Tackling Micronutrient Deficiencies: Causes and Solutions Presentation

Tackling Micronutrient Deficiencies:
Causes and solutions
Wan Abdul Manan Wan Muda,
for Wan Abdul Manan Wan Muda, Jomo KS and
Tan Zhai Gen
1st October 2019

Micronutrient Nutrition
• Micronutrients – also known as vitamins and minerals –
are essential components of a high-quality diet and have
a profound impact on health. Required only in tiny
quantities, however they are essential building blocks of
healthy brains, bones and bodies.
• Micronutrient deficiencies are often referred to as
‘hidden hunger’ because they develop gradually over
time, their devastating impact not seen until irreversible
damage has been done
• Millions of children suffer from stunted growth,
cognitive delays, weakened immunity and disease as a
result of micronutrient deficiencies.
+ Tackling Micronutrient Deficiencies: Causes and solutions

Common Micronutrient Deficiencies
• Iodine deficiency - can lead brain damage in children,
particularly, during fetal development and in the first few
years of a child’s life.
• Vitamin A deficiency - weakens the immune system and
increases a child’s risk of contracting and dying from
infections like measles, and diarrhoeal illnesses.
• Iron deficiency - anemia, risk of hemorrhage during
childbirth can lead to maternal deaths. Risk of babies born
prematurely, vulnerable to infections, learning disabilities,
and delayed development.
• Zinc deficiency - impairs immune function and risk of
gastrointestinal infections which can lead to mortal
diarrhea.
• Calcium, vitamin D, and folate deficiencies are of
concern during pregnancy, risk of health complications for
both the mother and growing baby.

Micronutrients intakeSource: Bee Koon P et al. (2013).Nutritional status and dietary intakes of children aged 6 months to 12 years: findings of the
Nutrition Survey of Malaysian Children (SEANUTS Malaysia) British Journal of Nutrition, 110, S21–S35
doi:10.1017/S0007114513002092

Micronutrient Requirements
• The dietary requirement for a given micronutrient is
defined as the level which meets criteria for being
adequate to minimise risk of nutrient deficit or excessive
intake.
• Nutrient requirements vary between individuals based on
a range of factors, including age, sex, physical activity
levels, and can be higher during periods of pregnancy,
lactation, and disease.
• The UN Food and Agricultural Organization (FAO) and
World Health Organization (WHO) publish tables of
nutrient requirement values across demographic groups

Micronutrient Nutrition
Micronutrient deficiency is more prevalent in countries with
poor dietary diversity
• To ensure adequate micronutrient intake through dietary intake
alone (with the use of fortified, processed foods), a diverse diet is
required.
• Micronutrient-rich foods include fruit and vegetables, meat
and dairy, pulses, seafood, nuts and seeds.
• In contrast, cereal, root and tuber commodities tend to be energy-
dense but micronutrient-poor.
• In the chart below we have plotted the hidden hunger index in
children (on the y-axis) versus the share of dietary energy attained
through the consumption of cereals, roots and tubers. Overall, we
see that countries where the average diet is rich in micronutrient-
poor cereals tend to have higher levels of micronutrient deficiency
(here shown as hidden hunger in children).

92.3
58.1
76.2
83.7
58.9
92.3
41.3
90.1
55.7
63.1
89.1
53.4
90.1
29.9
0 20 40 60 80 100
Vitamin A
Vitamin C
Niacin
Riboflavin
Thiamin
Iron
Calcium
Girl Boy
Source: Nutrition Society of Malaysia, 2015
Nutrient intakes as a percentage of
children’s Recommended Nutrient
Intake

Urinary iodine level (µg/L) in Malaysia
by state, 2008
140.7
207
131
101.9
150.2
76.9
78.7
76.5
118
125.5
120.8
126
77.8
85.8
85.2
115.2
0 50 100 150 200 250
WP Labuan
WP Putrajaya
WP Kuala Lumpur
Sarawak
Sabah
Kelantan
Terengganu
Pahang
Johor
Malacca
Negeri Sembilan
Selangor
Perak
Penang
Kedah
Perlis
Recommended minimum
iodine level of 100 µg/L
Source: Wan Nazaimoon & Rusidah, 2010

