© 2002 The American Society for Nutritional Sciences J. Nutr. 132:839S-844S, 2002
Supplement: Forging Effective Strategies to Combat Iron Deficiency
Policy and Sustainability Issues1 ,2
Guy Nantel3 and
Kraisid Tontisirin
Food and Nutrition Division, FAO, Rome, Italy 00100
3To whom correspondence should be addressed. Food and Nutrition Division, Food and Agriculture Organization of the United Nations, Viale delle Terme di Caracalla, Rome, 00100, Italy. E-mail: Guy.Nantel{at}fao.org
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ABSTRACT
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The need for combined and integrated strategies to address iron deficiency is widely recognized, utilizing targeted supplementation, as well as food based strategies including both fortified and nonfortified foods. The challenge is not so much knowing "what" to do as is understanding "how" to implement effective and sustainable interventions. Because the causes of iron and other micronutrient deficiencies are complex, including inadequate food intake, unsanitary conditions and inadequate health services, the solutions may also be complex, requiring multisectoral and interdisciplinary approaches. Top-down strategies are unlikely to be effective and sustainable. Rather, the beneficiaries of the program at the community level must be able to understand malnutrition in simple terms, to envisage potential solutions and to become "demanders" of services. The experience in Thailand provides an example of a country-wide, community-based and participatory approach utilizing facilitators and motivators at the local level to implement and sustain interventions. The experience in Thailand indicates the potential for developing effective and sustainable interventions to address iron deficiency and other micronutrient problems as part of a broad, community-based effort.
KEY WORDS: • community • sustainable interventions • iron deficiency
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INTRODUCTION
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Effectively combating iron deficiency requires, in the first instance, making some choices among the many technical strategies available, and then implementing those strategies. There are normally three categories of technical choices that can be envisaged, i.e., the use of supplements, fortified foods and nonfortified foods (so-called "food based approaches," although fortification is also a food based approach). All have advantages and shortcomings, and choices depend very much on the specificity of the iron deficiency situation for which they are required. In developing countries, however, rarely are "exclusive" or "specific" situations encountered, and for all practical purposes, many of the available strategies have to be used concurrently.
In considering "the forging of effective strategies," in reference to the title of this conference, the technical strategies available can answer the question of "what" can be done, but they do not tell us "how" it can be done. An important aspect of the "how" question is that of sustainability, i.e., an outcome in which an intervention will continue to have a beneficial effect on a population long after the project itself has ended. The implication is that the target population with whom an intervention has been carried out has acquired some ability, understanding and capacity to continue implementing the solutions proposed long after the project has finished.
This article looks briefly at common technical solutions and then addresses the issue of implementation that answers the "how" question. In developing countries, in which nutritional problems are many and varied among all age groups and both sexes, it is felt that the manner in which implementation is carried out stands to have a major effect on the long-term success or failure of projects or programs in addressing iron deficiency. It is the position of this paper that so little progress has been observed in alleviating iron deficiency over the past 30 y largely because technical strategies have been considered almost exclusively, whereas implementation issues have been largely ignored.
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Supplementation
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Supplementation is the technical strategy required for acute situations in which the demand for iron is quite high and cannot be easily met from the iron available in foods, whether fortified or not. Typical situations for iron supplementation are found in pregnancy, particularly in the second half, and also in situations of severe anemia in which an initial catch-up intervention is warranted. It is a good curative solution which deals with acute situations. It cannot be considered to be a sound preventative approach in view of its unpleasant side effects (constipation) and compliance problems. There is promising work on the development of protocols that allow only twice or once a week supplementation without compromising efficacy, and with reduced side effects relative to daily supplementation. However, the very limited ability to maintain such a schedule in developing countries makes this approach particularly difficult.
On the basis of these limitations, iron supplementation should always be accompanied by a food-based approach that can be implemented once the "curative" phase of the intervention has been completed. Furthermore, a supplementation initiative, because of its limitation over the long term, should always have a built-in education or promotion program to take advantage of the educational opportunities offered by the "captive" audience of the supplementation process to provide information and education about iron-rich foods, both fortified as well as nonfortified. In fact, the advice should be about the whole diet, and not only about iron.
