptibility to, and severity of, childhood
diarrhea, but increased losses of endogenous zinc that occur during diarrhea may further deplete
body zinc and propagate a cycle of diarrhea and further zinc depletion.
Impaired utilization
Impaired utilization of zinc may occur as a result of administration of certain drugs (e.g.,
ethambutol, halogenated 8-hydroxyquinolines, penacillamine) that chelate zinc systemically and
make it less available for use by tissues. Presence of infection in general results in sequestration
of zinc in the liver and decreased circulating levels of zinc, which will reduce the availability of
zinc to other tissues.
Population level strategies for prevention and control of zinc deficiencies
The three major categories of nutrition-focused zinc intervention strategies are supplementation,
fortification, and dietary diversification/modification.
Supplementation
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Supplementation refers to the provision of additional nutrients, usually in the form of some
chemical (or pharmaceutical) compound, rather than in food. Supplementation programs are
particularly useful for targeting vulnerable population subgroups whose nutritional status needs
to be improved within a relatively short time period. For this reason, such programs are often
viewed as short-term strategies.
Zinc supplementation as adjunctive therapy for diarrhea
Results of several randomized clinical trials have shown consistently that zinc supplementation
reduces the duration and severity of diarrhea in children. Moreover, zinc is excessive lost in the
feces during diarrhea episode. For both reasons, it seems worthwhile to include zinc supplements
in the treatment regimen of children with diarrhea, particularly in settings where there is an
elevated risk of zinc deficiency in the population. It is possible that diarrhea or other conditions
that affect intestinal health increase intestinal losses of endogenous zinc, thus increasing zinc
requirements. Therefore, it is also conceivable that other programs to prevent or treat diarrhea
may reduce the risk of zinc deficiency by decreasing excessive losses of zinc via the intestine.
Fortification
Food fortification is the addition of nutrients to commonly eaten foods, beverages or condiments
at levels higher than those found in the original food, with the goal of improving the quality of
the diet. The contribution of fortification programs to the virtual elimination of micronutrient
deficiencies is widely acknowledged. Fortification is increasingly recognized as an effective
strategy to improve the micronutrient status of the population. Relative to other approaches,
fortification is thought to be the most cost-effective means of overcoming micronutrient
malnutrition.
Dietary diversification/modification
Strategies to diversify or modify the diet aim to enhance the access to, and utilization of, foods
with a high content of absorbable zinc throughout the year. These strategies can involve changes
in food production practices, food selection patterns, and traditional household methods for
preparing and processing indigenous foods. Dietary diversification/modification represents a
sustainable, economically feasible, and culturally acceptable approach that may be used to
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improve the adequacy of dietary intakes of several micronutrients simultaneously with limited
risk of antagonistic interactions.
Dietary diversification/modification strategies encompass a wide variety of approaches, but all
are generally regarded as long-term strategies in terms of development, implementation, and
potential for impact. They are often described as a sustainable approach because the process
empowers individuals and households to take ultimate responsibility over the quality of their diet
through self-production or acquisition of nutrient-rich foods and informed consumption choices.
Because impacts are likely to be achieved only in the long term, however, these strategies should
be implemented jointly with other shorter-term approaches, such as supplementation and
fortification, as required, to address the needs of specific target groups. Diets in Ethiopia are
often based predominantly on cereals and legumes or starchy roots and tubers, while
consumption of foods with a high content of readily absorbable zinc, such as meat, poultry, and
fish, is often limited because of economic, cultural and/or religious constraints. Dietary strategies
aimed at improving intakes of absorbable zinc by increasing the total intake of zinc and
enhancing zinc absorption by altering the levels of food components that modify zinc absorption
are essential.
Household food processing methods to increase absorbable zinc in the diet
At the household level, reduction in the phytate content of the diet can be achieved in two ways:
 Inducing activity of plant-associated phytase (myo-inositol hexaphosphate
phosphohydrolases; EC 3.1.3.26) and the enzymatic hydrolysis of phytic acid (myo-
inositol hexaphosphate) through germination, fermentation and soaking
 Diffusion of water-soluble phytate through soaking.
Germination
Most cereal grains and legumes contain some endogenous phytase. Germination increases the
activity of endogenous phytases in cereals and legumes as a result of de novo synthesis or activa-
tion of the enzyme. After 2 to 3 days of germination, the hexa-inositol phosphate content of
cereals is reduced by 13–53% in cereals and 23–53% in legumes. Soaking also activates
endogenous cereal phytases. Flours prepared from germinated grains can be added to
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ungerminated flours to promote phytate hydrolysis during food processing. The result is a
porridge with higher energy and nutrient density and a lower phytate:zinc molar ratio.
Fermentation
Fermentation can induce phytate hydrolysis via the action of microbial phytases (EC.3.1.3.8),
which can originate either from the microflora on the surface of cereals and legumes or from a
starter culture inoculate. Reductions of about 50% of phytate appear to be achievable through
fermentation.
Soaking
Soaking can reduce the phytate content of certain cereals (e.g., maize and rice) and most legumes
because their phytate is stored in a relatively water-soluble form, such as sodium and potassium
phytate, and hence can be removed by diffusion. Removal of water-soluble phytate can be
achieved more effectively by soaking legume flours rather than whole legumes. Reductions in
IP5 + IP6 content ranging from 51–57% have been achieved, when maize flour is soaked and the
excess water is removed by decanting.
Assessment methods for ZiDs