Population affected by anaemia by age
group, 2015
Men 15-59 years
23%
Women 15-45
years
51%
Women 50-59
years
8%
Elderly
women
10%
Elderly
men
8%
Source: NHMS 2015, as reported by Awaluddin, et al., 2017
Total population 4.9 million (95% CI 4.6-5.1)

Prevalence of anaemia (Hb, 11gm) among pregnant mothers
at the 36th week of gestation who attended government
health facilities, 2004–2015
38.3
32.6
28.9
26.7
24
21.5 20.8
16.2
14
11.8
9.3 8.2
0
5
10
15
20
25
30
35
40
45
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Prevalence(%)
Year
Source: Health Information Centre, Ministry of Health, Malaysia

Prevalence of Vitamins and Minerals Supplement Uses
Malaysian Adults – Total – 28.05% Men – 24.29% Women –
32.12%
Type of Supplements:
Vitamin C 15.68%
Multivitamin and multimineral 8.87%
Calcium 5.84%
Vitamin B-complex 5.62%
Folic Acid 2.70%
Vitamin E 2.62%
Iron 2.06
Zinc 1.32
Vitamin A NA
Vitamin B12 0.78

Intake of Fruits and Vegetables
WHO recommendations: 5 servings per day (Fruits = 2 servings, Vegetables
= 3 servings)
About 10% of Malaysian adults met the WHO recommendations
Adequate intake of fruits (=2 servings) – 9.9%
Adequate intake of vegetables (=3 servings) – 11.2% (NHMS 2015)
Top 5 Vegetables and Fruits consumed by Malaysian adults (MANS
2014)
Vegetables Prevalence Fruits Prevalence
Green leafy vegetables 66.0% Apple 34.3%
Cabbage 19.0% Papaya 21.0%
Fruity vegetables 10.8% Orange/mandarin 16.3%
Seedy vegetables 10.7% Banana 15.3%
Tuber vegetables 10.5% Guava 14.4%

Prevention and treatment of micronutrient deficiency
If micronutrient requirements cannot be met through
dietary intake alone (for example if households do not have
access to or cannot afford the dietary diversity required)
common strategies to address deficiencies are:
• Supplementation: supplementation is the delivery of
concentrated micronutrients in pill, powder or liquid
form;
• Food fortification: fortification is a subset of food
processing and involves the addition of small amounts
of micronutrients to food products (such as cereals,
wheat flours and rice);
• Biofortification: the use of agronomic and plant-
breeding approaches in agriculture to increase the
concentration of micronutrients in staple food crops.
The most well-known example is so-called ‘golden rice‘,
which is rice grown with high concentrations of
vitamin-A.

JENIS
MAKANAN
Pakej 1 Pakej
2
Pakej
3
Pakej
4
Pakej
5
Pakej
6
Pakej
7
Pakej
8
Pakej
9
Pakej
10
Pakej
11
Pakej
12
Pakej
13
Beras (5 kg) √ √ √ √ √ √
Bihun (2.8-3 kg ) √ √ √ √ √ √
Susu Tepung Penuh Krim
(1.8 -2 kg)
√ √ √ √ √ √ √ √ √ √ √ √
Bijirin Sarapan (0.9-1 kg) √ √ √ √ √ √ √ √ √ √ √ √
Biskut (1.8-2 kg) √ √ √ √ √ √ √ √ √ √ √ √
Telur (30 biji) √ √ √ √
Ikan sardin (7 tin
kecil:155g/tin)
√ √ √ √
Ikan bilis (500 g) √ √ √ √
Marjerin (240-250g) √ √ √ √ √ √
Minyak Masak (1 kg) √ √ √ √ √ √
Serbuk Malt Coklat (1 kg) √ √ √ √ √ √ √ √ √ √ √ √
Multivitamin
(30/ 60 biji atau 50-120ml)
√ √ √ √ √ √ √ √ √ √ √ √ √
Susu Khas/ Susu Formula
(1.6-2 kg)
√
PILIHAN PAKEJ

National Plan of Action on Nutrition Malaysia III

• Sabah and Sarawak was gazette as areas that selling of
iodized salt is mandatory under the Food Act 285
• Proposal to include Peninsular Malaysia and Labuan to
ban the sale of salts that do meet Potassium Iodide and
Sodium Iodide as a strategy to reduce iodine deficiency
is still pending – Universal Salt Iodisation (USI)
• Prevention and cure include:
Mandatory sale of iodised salt in Sabah and Sarawak
Education and promotion including nutrition and health counseling to
improve nutritional status in the affected
Distribution of iodised salt to pregnant mothers and malnourished children
in the endemic areas
Monitoring activities
Research
1
8
Prevention and Monitoring of Iodine Deficiency
Disorders in Malaysia
18
Bahagian Peakanan, KKM