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Fortification of foods
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The iron fortification of foods is a strategy of choice that has been used in many developed countries to help meet dietary iron needs, and it is being used increasingly in developing countries. But fortification comes at a potentially heavy cost for developing countries. First, (in most instances) fortification introduces a manufacturing step, therefore a potentially expensive process. In addition, there is a need for quality control when the fortificant is added. This introduces a level of technical sophistication, which requires training. Too much iron can lead to iron toxicity in genetically susceptible individuals consuming large quantities of the fortified food. If insufficient amounts of the fortificant are added out of concern for safety, the problem of improving iron status will not be resolved efficiently, and yet the cost of the fortification will remain.
An appropriate food vehicle that is consumed by the majority of the target population has to be identified. In most programs, this involves a centralized processing operation, which ends up removing the food from the hands of the small-scale community operators, families and individuals. One must also consider that at the very least, the fortified food will require some packaging and a label. All of these issues contribute to increased cost of the fortified food, and sometimes prohibitively so in a developing country context.
It is important to bear in mind that in many instances for staple food fortification, e.g., flour fortification, to be effective, the fortification process requires that only the fortified food be available in the marketplace. To be successful, a fortification program will require legislation to allow for the sale of the fortified food only, because the nonfortified equivalent will be cheaper and will receive consumer preference, thus defeating the purpose of the fortification program. This implies the need for inspection and monitoring services to ensure compliance with the law, another important expense, even if inspectors are already there to carry out other compliance functions such as monitoring for food safety. Iron fortification is generally a powerful approach for enriching the diet with iron; it is particularly useful for urban areas in which a large amount of the food is purchased, and therefore the "costs of manufacturing" have already been absorbed for the sake of convenience.
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Bioavailability
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The iron from non-animal foods generally has low biovailability, but it can be significantly enhanced by adding foods rich in vitamin C to the meal. About 25 mg vitamin C is required during the same meal and can be obtained from vitamin C-rich fruits and vegetables. The mechanism by which this occurs is not well understood. It is also necessary to refrain from drinking tea or coffee with meals or immediately after because tannins bind the iron and make it unavailable. Small amounts of meat, fish and poultry protein are also able to stimulate the absorption of nonheme iron, again involving an unknown mechanism. It is often for reasons of cost that animal protein is not consumed in poor populations, and in such cases, it would be a sound strategy to consider the introduction of small quantities of animal food for the purpose of enhancing iron absorption from nonmeat sources. Raising of chickens or setting up fish ponds is usually within the realm of capabilities of communities, individuals and households in developing countries. Other effective ways of increasing iron bioavailability include germination, soaking, fermentation and malting of grains, which activate phytases that breakdown phytic acid, the most important antinutrient that inhibits iron absorption. These techniques also reduce the levels of tannins and polyphenols. The potential for using food based strategies to reduce iron deficiencies was reviewed recently by Ruel and Levin (1
).
A problem that remains, however, is to provide sufficient iron to women so that they can recover from iron deficiency during pregnancy and to iron deficient infants. Food sources of iron appear to have a limited capacity in this respect because they do not have a high enough iron density. This remains a disturbing observation, however, as if nature did not provide the capacity to meet iron needs from foods. In this respect the thoughts of George Beaton (2
) and Rebecca Stoltzfus (3
) must be kept in mind; they suggest that our estimates of iron deficiency are not really credible, and that we should rethink the problem in terms of functional consequences, rather than normative indicator distributions. It is clear, nevertheless, that catch-up for iron deficiency in pregnancy and infancy appears particularly difficult without supplementation on the basis of our current understanding.