Assessment of zinc status in individuals will find application most often in clinical settings
among those seeking medical attention for a health condition. In the context of lower-income
countries, it is likely that diagnosis of isolated zinc deficiency will be rare, but rather will be
found in association with a variety of health conditions for which primary treatment is being
sought. For example, children presenting with severe malnutrition, diarrheal infections, or
respiratory illnesses may be zinc depleted, in which case usual treatment strategies should ensure
correction of the zinc deficiency state. As with other nutrients, a number of general techniques
can be used to estimate the risk of zinc deficiency in individuals or in populations. These are
categorized as the following:
1. The presence or prevalence of clinical outcomes of zinc deficiency (e.g., stunting,
diarrhea), or other ecologic factors associated with risk of zinc deficiency or risk of
inadequate zinc intakes.
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2. Assessment of the adequacy of dietary zinc intakes in relation to theoretical requirements

for absorbed zinc.
3. Biochemical measures of zinc concentration, activity of zinc-dependent enzymes, or other
zinc-responsive biocomponents in biologic fluids or tissues, assessed in comparison to
reference values or established cutoffs.
4. Measurement of functional responses following the intake of adequate supplemental zinc.
Monitoring and evaluation of ZiD prevention and control programs
Monitoring and evaluation are essential components of intervention programs and thus should be
integrated into the overall program strategy development. Monitoring and evaluation are key to
ensuring that programs are implemented as planned, that they are reaching their target population
in a cost-effective manner, and that they are having the expected impact. Monitoring implies the
continuous collection and review of information on project implementation activities, coverage
and use, which can be used to re-design or re-orient the program and to strengthen its
implementation and the quality of service delivery in an ongoing fashion. A monitoring system
can be used to assess service provision (availability, accessibility, and quality), utilization,
coverage, and cost. Ideally, the following three types of indicators would be used together to
obtain the best estimate of the risk of zinc deficiency in a population and to identify specific
subgroups with elevated risk. These recommended indicators should be applied for assessment of
zinc status and to indicate the need for zinc interventions.
Biochemical Indicators
Biochemical indicators may be used as an objective and quantitative means of assessing the zinc
status of a population. The recommended biochemical indicator is the prevalence of serum zinc
concentration less than the age/sex/time of day-specific cutoffs. The risk of zinc deficiency is
considered to be elevated and of public health concern when the prevalence of low serum zinc
concentrations is greater than 20%. In this case, an intervention to improve population zinc status
is recommended.
Dietary Indicators
The assessment of dietary zinc intakes at the population level is recommended for several
reasons. It would provide information on the dietary patterns that may be associated with zinc
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adequacy or inadequacy and it can help to identify populations or subpopulations at elevated risk
for inadequate zinc intakes. For dietary indicators, the prevalence (or probability) of zinc intakes
below the appropriate estimated average requirement (EAR) should be used, as determined from
quantitative dietary intake assessments. Where the prevalence of inadequate intakes of zinc is
greater than 25%, the risk of zinc deficiency is considered to be elevated.
Stunting
Previous studies indicate that stunted children respond to zinc supplementation with increased
growth. When the prevalence of low height-for-age is 20% or more, the prevalence of zinc
deficiency may also be elevated.
Table x: Summary of indicators for the assessment of zinc status in a population.

