Abstract
Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population‐based surveys in low‐ and middle‐income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision‐making processes.
Highlights
Deficiencies of micronutrients (MNs), such as iron and vitamin A (VA), have been recognized for decades as a public health problem disproportionately affecting women and young children in low- and middle-income countries (LMICs) and resulting in unnecessary morbidity and mortality.[1,2] In response, governments and national and international organizations have implemented programs to address these deficiencies, including large-scale food fortification, biofortification, MN supplementation, and behavior change communication aimed at changing food production decisions and consumer practices related to food selection and preparation
Because limited data were available from LMICs, we summarized the results of modeling studies that reported predicted effects of MN intervention programs
While fortification at the target levels is predicted to substantially reduce the prevalence of inadequate intake, the effect of oil and flour fortification is limited by the reach in some areas, so we explored scenarios to fortify multiple food vehicles, with varying predicted effects on excessive intake
Summary
To manage the benefits and risks of nutrition programs, information is needed on (1) the distribution of inadequate and excessive intakes, (2) the population subgroups most likely to be affected, and (3) the relative contributions of different nutrient sources (including the usual diet, self-administration of supplements, and the types and performances of existing and alternative intervention programs). A high prevalence of zinc intakes above the UL has been observed among young children in high-income countries,[34,35,36,37] but is generally not considered to be a problem.[38] On the other hand, excessive intakes of nutrients for which the consequences of excess are more severe could warrant policy changes (e.g., in the case of high preformed retinol intakes among pregnant women) These discussions may be informed by the measurement of biomarkers of excessive MN status, where available. We reanalyzed data from a national dietary survey in Cameroon[47] to model the predicted effects of various MN program scenarios
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