Many of the common vitamin C-containing foods are seasonal (fruits), and much of the vitamin C tends to be lost with the inadequate means available for food storage in developing countries. Research is required on better processing and storage to improve the situation and extend the availability of vitamin C foods between seasons. In addition, there is a need to examine a wider range of foods, such as noncultivated foods (sometimes referred to as "traditional foods") which are or were consumed in developing countries at one time, and have been dropped from the diet as a result of the development process. This is certainly the case for vitamin A because a number of vitamin A native foods have been abandoned. Because it has been observed that vitamin A added to iron supplements enhances the improvement in iron status (4
), a more serious look at the potential of native foods is warranted. Another inadequately explored possibility as a source of dietary iron is the proper use of iron utensils such as iron cooking pots; the iron leaching out from them, particularly when cooking acid foods, can make an important contribution to dietary iron intake (1
).
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Integrated approaches
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Given the shortcomings of each of the basic three strategies of supplementation, fortification and unfortified foods, there is no doubt that the three approaches must all be used together in an integrated manner as part of any effective strategy to alleviate iron deficiency. Past efforts in addressing iron deficiency anemia in developing countries have met with little lasting success over the past 20 y, and the condition remains endemic throughout the world. One of the reasons is that supplementation has been the favored strategy, but it has unfortunately been carried out alone without integrating it with the other food based approaches. Considerable efforts are now being devoted to developing and introducing fortification strategies, and it is hoped that efforts will be made to integrate them into an overall strategic dietary approach to reduce iron deficiency.
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Consumer education
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To be effective, any strategy will have to/should include a well-targeted consumer education/health promotion campaign to optimize its effect. A fortified food that is introduced for alleviation of iron deficiency must be the focus of a promotion campaign because it is necessary to promote the consumption of the fortified food to guarantee the efficacy of the program. However, it is equally important to situate the fortified food within its dietary context and explain why the food is fortified and how it can contribute to solving the problem. It is also important to offer dietary alternatives as a complementary strategy for those who cannot afford the fortified food, so that they are not left without a solution. This complementary strategy is also necessary to educate consumers on diversifying their food intake and on making choices for the right food combinations that will enhance iron availability (e.g., consuming vitamin C-containing foods with iron-rich vegetable foods or consuming animal foods, liver in particular). Making major health claims for the fortified food alone without situating it in a dietary context would be inappropriate; the promotion of a variety of dietary strategies can be easily done with the help of the food-based dietary guidelines (5
).
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Taking a step back: examination of fundamental causes
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Up to this point, the strategies discussed offer potential answers to the question of what can be done about iron deficiency. The reality, however, is that iron deficiency rarely occurs alone in developing countries. It is estimated that there are 
2 billion people who are iron deficient in the world (6
), and the Food and Agriculture Organization estimates there are 800 million people in the world who do not meet their minimum energy requirements (7
) (i.e., they do not have enough food to eat). This implies that of the 2 billion iron deficient people, at least 800 million of them are in this condition simply by virtue of not having enough food to eat. Additionally, among those that just barely meet their daily energy needs, a majority "survive" on a monotonous diet based almost entirely on one or two staples. These people are also likely to be iron deficient. The root of the problem, therefore, is far more than iron deficiency alone, i.e., it is a deficit in food. Thus, it is necessary to take a step back and reexamine the fundamental causes of the broader problem to devise effective solutions.
First, it is known that iron deficiency is most often associated with other micronutrient deficiencies (folate and B-12, vitamin A, some B vitamins) (8
). To address one or only a few nutrient deficiencies will therefore not truly resolve the problem. A broader and integrated dietary approach is required. In simple terms, this involves providing enough food and of a sufficient variety to meet both macro and micronutrient needs. However, the matter is more complex. There are multifactorial causes of iron deficiency (and other micronutrient deficiencies) that fall outside the realm of dietary interventions and that cannot be addressed simply by enriching the diet with the deficient micronutrients. Typically, there are several disease conditions that can result in anemia, such as intestinal parasites (hookworm infection and blood loss); malaria; chronic infections; chronic diarrhea (preventing adequate absorption) resulting from unsanitary conditions and inadequate amounts of drinking water. These conditions must be readdressed before envisaging successful dietary interventions.