Indicator category Measurement variable Variable unit criteria Recommended
cutoff to identify an
elevated risk of zinc
deficiency
Suggestive Rates of stunting among Length-for-age or > 20%
evidence (existing children < 5 years height-for-age Z-score <
health/ecologic Absorbable zinc content –2
information) in the food supply, based Estimated percent of > 25%
on national Food Balance population with access
Sheets to absorbable zinc in
food supply below the
weighted mean
physiologic requirement
Dietary Adequacy of population Probability approach: > 25% of population
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zinc intakes based on Probability of zinc at risk of inadequate

dietary surveys intakes below the EAR intakes
EAR cut-point method:
Proportion of individuals > 25% of population
with intakes below the with inadequate
EAR intakes
Biochemical Plasma/serum zinc prevalence of low > 20% below cut-off
concentration concentrations compared
to appropriate age, sex,
fasting status, and time
of day cut-off
Response to zinc Change in weight-for-age Effect size compared to > 0.2 SD units; p <
supplementation or height-for-age Z-score appropriate control .05
among a representative group
sample of children
Impact evaluation
Evaluation seeks to determine the extent to which the project goals and objectives have been
achieved and whether the intervention is having the expected impact on the targeted population.
The prevalence of low serum zinc and inadequate zinc intakes may be used to evaluate the
impact of zinc nutrition interventions on the target population’s zinc status.
Table x: Examples of indicators that can be used for different evaluation purposes and different
types of interventions for the control of zinc deficiency.
Objective of Types of interventions for the control of zinc deficiency
evaluation Supplementation Fortification Dietary modification
(Education, home processing and
production interventions)
Provision and Number of Number of food Number of education sessions
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availability of programs or facil- products fortified provided

services ities offering Number of markets Number of inputs distributed to
supplements with fortified products promote small animal husbandry
Number of available or fish ponds
supplements
available for target
population
Accessibility % of the population % of the population % of the population who could be
of services living at reasonable with access to markets reached by education or
distance from where fortified distribution of inputs
distribution point products are available
Quality of % staff trained in Quality control of Quality of the education,
services intervention product: level of communication, behavior change:
(importance of zinc, fortification, stability Number of staff trained, duration
vulnerable groups, during storage of training, knowledge of staff
supplementation Duration and intensity of
dosage, schedule) education sessions
Quality of inputs provided,
amount and quality of education
provided with production
intervention
Utilization of Number of Number of families Number of families who have
services by individuals coming who purchase fortified heard messages or attended
targeted popu- to receive supple- product in sufficient education sessions
lation ments amounts Number of families who have
Number of individuals received and used production
who receive fortified inputs
product with regular
109
frequency
Coverage of % at-risk % of at-risk % of at-risk population who have
the targeted individuals who population consuming received education and other
population take supplements sufficient amounts inputs
with recommended and right frequency of
frequency fortified product
Impact on the Assessment of Amounts and % of targeted population with
targeted changes in frequency of intake of increased knowledge
population biochemical, fortified product by % of targeted population who
clinical, functional targeted individuals adopted recommended practices
indicators of zinc Changes in or production activity
deficiency in biochemical, clinical, Changes in amount of food
targeted individuals functional indicators (animals, fish) produced and/or
of zinc deficiency in consumed
targeted population Changes in amount and frequency
of intake of sources of
bioavailable zinc
Changes in biochemical, clinical,
functional indicators of zinc
deficiency
Zinc supplementation in the treatment of diarrheal diseases

