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Micronutrient Supplementation

Vitamin A Deficiency

Vitamin A Deficiency is a severe nutritional problem, particularly in the developing world; it affects 250 million people worldwide, half of them children under the age of five (Bassett & Winter-Nelson, 2010).  The condition results from an insufficient consumption of Vitamin A, an essential nutrient that allows the body to maintain healthy eyesight and fight off infections (Sommer, 2001).  A healthy level of Vitamin A for a child is approximately 400 micrograms retinol equivalent per day (Sommer, 2001), but consuming a much lower level of Vitamin A can lead to night blindness, complete blindness, a compromised immune system, and severe illness.  In fact, it is estimated that up to half a million children will go blind each year due to Vitamin A Deficiency (Bassett & Winter-Nelson, 2010).

If a person consumes a varied diet rich in animal protein and a mix of grains, his or her diet probably contains sufficient amounts of Vitamin A.  The nutrient is commonly found in eggs, milk, butter, carrots, and green leafy vegetables (Sommer, 2001).  Most people in developed countries usually consume enough of these foods to prevent the blindness and weakness associated with Vitamin A Deficiency.  In poorer developing countries, however, where milk and eggs are not a major part of the average diet, Vitamin A Deficiency is still a huge problem.  The extent of the issue is shown in the map below. 

Map of Vitamin A Deficiency
Source: Bassett & Winter-Nelson, 2010


In developing countries with limited cold chain distribution systems, it is not always feasible to increase the amount of milk or the number of eggs in the average diet.  Therefore, the best immediate option to improve Vitamin A intake is to supplement diets with either Vitamin A pills or fortified household staples such as sugar.  Our proposed solution to the Vitamin A Deficiency problem involves both efforts.  

In the short term, supplementation through Vitamin A pills should be increased overall. Organizations such as the WHO should provide Vitamin A pills to programs that already administer immunizations, so the existing framework of volunteers and doctors in many countries can be used to fight Vitamin A Deficiency as well (Sommer, 2001). In addition, supplements can be distributed through primary schools in areas where a large proportion of children are Vitamin A deficient. 

Supplement programs have been both effective and cheap in the past; they just need to be scaled up in the future.  UNICEF conducted a program giving children in poor regions twice-yearly massive doses of Vitamin A supplements (up to 200,000 International Units or 660,000 micrograms retinol equivalent)(Sommer, 2001), and as a result, child mortality in those regions fell by a remarkable 25-30% (Bassett & Winter-Nelson, 2010).  Such massive doses of Vitamin A supplements cost approximately 2-4 cents per dose, which is 4-8 cents per child per year (Sommer, 2001). This means that an effort of 10 million dollars per year is required to purchase Vitamin A supplements for all the 125 million Vitamin A deficient children in the developing world.  

Meanwhile, severely deficient countries around the world should attempt to fortify household sugar with Vitamin A. Sugar fortification involves mixing sugar with small amounts of oil and retinyl palmitate, the raw form of Vitamin A used for fortification, to create a physical (rather than chemical) bond.  Sugar seems to be a good candidate medium because it is used by a large number of people, it is manufactured in a small number of central mills in each country, and its sticky nature lets it physically adhere to the Vitamin A material (Serlemitsos, & Fusco, 2001).  The additional infrastructure required for a plant to produce fortified sugar includes equipment such as mixers and heaters (Serlemitsos, & Fusco, 2001). 

For existing sugar mills, making the shift to fortified sugar can be a win-win situation for both private and public interests, as proved to be the case in Zambia (Serlemitsos, & Fusco, 2001).  Following the model enacted in that country, this plan suggests that successful sugar fortification requires the interplay of many different actors.   The cooperation of the government is essential to protecting the private sugar mills who decide to transition.  The government, motivated by the striking public health benefits of Vitamin A-fortified sugar, should publicize the fortified sugar through radio ads and public service announcements, and consider legislation promoting its sales. Experts from international NGO’s and the United Nations can help provide advice to private sugar producers.  And with the support of national and international bodies, the private sugar producers will begin to see the switch to fortified sugar as a profitable venture.  

For the fortification of sugar with Vitamin A, it costs approximately $1,000,000 to make 100,000 metric tons of fortified sugar, which adds approximately 5% to existing production costs (Serlemitsos, & Fusco, 2001).  Much of this cost can be managed by private sugar companies, since by switching to fortified sugar they can benefit from the positive press of governmental public health campaigns.  National governments and public health-related NGO’s, motivated by the idea of increasing public health in a country, could also carry some of the cost.  NGO’s such as the Micronutrient Initiative could be extremely helpful in providing technical advice and support to sugar companies making the switch to Vitamin A fortification.  Based on the 5-year transition of Zambia Sugar Company from non-fortified to fortified, the fortification portion of our plan is probably operative on the order of 5 or 10 years (Serlemitsos, & Fusco, 2001). 