When we are able to see the problem in its broader context, overall malnutrition is the outcome of a process in which some very basic and fundamental (physiologic) needs have not been met. They include an insufficient intake of food energy with its accompanying inadequate nutrient intakes, a lack of variety in foods consumed (particularly fruits and vegetables), which further exacerbates the micronutrient deficits, unsanitary conditions, which lead to chronic diarrhea accompanied by loss of appetite and poor nutrient absorption, inadequate access to clean (drinking) water, which is an impediment to sanitary conditions, and inadequate health services. The conditions that lead to iron deficiency and other micronutrient deficiencies are therefore complex, and the solutions to the problems are also potentially complex.
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Women and children
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Thinking strategically, it is first necessary to have women and children in good health because this is essential to break the cycle of poverty and malnutrition. Children have to be able to grow normally and learn so that they can become functional adults, and women as care givers have to have the time, the energy and the capability to nurture their children so that they are able to develop their capacities. All efforts must be made to meet women and children’s nutritional needs. Women of childbearing age, pregnant women and infants are the population groups that suffer the most from iron deficiency. Progress measured therefore in terms of improvement in the nutritional status of young children and women constitutes the most appropriate indicator. If this improvement cannot be achieved, the goal of breaking the cycle of malnutrition is unlikely to be met soon.
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Need for a multisectoral approach
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In more general terms, malnutrition, including iron deficiency, of course, has multifactorial causes in developing countries. Successful strategies must address all of the causal factors more or less simultaneously, in spite of the fact that at first glance this appears to be an impossible task. In other words, the solutions call for a multisectoral and interdisciplinary approaches.
Figure 1
presents a conceptual framework illustrating the main disciplines or sectors that must be involved in an integrated and coordinated manner to improve the nutritional status of populations. At the bottom of this figure are the people sources, (i.e., the human resources); the purpose is to bring those human resources to a "functional and productive capacity" at the top ("the social capital"). On an individual basis, that state can be characterized as one of "nutrition well-being." It is necessary to consider that before any significant economic activity can realistically occur on a wider scale, the physiologic needs of people must be met so that individual preoccupations are no longer restricted to immediate survival. Many sectors and disciplines are involved in addressing the physiologic needs (those shown are thought to be the main ones). In the analysis, it is crucially important to understand that malnutrition, which in this instance is perhaps more convincingly represented as "undernutrition," is the expected outcome of processes that have led to abject poverty, and for which all household coping mechanisms have been exhausted.
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Figure 1. A conceptual framework for improvement of nutritional status. The goal is to start with the people (at the bottom) and bring them to "nutritional well-being" at the top, where basic physiologic needs will have been met. The process shows that the problems encountered along the way, the "underlying factors," fall into different sectors or disciplines. Thus, an integrated multisectoral and multidisciplinary approach is required. (Adapted by the Food and Nutrition Division, FAO, from the Joint WHO/UNICEF Nutrition Support Program in Iringa, Tanzania, 1988.)
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As nutritionists, we have focused on the end point, the "visible" signs of malnutrition and have attempted to correct and compensate for that situation without looking carefully at the causal factors. This is not altogether surprising because they fall outside the realm of nutrition. However, it does not prevent the obvious conclusion that a solution to the problem requires input from sectors outside the field of nutrition. Many introductory statements in papers and discussions about iron deficiency allude to the fact that the efforts of the past 30 y have not improved the situation significantly. The above analysis offers a possible explanation.
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Need for a paradigm shift
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It appears that a radically different approach is required—something that would qualify as a paradigm shift. First, it is necessary to address the nutritional situations in an integrated multisectoral approach and not in a piecemeal fashion. Malnutrition has to be seen as an outcome, and the physiologic needs of people constitute essential minimum needs. The specific essential minimum needs of households will vary within the same community, so that a "one-size-fits-all" solution is not possible. The implication is clear, i.e., because of the impossible complexity of addressing the needs if it were done in a top-down fashion, the beneficiaries of the development programs must be called upon to contribute to the process by devising solutions for themselves. It is necessary to develop household capacity to understand malnutrition in simple terms and to help them envisage potential solutions for improving the situation. In this way, the households, individuals and communities can become "demanders" of services, and the service delivery processes can be gradually adapted to meet the demands. Thus, a demand-driven process is created, with the community and individual households finding their own solutions, and calling upon services to support their initiatives.