19
Anemia Prevention and Monitoring Program Among
Pregnant Mothers
Activities:
• Supplying hematinic (Ferrous
Fumarate, Vitain C, Folic Acid
and B=complex)
• Developed nutritional
guidelines for anemic pregnant
mother for health workers
• Educational materials
(booklets and posters).
• Nutrition education and
counseling for anemic
pregnant mothers.

Approaches to Combat Micronutrient Deficiencies
• Supplementation - Analysis of available supplementation programs
show that provision of micronutrient supplementation is most effective
when combined with other maternal and child health interventions
through primary health care systems or health care delivery systems
• Pregnant women and lactating women - Strong evidence exists
that daily iron supplementation improves hemoglobin concentrations
and iron stores and reduces the risk of anemia, iron deficiency, and iron
deficiency anemia during pregnancy
• Children – to increase hemoglobin concentrations has also been seen
in children however not for the overall physical growth of infants or
children. It can also modestly improve mental development scores
• Vitamin A supplementation in children - Integrated approaches
are not only more effective, but also cheaper than stand-alone
supplementation programs
• Iron and folic acid supplementation during pregnancy - Iron
supplementation during pregnancy is usually delivered through
antenatal care

Fortification
• Food fortification can be with single, dual, or multiple micronutrients are
normally targeted toward foods that are eaten by specific population groups. For
school children, for example, a MMN-fortified foods (beverages, milk products,
biscuits, seasoning powder) for child growth and improved cognitive domains
and reduced morbidity
• Mass fortification – the focus is on foods that are widely consumed by the
majority of the target population. For example of fortified foods in developing
countries are salt (with iodine) and wheat or maize flour (with several
micronutrients), folic acid-fortified flour, traditional condiments and seasonings
(eg, soy and fish sauces or curry powder) have been proposed as fortification
vehicles, mainly in countries where they are widely consumed.
• In Vietnamese women, for example, consumption of fortified fish oil was shown to improve
iron status and reduce the prevalence of anemia (Van Thuy et al, 2003 &2005)
• In Guatemala, fortification of sugar with vitamin A has led to a dramatic reduction in the
prevalence rates of vitamin A deficiency (Dary & Mora, 2002)
• In Uganda, vegetable oil is fortified with vitamin A. In Brazil, fortifying potable water with
iron has been shown to be efficient in reducing iron deficiency and anemia in infants and
small children, and feasible and can be done at community level
• MMN – Multiple micronutrient

Biofortification
Is the process of enhancing the nutrient content of staple crops through
traditional breeding and modern technology
• Biofortified varieties of rice, wheat, maize, cassava, pearl millet, beans,
and sweet potato are currently being developed with conventional
breeding being the primary focus to increase the content of iron, zinc,
and provitamin A carotenoids
• The amount of micronutrients that can be provided by biofortified
staple foods is much lower than the amount that can be achieved by
supplementation or food fortification
• The benefit of biofortification depends on the amount of the staple food
consumed per day

Approaches to Combat Micronutrient Deficiencies
Local production of micronutrient rich foods through home
gardens, livestock, and small fish – co-strategy to increase dietary
diversity
• Nutrition-sensitive agricultural interventions, when community-based,
culturally acceptable, and economically feasible, have the potential to be the
most sustainable long-term intervention of all for preventing multiple
micronutrient deficiencies
• A systematic review showed that most agricultural studies, including home
gardens, with or without animal production strategies were associated with
increased dietary diversity
• Agricultural interventions can complement supplementation and fortification
programs. In contrast to supplements and fortified foods, agricultural
interventions deliver macro- and micronutrients, fiber, and phytochemicals.
Additional non-nutritional benefits include empowerment of women through
production for sale in markets
• Some small fish species in developing countries are rich sources of vitamin A,
iron, and zinc, and are more affordable and accessible than the larger fish.
These locally available small fish have potential as a cost-effective food-based
strategy to enhance micronutrient intake; however, only a few studies are
available, and more research is needed (Kawarazuka and Bene, 2011)