The following indicators can be used for M and E of zinc supplementation in the treatment of
diarrheal disease.
Process indicators
• % of health care staff trained in the management of diarrhea including new ORS and 10-
14 day treatment with zinc
• Zinc and new ORS available at the central storage facility
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• % of health facilities, storage facilities and private sector outlets with ORS and zinc
available
• % of facilities with the revised treatment guidelines
• % of cases of diarrhea in children under five prescribed of sold zinc and the new ORS
Outcome indicators
• % of cases of diarrhea in children under five treated with a course of zinc
supplementation for 10-14 days, in addition to ORS
Knowledge, attitudes and practices indicators
• % of caregivers who are aware that zinc is an appropriate treatment for diarrheal disease
• % of medical providers who believe that zinc is an effective treatment for diarrhea in
children under the age of five
Linkage between zinc nutrition and health and other nutrition sensitive sectors
To reach the specific target groups with a particular intervention, such as zinc supplements or
educational messages to promote dietary modification, an appropriate delivery mechanism must
be identified. For example, infants might be reached through well-baby clinics or growth
monitoring programs if these have suitably high population coverage. Educational messages for
pregnant and lactating women might be delivered through women development army (WDA) or
antenatal clinics. Obviously, if a successful micronutrient intervention program is already in
place, it might be most prudent to link zinc activities with the existing program.
Health sector
Interventions that are prime opportunities for zinc intervention in the health sector include iron
supplementation programs for women, which could easily add a zinc supplementation
component. Similarly, existing food fortification programs could add zinc as one of the nutrients
included in the fortification process. Education interventions to promote increased zinc intake or
the use of home processing techniques to increase zinc absorption can be included in any nutri-
tion or health education program curriculum. It is particularly relevant in the context of programs
promoting exclusive breastfeeding and optimal complementary feeding practices for young
infants. In situations where effective prenatal care programs are in place and bring mothers in
111
frequent contact with the health system, increased zinc intake could also be promoted among
mothers and their families. Although the immunization schedule has the advantage of starting
very soon after birth, thus allowing an early first contact of the infant with the health system, the
immunization schedule does not allow for providing a supply of zinc supplements monthly. The
same is true for other interventions that bring mothers to the health center infrequently, such as
vitamin A supplementation, which is repeated only once every 6 months. For zinc
supplementation, monthly contacts with the health services, such as to receive a monthly supply
of supplements, would be ideal, although bi-monthly provision of zinc supplements could be
similarly effective and even more efficient by reducing the burden on health centers imposed by
monthly delivery.
Table x: Opportunities for linking interventions to control zinc deficiency with existing maternal
and child health and nutrition programs.
Maternal and child Opportunities for linking with interventions to control zinc deficiency
health and nutrition
programs
Supplementation Fortification Dietary
diversification/
modification
Child health and nutrition (prevention)
Malaria control (bed Contacts with health combined education

nets, education, services may be too programs*
prophylaxis drugs) infrequent and
irregular*
Immunization
may allow early
exposure to health education as part of
Growth services during first growth monitoring***
monitoring/well-baby few months of life**
clinic
good vehicle if
once/month***
Education and behavior change interventions

Promotion of may allow early promotion of
112
exclusive exposure to health exclusive

breastfeeding services** excellent for breastfeeding is an
promoting the use of excellent food-based
Education on timely because of processed, fortified strategy for children
complementary increased needs of complementary foods, 0–6 months****
feeding practices infants from 6 months if available excellent for the
of age** locally**** promotion of home
Hygiene, prevention may be too infrequent preparation and
of illnesses or irregular* processing techniques
to increase zinc
Control and treatment may be too infrequent content and
of infectious diseases or irregular for absorption****
prophylaxis* education regarding
opportunity to include fermentation
zinc in treatment (improved zinc
regime*** absorption/diarrhea
Deworming prevention)*
may be too infrequent

or irregular; possible
to provide shorter
Vitamin A capsules term supply (e.g., 1–2
distribution months)* excellent opportunity
to fortify with zinc if
Iron supplementation food donations are
too infrequent: every fortified locally****
6 months*
Food distribution
programs excellent: zinc can be
included in supple-
ment****
good opportunity if
once per month***
Child health (curative)

Treatment of ARI opportunity to treat
severe zinc
Treatment of diarrhea deficiency*
Treatment of severe treatment should

PEM include zinc***
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opportunity to treat
severe zinc
deficiency***
Maternal health, nutrition and care
Prenatal care timely, but may be if contacts are