Are there examples in the world that have been characterized by rapid progress in nutrition status and sustainability (where the activities initiated by a project continue to survive beyond the life cycle of the project and its funding)? There are examples of sustainable community-based, nutrition improvement interventions, but unfortunately very few have been documented. However, one noteworthy, documented example is in Thailand. The county’s outstanding success in fighting hunger and malnutrition stems from the fact that it has been able to develop a countrywide sustainable community-based and participatory system for the implementation of a poverty alleviation plan. A key goal and indicator for this plan is the improvement of the nutritional status of the population. This indicator was decided after realizing that malnutrition is the inevitable outcome when various basic needs were not met. This strategy has been implemented successfully on a countrywide basis since 1982 and continues to this day. Figure 2
shows data from 1982 to 1998 of underweight for children <5 y old. There was rapid progress in reducing underweight in the whole country over the first 3 to 4 y. This effort has been sustained at a reduced pace ever since, with virtual elimination of severe and moderate forms of malnutrition, and with mild malnutrition standing at 8% in 1998. This figure also provides data on the prevalence of poverty from 1988 onwards.
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Figure 2. Prevalence of underweight in children <5-y-old in Thailand. Data are from 1982 to 1998. (Reprinted with permission from Bureau of Health Promotion, Ministry of Public Health, Government of Thailand, 1998).
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Lessons learned
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The Thailand example illustrates several important elements that must be in place for the improvement of nutrition situations. First, for programs or processes to become sustainable, they must be owned by the communities. Individual households and the community at large must have developed the capacity to understand problems and to devise plausible solutions. To the greatest extent possible, members of the community must have control over problem solving. Second, technical information and assistance have to be available to community members for problem solving. The latter, in effect, is the contribution from government, i.e., the government support process, which makes information available to the community, finds access to resource persons when necessary and provides training for key community resource persons.
Typically, individual households must have the ability to recognize and understand nutrition problems. For example, one excellent way to do this is to train mothers to monitor growth of young children using growth charts. When growth falters, the mother can seek assistance to address the problem. Thus, a monitoring device is provided for the mother to receive constant feedback on the optimum growth of her child.
In Thailand, this training is provided by "mobilizers" (>95% of whom are women) who are community volunteers and have been trained to provide this kind of service. The mobilizers are identified and recruited as a result of a sociogram process in which the individual members of a cluster or neighborhood in a community are asked whom, among their neighbors, they find trustworthy, someone that they tend to consult when they need advice about a particular problem. These individuals can be recruited to act as "resource" persons for their 10 or so households. These volunteers already have a relationship of trust with the 10 households of their neighborhood, so that their involvement in addressing problems of nutrition is really an extension of their natural disposition. Thailand now has >500,000 such volunteers. They constitute the first level of assistance and information at the community level. Figure 3
provides a graphic concept of the interactions between the community members and the government at the local level, with a government-community partnership being constituted at the interface.
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Figure 3. Depiction of the relationships between government and communities for improving nutrition in Thailand. BF, breastfeeding; CF, complimentary feeding.
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There have been many community based initiatives that have been successful as long as the project and external funding continued. Their breakdown at the end of the project shows that they did not have a built-in process to ensure sustainability. The Thailand example shows that a contributing cause for failure is the lack of support from the governments (central, provincial, district and subdistrict) for the initiatives being taken at the community level. This support can and should be developed from the higher level (central government) with appropriate policy and through a high level intersectoral process. An effective intersectoral process calls for the setting up of an Intersectoral Committee (Thailand has a Rural Development Committee), which is responsible for bringing the different sectors together to develop the strategy for the implementation of the Poverty Alleviation Strategy. The objective of such a strategy at the start must focus on meeting essential minimum needs of the population, i.e., the physiologic needs. When these are in control, social needs, livelihoods and other needs can be addressed. The structure put in place has to become responsive to the communities’ perceived needs, with a government committed to meeting those needs (political will) in the best way possible.
