Introduction and Executive Summary for the Supplement Micronutrients in Latin America: Current State and Research

Global health and nutrition stakeholders are facing a period full of changes and challenges, especially in low- and middle-income countries (LMIC). Almost every country is experiencing at least, one burden of malnutrition, ¹ and among them many are facing the triple burden of malnutrition, both associated with unhealthy and nondiverse diets and reduced physical activity. According to the State of Food Security and Nutrition in the World Report, in 2022, between 691 and 783 million people faced chronic hunger, representing an increase of 122 million people compared to 2019. It also informed that 3.1 billion people could not afford a healthy diet. ² On the one hand, economic shocks, war, violence, and climate-related disruptions are the leading causes of the current steep increase in the global burden of hunger in all its forms. The COVID-19 pandemic and other repeated pandemic shocks further reduce food and nutrition security of poor countries. ³ On the other hand, chronic noncommunicable diseases, most of which are associated with overweight-obesity and unhealthy behavioral and environmental risk factors, continue to rise as the principal causes of death and disability worldwide, also disproportionately impacting LMIC. ⁴ While the prevalence of hunger in Latin America and the Caribbean (LAC) is lower than the global average, food insecurity affects a higher proportion of the population in the region (40%) relative to the global prevalence (29.3%). The region also experiences the highest cost of a healthy diet, with 131 million people unable to afford to meet the recommended nutritional requirements that healthy diets would provide. ^{5 -7} Consequently, the risks of nutrient deficiency and excess for the region can be inferred, but the scarcity of current nationally representative data on micronutrient deficiencies is neither useful for program planning or evaluation nor conducive to narrowing the equity and justice gaps in the region. ^{8 -10}

The term “micronutrients” comprises 16 minerals and 14 vitamins required for normal growth and development. Micronutrient deficiencies (also known as hidden hunger) can curtail individual and social development when their prevalence exceeds a defined public health threshold. ^11,12 Micronutrient deficiencies can cause visible and dangerous health conditions, but they can also lead to less clinically notable reductions in energy level, mental clarity, and overall capacity. This can lead to reduced educational outcomes, reduced work productivity, and increased risk from other diseases and health conditions. ¹³ Globally in this respect, micronutrient deficiencies of public health importance have consistently included vitamin A, iron, and iodine. ¹³ Other deficiencies may be of public health importance at subnational or other geographical levels. With the available information, it has been estimated that globally at least half of children under five and one-third of women of reproductive age suffer from mineral and vitamin deficiencies. ^14,15 In the LAC region, for example, anemia affected 22% of women of reproductive age according to data before the COVID-19 pandemic. ⁵

Over half a century since the 1950s, the LAC region has made important contributions to the study and control of micronutrient deficiencies which have been applied in other regions. ¹⁶ In the 1980s and 1990s Latin American countries made great efforts to assess their populations’ micronutrient status and to implement supplementation and food fortification programs to tackle nutritional anemia, iodine deficiency disorders, and vitamin A deficiency. The region’s response was so successful that by 2001 it was at the forefront in the fight against micronutrient deficiencies, mostly through innovation in food fortification. ¹⁷ Deficiency of other micronutrients (zinc, riboflavin, cobalamin, vitamin D) has been identified in several studies in the region. ¹⁶ To aspire for a significant impact on public health, investment must be consistent with a country’s epidemiologic profile. Unfortunately, it’s been a long time since most countries in the LAC region have assessed the level of comsumption and status of micronutrients, which may affect the efficiency, effectiveness, and safety of nutrition policies and programs. In 2015 this journal published the supplement Prevalence of Micronutrient Deficiencies in Latin America and the Caribbean in which the authors made clear that they had to focus on the micronutrients that had updated national survey information. ⁸ As noted in that paper, the region had already experienced a pause in interest and investment in research and surveillance of known or emerging micronutrient deficiencies—a complacency that appears to persist to date.

Our original intention was to update the information published in that supplement. The fact that there is still so little updated information modified our idea while working on the design of this special issue and inviting the authors who kindly accepted to participate. Data collection on micronutrient status is often sporadic and less consistent than anthropometric indicators of malnutrition. Therefore, current and representative data are unavailable for most countries. ¹⁸ This supplement aims to present some of the updated research available on micronutrients and perspectives to highlight the relevance and the need to have updated information on micronutrient status at the country level.