infrequent** frequent enough, can
Prevention and be a good vehicle for
control of iron- supplementation education**
deficiency anemia programs can include
(supplementation) zinc****
Family planning,
reproductive health may be too irregular
and infrequent*
Vitamin A
supplementation too infrequent: every
6 months; possible to can be a good vehicle
provide shorter term for distribution of
School supply (e.g., 1-2 fortified foods**** can increase zinc
girls/adolescent girls months)* intake, depending on
nutrition and health foods provided and
programs depends on the nature menu****
of the
School feeding program*
programs (food for
education) good vehicle for
supplementation****
Other
Food fortification (of zinc can be
staples) included****
depending on
AIDS prevention frequency of
exposure* opportunity to
Agriculture programs promote home
(e.g., promotion of production and intake
animal products [fish of animal prod-
ponds, small ucts****
livestock]) combined
with education
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One asterisk (*) represents a possible opportunity, but one that is not likely to be the most
effective
Two asterisks (**) represent an opportunity that has limited usefulness because the frequency of
exposure to the intervention is too limited or irregular.
Three asterisks (***) are given to interventions that theoretically bring mothers to the health
center on a monthly basis, but high compliance to the monthly schedule would need to be
achieved for the intervention to be an optimal approach for zinc supplementation.
Four asterisks (****) are given to interventions that are prime opportunities for the particular
zinc intervention considered.
Agriculture sector
Agricultural programs combining increased production of animal products and education to pro-
mote greater intake by vulnerable groups are the ideal mechanisms to target multiple
micronutrients, including zinc, at little additional cost. Several strategies can be used to increase
the zinc content of plant-based staples. These include the use of zinc fertilizers, plant breeding
and genetic modification techniques. When zinc fertilizers are applied to zinc-deficient soil, zinc-
containing fertilizers can increase the zinc content of cereal grains. Plant breeding can produce
new cereal varieties that have higher grain zinc concentrations than pre-existing wild strains and
that better tolerate zinc-deficient soils. Genetic engineering has recently been employed to
produce rice grains containing an increased content of iron as well as a significant amount of β-
carotene in the endosperm. This technique could be applied to enhance the zinc content of cereal
grains. Genetic modifications can also be used to incorporate phytase enzymes (myo-inositol
hexaphosphate phosphohydrolases) into staple crops. This would dramatically decrease their
phytic acid (myo-inositol hexa phosphate, IP6) content; phytase enzyme hydrolyzes phosphate
groups from the inositol ring to yield intermediate myo-inositol phosphates (bi-, tri-, tetra-, and
penta-phosphates). The myo-inositol phosphates with less than five phosphate groups (i.e., IP-4
to IP-1) do not inhibit zinc absorption. Genetic modification can also be used to increase the
level of promoters of zinc absorption in plant-based staples.
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Similarly, the zinc content of diets can be increased through small-livestock husbandry,
aquaculture, and production of other indigenous zinc-rich foods can be promoted, where feasible.
Education and behavior change strategies can also be used, either alone or in combination with
production activities, to promote greater intake of zinc-rich foods. Production of a variety of
small livestock (e.g. poultry and small ruminants) can be promoted to increase the availability of
these zinc-rich foods within a community or household. Education is key to the success of these
interventions, and efforts must be made to ensure that the livestock produced is not entirely sold
for cash. Some of the food that is produced should be reserved for household consumption and
targeted to those household members at higher risk of inadequate zinc intake. Regrettably,
evidence from Ethiopia suggests that the increases in household income achieved through
increased livestock production do not necessarily translate into improved dietary quality among
producer households. Nutrition education and behavior change interventions seem to be essential
in achieving nutritional impact because the increases in income may be invested in basic
necessities or consumer goods other than food. Inclusion of fish (whole) in the diet can increase
the content and density of zinc and other nutrients. As was described for small livestock
production, promotion of aquaculture must also include educational efforts to ensure that
increased production translates into greater intakes by vulnerable groups. In Ethiopia, more
information is required on the content of zinc and zinc absorption modifiers in local indigenous
foods to identify those that might be suitable sources of absorbable zinc.
Assessment questions for Zinc Nutrition