Food-based Approaches

Food-based Approach
• The importance of food-based strategies to combat micronutrient
deficiencies was advocated by FAO (Rome) back in 1992, at the
International Conference on Nutrition and reiterated in 2nd ICN in 2014.
• Food Security should address the issue of quantity, as well as quality of the
diet, in terms of food groups: cereals and millets, pulses and legumes, milk
and meat products, fruits and vegetables and fats and sugars.
• This strategy promotes dietary diversification, using locally available
foods to satisfy local food habits and facilitates recommended nutrient
intakes.
• Unlike supplementation or fortification, which can address the deficiency
of only select nutrients, dietary diversification is a more holistic and
balanced approach with little or no danger of toxicity.
• It demands creating an enabling environment of awareness, and ensuring
access at affordable cost to a variety of foods, within and across food
groups to obtain adequate micronutrients
Source: Bamji MS and Nair KM, 2016

Common Pulses
Pulses are the dried seeds of the legume plants. Hundreds of different varieties of pulses are grown around the
globe.
Dry beans Lentils Faba beans Dry peas
Chickpeas
Cow peas Bambara beans Pigeon peas Lupins Vetches

Conclusion
• Micronutrient deficiencies can undoubtedly have profound influences on
the health of at-risk populations. Poor households are the most
vulnerable to micronutrient malnutrition, and more permanent solutions
are still required. For example, anemia remains a public health problem
of huge magnitude, yet little progress in controlling it has been achieved
in the developing world.
• Both dietary and non-dietary factors, such as; access to clean drinking
water and sanitation, health care, purchasing power, women’s education
and empowerment, contribute to micronutrient inadequacy
• To be successful, fortification and supplementation programs must have
high-level government involvement. Fortification programs, for example,
require political support, adequate marketing, and long-term commercial
commitment.
• Supplementation which is a short term strategy expected to produce
quick remediation provided for combating anaemia, and vitamin A
deficiency, it has now become a long term strategy for many
governments.
• Food-based strategies need to be promoted vigilantly by all stakeholders
and the link between agriculture, nutrition, and health and local
environment need to be highlighted prominently

References
Girard AW, Self JL, McAuliffe C, Olude O (2012). The effects of household food production strategies on the health and
nutrition outcomes of women and young children: a systematic review. Paediatr Perinat Epidemiol. 26(Suppl 1):205–
222.
Dary O, Mora JO (2002). International Vitamin A Consultative Group. Food fortification to reduce vitamin A deficiency:
International Vitamin A Consultative Group recommendations. Journal of Nutrition 132(Suppl 9): 2927S–2933S
Zaiton Daud (2018). Program Pemakanan Di Malaysia, Putrajaya: Bahagian Pemakanan, Kementerian Kesihatan
Malaysia
Bee Koon Poh, Boon Koon Ng, Mohd Din Siti Haslinda, Safii Nik Shanita, Jyh Eiin Wong, Siti Balkis Budin, Abd Talib
Ruzita, Lai Oon Ng, Ilse Khouw and A. Karim Norimah (2013). Nutritional status and dietary intakes of children aged 6
months to 12 years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia) British Journal of
Nutrition, 110, S21–S35 doi:10.1017/S0007114513002092
Thompson B and Amoroso L (2011). Combating Micronutrient Deﬁciencies: Food-based Approaches. Rome: FAO
Bamji MS and Nair KM (2016). Food-based Approach to Combat Micronutrient Deficiencies. Proc Indian Natn Sci Acad
82 No. 5 December pp. 1529-1540 DOI: 10.16043/ptinsa/2016/48885
Van Thuy P, Berger J, Nakanishi Y, Khan NC, Lynch S, Dixon P (2005). The use of NaFeEDTA-fortified fish sauce is an
effective tool for controlling iron deficiency in women of childbearing age in rural Vietnam. Journal of Nutrition
,135(11):2596–2601.
Van Thuy P, Berger J, Davidsson L, et al. (2003) Regular consumption of NaFeEDTA-fortified fish sauce improves iron
status and reduces the prevalence of anemia in anemic Vietnamese women. American Journal of Clinical Nutrition,
78(2):284–290
Kawarazuka N, Béné C (2011). The potential role of small fish species in improving micronutrient deficiencies in
developing countries: building evidence. Public Health Nutr. 14(11):1927–1938.

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