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Mobilizers
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Mobilizers, who are volunteers, are extremely important for rapid progress in improving nutrition situations, because they are responsible for assisting individual households develop their self-help capacity. In effect, their action is what accounts for mass mobilization. It is therefore extremely important that everything possible be done to retain the mobilizers because they are key to effective community mobilization. The fact that they are volunteers should never be construed as "cheap labor" because that is not the case. To be retained they need fringe benefits, and above all, solid social recognition. In Thailand they get T-shirts, badges and certificates for the work they do. They need to be visible publicly (to be recognized publicly) in periodic (monthly?) meetings. Their families should have access to free health care. They should get free training and possible opportunities for training outside their own community. The households served may choose to provide them with some food or services in recognition of their assistance. Perhaps it is fair to say that it may be appropriate to spend more money to retain the services of these volunteers than they would receive if they were paid.
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Facilitators
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A particularly important point for the success of this approach is also the quality of supervision for the mobilizers. Those that carry out the supervision are facilitators. That group is composed of service delivery people from different sectors (e.g., agriculture extension agents, health delivery service individuals, educators). In this context, the facilitators must be retrained to have a broader capacity for intervention and action. They have to understand the participatory concept being implemented in the community, and that their role is one of a first level multisectoral resource person. They are still expected to deliver services in their own sector of specialty, but in addition, they become referral agents to other facilitators and resource persons when a problem is outside their knowledge and capacity. They can also maintain links with academic institutions, nongovernmental organizations, village committees, higher government levels and its resources. The facilitator is the key resource person who has to be easily and informally available to the mobilizers. They must find ways for effective response to the demands of the community.
For example, an agricultural extension worker should know what to do or whom to contact when a mobilizer seeks advice concerning a child that is not growing normally. Similarly, a health worker should be able to provide basic advice about home gardening. These facilitators should know where to access information and technical resources. They should also know effective ways of initiating requests for financial resources. The facilitators would have to meet regularly (perhaps once a month) with their mobilizers to discuss problems, progress, and provide some training and information; it is their responsibility to always be accessible for problem solving and general assistance.
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Essential minimum needs
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In the ideal situation, such as the one Thailand has created, the central government, as part of its strategy of implementation, can develop a list of essential minimum needs, which the government recognizes as the range of basic needs in the country and the high priority given to addressing them. They also constitute a policy commitment of the government to support actions to meet those needs. The list can be developed by a high level interserctoral committee, for example, a rural development committee or a poverty alleviation committee, who are responsible for implementation. The focus on developing such a list is expected to build support from all of the sectors toward a common goal while defining the responsibility of each sector for implementation. It must be understood by all of the sectors represented that improvement in nutritional status is a prerequisite for economic development because it is the first and inevitable step to building social capital. Individuals have to become food secure and healthy so that they can engage in economic activity instead of focusing on survival.
Figure 4
provides a list of essential minimal needs for Thailand (called basic minimum needs in Thailand). At the community level, essential minimum needs constitute a mechanism for engaging in community dialogue about basic needs. Through a participatory process, with the involvement of facilitators, mobilizers and village authorities, a community is free to accept only part of the list or devise others that it sees appropriate. The essential minimum needs retained from the list, with the local adjustments, become the goals for individual households. The community then decides on the way it wants to monitor progress of the selected goals.
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Figure 4. Example of essential minimum needs and criteria (based on the basic minimum needs model used by Thailand). BCG, bacillus calmette guerin; DPT, diphtheria, pertussis and tetanus; OPV, oral polio vaccine. Adapted from (9
).