Choose the best answer.
116
1. Deficiency of which of the following minerals is associated with retarded growth and
sexual development in children?
a. Iron
b. Zinc
c. Iodine
d. Vitamin A
2. Which of the following represents the most reliable dietary source of zinc?
a. Nuts and oils
b. Milk and yogurt
c. Fruits and vegetables
d. Meats and whole-grain cereals
3. Which of the following are vulnerable groups for zinc deficiency?
a. Newborn and children
b. Pregnant women
c. Elderly
d. All of the above
4. Zinc supplementation given during an episode of acute diarrhea
a. Reduce the duration of the episode
b. Reduce the severity of the episode
c. A and B
d. None of the above
5. The limited available reports indicate that zinc deficiency is of public health concern in
children and mothers from Ethiopia.
a. False
b. True
6. One of the following is not an adverse consequence of zinc deficiency?
a. Impaired immunocompetence
b. Impaired growth and development of infants, children and adolescents
c. Impaired maternal health and pregnancy outcomes
117
d. None
7. Which of the following is not a cause of zinc deficiency?
a. Inadequate intake
b. Increased requirements
c. Malabsorption, increased losses and impaired utilization
d. None
8. Which of the following are population level strategies for prevention and control of zinc
deficiencies?
a. Supplementation
b. Fortification
c. Dietary diversification/modification
d. All
9. Which of the following is not a household food processing method to increase absorbable
zinc in the diet?
a. Germination
b. Fermentation
c. Soaking
d. None
10. Which of the following indicators cannot be used as a process indicator for M and E of
zinc supplementation in the treatment of diarrheal diseases?
a. % of health care staff trained in the management of diarrhea including new ORS
and 10-14 day treatment with zinc
b. % of health facilities and storage facilities with ORS and zinc available
c. % of facilities with the revised treatment guidelines
d. % of cases of diarrhea in children under five treated with a course of zinc
supplementation for 10-14 days, in addition to ORS
11. Agricultural strategies to increase the zinc content of plant-based staples include
a. Use of zinc fertilizers
b. Plant breeding
118
c. Genetic modification techniques

d. All
12. The zinc content of diets can be increased through
a. Small-livestock husbandry
b. Aquaculture
c. Production of indigenous zinc-rich foods
d. All
119
References
1. Prasad AS, Schalert AR, Miale A, Farid Z, Sandstead HH (1963). Zinc and iron
deficiencies in male subjects with dwarfism and hypogonadism but without
ancylostomiasis and schistomiasis or severe anemia. Am J Clin Nutr 12, 437-444.
2. Rue1 MT, Rivera JA, Santizo MC, Lonnerdal B, Brown KH. Impact of zinc
supplementation on morbidity from diarrhea and respiratory infections among rural
Guatemalan children. Pediatrics 1997; 99: 808-13.
3. Maria J Salgueiro; Marcela Zubillaga; Alexis Lysionek; Maria I. Sarabia; Ricardo Care;
Tombs De Paoli; Alfiedo Hager; Ricardo Weill and Jose Boccio. Zinc as an essential
micro nutrient: A REVIEW. Nutrition Research, Vol. 20, No. 5, pp. 737-755. 2000.
4. Sazawal S, Black RE, Bhan MK, Jalla S, Bhandari N, Sinha A, Majumdar S. Zinc
supplementation reduces the incidence of persistent diarrhea and dysentery among low
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5. Rue1 MT, Rivera JA, Santizo MC, Lonnerdal B, Brown KH. Impact of zinc
supplementation on morbidity from diarrhea and respiratory infections among rural
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6. WHO. Technical updates of the guidelines on the Integrated Management of Childhood
Illness (IMCI): Evidence and recommendations for further adaptations. Department of
Child and Adolescent Health and Development (CAH). World Health Organization, 20
Avenue Appia 1211 Geneva 27. Switzerland, 2005.
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Zinc Supplementation in Acute and Persistent Diarrhea: A Systematic Review. PLoS
ONE 5(4).
8. Walker CLF, Ezzati M, Black RE (2009). Global and regional child mortality and burden
of disease attributable to zinc deficiency. Eur J Clin Nutr 63, 591-597.
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Westcott J, Krebs NF, Hambidge KM (2009). Zinc status and cognitive function of
pregnant women in Southern Ethiopia. Eur J Clin Nutr 63, 916-918.
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10. EDHS (2011). Ethiopia Demographic and Health Survey 2005. Addis Ababa: Central
Statistical Agency.
11. Hotz C, Brown K (2004). Assessment of the risk of zinc deficiency in populations and
options for its control. Food Nutr Bull 25, S99-S199.
12. Gibson RS, Manger MS, Krittaphol W, Pongcharoen T, Gowachirapant S, Bailey KB,
Winichagoon P (2007). Does zinc deficiency play a role in stunting among primary
school children in NE Thailand? Br J Nutr 97, 167-175.
13. Umeta M, West CE, Haidar J, Deurenberg P, Hautvast, JG (2000). Zinc supplementation
and stunted infants in Ethiopia: a randomised controlled trial. Lancet 355, 2021-2026.
14. Kassu A, Yabutani T, Mulu A, Tessema B, Ota F (2008). Serum zinc, copper, selenium,
calcium, and magnesium levels in pregnant and non-pregnant women in Gondar,
Northwest Ethiopia. Biol Trace Elem Res 122, 97-106.
15. Haidar J, Umeta M, Kogi-Makau W (2005). Effect of iron supplementation on serum zinc
status of lactating women in Addis Ababa, Ethiopia. East Afr Med J 82, 349-352.
16. Food and Nutrition Bulletin, vol. 25, no. 1 (supplement 2) © 2004, The United Nations
University.
17. Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, Khatun F, Martorell
R, Ninh NX, Penny ME, Rosado JL, Roy SK, Ruel M, Sazawal S, Shankar A (Zinc
Investigators’ Collaborative Group). Prevention of diarrhea and pneumonia by zinc
supplementation in children in developing countries: pooled analysis of randomized
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18. Esrey SA, Feachem RG, Hughes JM. Interventions for the control of diarrheal diseases
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20. Prasad AS, Brewer GJ, Schoomaker EB, Rabbani P. Hypocupremia induced by zinc
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21. Chandra RK. Excessive intake of zinc impairs immune responses. JAMA 1984;
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Blended Integrated Nutrition Learning Module (BINLM) By ChimdesaJ.