Both aspects of this plan (supplements and sugar fortification) should be implemented in regions with the largest Vitamin A deficiencies, such as Sub-Saharan Africa, India, the Philippines, Indonesia, and Mexico.  In these regions, more than 30% of children are Vitamin A deficient. 

It is worth noting that large supplemental doses of Vitamin A should be phased out over time, as sugar fortification increases and diets diversify around the world.  The goal is to reduce the population’s dependence on immunization and supplementation campaigns to get the required amount of Vitamin A. 


Iodine Deficiency

Iodine is a micronutrient used by the human thyroid gland to produce certain hormones essential to proper development and brain functioning (Mannar).  Normal dietary sources of iodine include seafood and fruits and vegetables, but in landlocked countries and in countries where soil is naturally lacking in iodine, iodine deficiency often occurs.  Known as the leading preventable cause of mental retardation in the world, iodine deficiency lowers a person’s I.Q. by as much as 10-15 points (McNiel, 2006).  It affects an estimated 1.9 billion people worldwide, including 740 million people with visible goiters, the tell-tale swelling of the thyroid typical of severe deficiency (Leathers & Foster, 2009; Bassett & Winter-Nelson, 2010).  The global distribution of this problem, as seen in the map below, is very different from the distribution of other health issues. 


Map of Iodine Deficiency
Source: Bassett & Winter-Nelson, 2010


Major improvements have occurred in the last two decades as iodized salt has become more prevalent.  It is estimated that iodized salt has already reduced the number of infants born with severe brain damage and the number of cases of severe goiter by half (Bassett & Winter-Nelson, 2010; Mannar).  According to the Micronutrient Initiative, each dollar invested in salt iodization returns about $28 dollars in health benefits.  Approximately two thirds of the world’s population now has access to iodized salt, up from only 25% in 1990, but the goal of Universal Salt Iodization (USI) is still not achieved (McNiel, 2006).  This is because some of the support for USI campaigns seen in the 1990s has been moved to other issues, and because small salt-producing plants in developing countries do not have the incentive to start iodizing salt (Mannar).  A renewed commitment to the issue is needed in the coming years. 

The solution to iodine deficiency relies on governments as well as on private salt companies making the switch to iodized salt production.  It is up to each government to pass legislation requiring all salt to be iodized, giving private companies the motivation to convert to iodized salt production.  Salt iodization is also relatively cheap: it costs only 3-4 cents to produce enough iodized salt for a person each year (Micronutrient Initiative). 

Iodized salt production requires the purchase of raw iodine material and an additional piece of mixing equipment (Mannar).  The raw material, potassium iodate, costs about $1.15 for two ounces, which is the amount needed to fortify one ton of salt (McNeil, 2006). The iodizing process itself adds less than 5% to the total cost of production.  More than a hundred salt iodization plants in China were upgraded to iodizing plants at less than $1 million dollars each (Mannar).  A sample project in Ethiopia where a salt plant switched to iodized salt suggests that salt plants remain generating profit after the switch, and the payback time on the initial investment is about five years (SNNPR Investment Expansion Process, 2009).  The funding for iodized salt production should come from a mix of public and private sources. 

Iodized salt production should be targeted especially at landlocked countries in Africa and Asia, and at many of the countries in Eastern Europe (Bassett & Winter-Nelson, 2010).  With the help of organizations like the Micronutrient Initiative and the UN spreading information about the benefits of iodizing salt, progress can be made in countries like the Philippines, the Ukraine, and the countries in Central Africa.  The final push towards USI can begin immediately.   Between 1990 and 2010, two thirds of the world’s population gained access to iodized salt.  If the final stages of the project are given enough international support, we predict that USI should be achieved within 10 more years. 

Works cited: 

Bassett, T. & Winter-Nelson, A. (2010). Atlas of world hunger. Chicago: The University of Chicago Press.

Leathers, H., & Foster, P. (2009). The world food problem: toward ending undernutrition in the third world. Colorado: Lynne Rienner Publishers Inc.

McNeil, D. (December 2006).  In raising the world’s I.Q., the secret’s in the salt. The New York Times, Retrieved November 29, 2010 from

The Micronutrient Initiative. Iodized salt. Retrieved November 12, 2010 from

Serlemitsos, J., & Fusco, H. (2001). Vitamin A fortification of sugar in Zambia. Retrieved November 13, 2010 from

SNNPR Investment Expansion Process. (2009). Profile of iodized salt production. Retrieved November 12, 2010 from,J,K/%20Iodi...

Sommer, A. (2001). Golden rice. Unpublished manuscript, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA. Retrieved November 13, 2010, from

Mannar, M. G. V. Iodized salt for the elimination of iodine deficiency disorders. Retrieved November 12, 2010 from