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The list of essential minimum needs is preferably accompanied by a list of activities (Fig. 3)
, which are presented as suggestions to communities on possible actions that could be used to address essential minimum needs. The communities are expected to modify or adapt the list in accordance to their specific needs and conditions, or invent their own to meet special needs. Obviously some of the essential minimum needs can be met simply by increasing the efficiency of use of services, such as health services, or by improving the services, such as adding antenatal care or nutrition information for infants and children. The same can be said of agriculture extension services, where the services are tailored to meet all the food security needs of the community. What is important, however, is recognizing that the formulation as needs automatically sets them as goals.
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Relating this process to iron deficiency
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Once a process such as this has been put in place, specific programs can be delivered to meet specific nutritional needs. These programs will be one element within an array of programs and actions contributing to build the social capital. For example, iron supplementation programs for pregnant women are much more likely to succeed because the mobilizers and facilitators of the community will be monitoring the situation. At the same time, alternate solutions might be tested or explored because the pregnant women expressed dissatisfaction with the side effects of the supplementation program. For children and others in the community, either fortified foods or foods rich in iron may be found and integrated into the diet along with appropriate preparation and cooking information.
In effect, this is a process that is implemented, and this process can be used to meet a variety of needs in a totally integrated manner with built-in capacity building. The process is an attempt to answer the question of "how" to do it in a manner that will be successful and sustainable.
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FOOTNOTES
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1 Presented at the Atlanta conference on Forging Effective Strategies to Combat Iron Deficiency held May 7–9, 2001 in Atlanta, GA. The proceedings of this conference are published as a supplement to The Journal of Nutrition. Supplement guest editors were Frederick Trowbridge, Trowbridge & Associates, Inc., Decatur, GA and Reynaldo Martorell, Rollins School of Public Health, Emory University, Atlanta, GA.
2 This article was commissioned by the International Life Sciences Institute Center for Health Promotion (ILSI CHP). The use of trade names and commercial sources in this document is for purposes of identification only and does not imply endorsement. In addition, the views expressed herein are those of the individual authors and/or their organizations and do not necessarily reflect those of ILSI CHP.
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LITERATURE CITED
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1.
Ruel, M. T. & Levin, C. E. (2000) Assessing the potential for food-based strategies to reduce vitamin A and iron deficiencies: a review of recent evidence, FCDN Discussion Paper No. 92 2000 Food Consumption and Nutrition Division, International Food Policy Research Institute Washington, DC. .
2.
Beaton, G. H. (2000) Iron needs during pregnancy: do we need to rethink our targets?. Am. J. Clin. Nutr. 72(suppl.):265S-271S.[Abstract/Free Full Text]
3.
Stoltzfus, R. J. (2001) Defining iron-deficiency anemia in public health terms: a time for reflection. J. Nutr 131:565S-567S.[Abstract/Free Full Text]
4.
ACC/SCN (2000) Micronutrient update. 4th Report on the World Nutrition Situation 2000:23-32 Geneva, Switzerland. .
5.
FAO/WHO () Preparation and Use of Food-Based Dietary Guidelines. (1996) Report of a joint FAO/WHO consultation, Nicosia, Cyprus..
6.
World Health Organization (2000) Nutrition for Health and Development. A Global Agenda for Combating Malnutrition 2000:16 WHO Geneva, Switzerland. .
7.
Food and Agriculture Organization (2000) The State of Food Insecurity in the World 2000 FAO Rome, Italy. .
8.
De Benoist, B. (2001) Iron-deficiency anemia: reexamining the nature and magnitude of the public health problem. J. Nutr. 131:64S.
9.
Winichagoon, P. Kachondham, Y. Attig, G. A. Tontisirin, K. eds. Integrating Food and Nutrition into Development 1992 Thailand’s Experience and Future Visions, The Institute of Nutrition, Mahidol University Salaya, Phuttahamonthon, Nakhon Pathom, Thailand. .
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Copyright © 2002 by American Society for Nutrition
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ABSTRACT
INTRODUCTION