Blended Integrated Nutrition Learning Module (BINLM)

Micronutrient Impact through programmes

23% reduction in under-five mortality rates

6% reduction in child mortality

Iodine 13-point increase in IQ

Iron 20% reduction in maternal mortality

Figure 1: Consequences of vitamin and mineral deficiencies during the life-cycle.

Low Birth Weight

 Describe the significance and physiological role of vitamin A

 Explain supportive activities in the prevention and control of VAD

Dietary intakes of retinol for children in international units:

Age 0 – 6 mo 7– 12 1 – 3 yr 4 – 8 yr 9 – 13 yr 14 – 18yr 14 – 18yr

RDA 1333 IU 1667 IU 1000 IU 1333 IU 2000 IU 3000 IU 2333 IU

Sources of Vitamin A (3, 4)

Clinical manifestations of Vitamin A deficiency

Prevention and Control of Vitamin A Deficiency

Vitamin therapeutic supplementation: For children with severe acute malnutrition

Vitamin therapeutic supplementation: For children with Xerophthalmia or Measles

In case of choking for children:

Management of adverse events

Only occurs if child takes

Only occurs if child takes

Promote and Support Optimal Breast Feeding

Vitamin A in the Breast milk of Infants 0-6 months

Age of Child Sources of Vitamin A

Day 14 to six Mature breastmilk in well-nourished mothers contains an average of 250

Food Diversification for Vitamin A

Monitoring and Evaluation

Cut-off values for public health significance of VAD (11).

Indicator Prevalence cut-off values for public

Serum or plasma retinol ≤ 1.9: No public health problem

Identification of Vitamin A Deficiency in Population

Vitamin A deficiency sign/symptoms WHO cut-off levels

Checklist for administer vitamin A following safety measures

A. In case of choking for infants:

B. In case of choking for children:

Assessment questions for the vitamin A

1. Which of the following vitamin A form is found in plants?

B. Required for proper immune responses

7. Which of the following could precipitate VAD?

1. Project Health Child: Overview of Vitamin A, Training Module

3. National Guideline for Control and Prevention of Micronutrient Deficiencies, FMOH,

 Describe the methods used to assess IDDs

Physiologic role of iodine

Iodine is an essential micronutrient for the biosynthesis of thyroid hormones, triiodothyronine

Health Effects of Inadequate and Excess Intakes of Iodine

Consequences of iodine deficiency disorders

In pregnant women, fetuses In infants, children and In adults

IDD and MDGs

MDG goal Relevance of iodine nutrition

Development stages most at risk for IDD

Pregnant women / Prenatal development

Lactating women / Newborns and infants

Children and adolescents

Human and economic loss due to IDD

Dietary sources of iodine

Recommended Dietary Allowances (RDA)

Life stage Recommended Dietary Allowances (RDA) for Iodine

Toxicity from excess intake of iodine

Tolerable Upper Limit (UL)

Age group UL (µg/day)

Major causes or risk factors of micronutrient deficiencies