For the above reasons, this supplement includes an advocacy document entitled “Persistent challenges of micronutrient deficiencies in Latin America need action” by Fernandez-Gaxiola et al, ¹⁹ which aims to bolster awareness about micronutrient deficiencies as preventable causes of impairment of multiple metabolic processes and complications of infections and chronic diseases. It also points out that these deficiencies cause irreversible harm, particularly in early life, affecting survival, growth, and development. It also emphasizes the need for continuous monitoring and evaluation to strengthen existing actions, including the need for further data on micronutrient deficiencies in general and on understudied population groups as a component of the double/triple burden of malnutrition.

The opening article in this Supplement “A Landscape of Micronutrient Dietary Intake by 15-65 years-old urban population in 8 Latin American Countries: Results from the Latin American Study of Health and Nutrition (ELANS)” by Monje-Rojas et al ²⁰ provides micronutrient intakes data from urban populations of adolescents and adults from Argentina, Brazil, Chile, Peru, Colombia, Costa Rica, Ecuador, and Venezuela, participants in the latest multicentric study on nutrition conducted in Latin America. Results reflect that pyridoxine, zinc, vitamin C, and vitamin A present a variable spectrum (16%-52%) in the prevalence of deficiencies, whereas magnesium, calcium, and vitamin D showed critical prevalences (>80%) of inadequacy. Although the data are not representative of the entire population of the participating countries, the selected cities are among the most populated in the region; the article emphasizes the coexistence of obesity and micronutrient deficiencies in Latin America and the need for action to increase the consumption of diverse foods and biofortification and fortification policies to improve the micronutrient status in the region.

Due to the demographic transition in Latin America and the Caribbean, and the fact that micronutrient deficiencies are detrimental for health throughout the life cycle, De la Cruz-Góngora et al ²¹ conducted a narrative review of the micronutrient status of older adults from the region confirming that only a few countries have documented one or more nutritional deficiencies for older adults in national health surveys. The two most studied and published deficiencies in the literature are vitamin D and B12, focusing in cognitive and bone mineralization outcomes. The review confirms the fact that there are relevant micronutrients that are not studied at all in this age-group, as well as the need for more research and biomarker infrastructure in the region to be able to take actions in the prevention of deficiencies and their health consequences on the elderly population.

The third article included in this Supplement is a “Perspective on Emerging Micronutrient Deficiencies in Latin America and the Caribbean” by Solomos. ²² The paper reviews epidemiological considerations on 4 emergent deficiencies in the region, vitamin D, vitamin E, essential fatty acids, and choline. In addition, it focuses on highlighting the public health implications of deficiencies of these 4 nutrients, which make them candidates for nutrients of clear interest for action by health systems and other sectors involved in food systems transformation at the community and/or population level. The article also provides several options for actions to prevent and improve deficiencies of each emergent nutrient.

Two of the main population groups vulnerable to micronutrient deficiencies are pregnant women and children under five years of age, mainly due to their high micronutrient requirements. Fernández Gaxiola et al ²³ point out that the magnitude of micronutrient deficiencies in these groups in the region remains uncertain due to scarcity of information in many countries. They also highlight the health, growth, and developmental benefits of micronutrient supplementation in women at reproductive age and children, particularly in the first 1000 days of life, which translate into economic benefits for individuals, families, communities, and countries. However, they also express the need for well designed, implemented, monitored, and evaluated supplementation programs aimed at correcting micronutrients gaps in the target populations.

Finally, Gomez et al ²⁴ worked on an innovative article to analyze the possibility of using the Women’s Dietary Diversity Score, an indicator of diet quality in women of reproductive age based on 5 food groups, as a proxy to determine the dietary diversity and predict micronutrient adequacy in men and women 15 to 65 years old, living in urban areas from 8 Latin American countries, the authors performed sensitivity and specificity analyses with satisfactory results for the 11 assessed micronutrients.

This supplement underlines the relevance of continuous research and surveillance in addressing micronutrient deficiencies and the need for innovative strategies such as varied and diverse diets, and well-designed and targeted supplementation and food fortification programs to improve the micronutrient status in the region. In addition, while robust and updated data of micronutrient state in Latin America is urgently needed to advise policy and programs, increased awareness among policymakers of the importance of investment in the generation of such data is critical.