Persistent Challenges of Micronutrient Deficiencies in Latin America Need Action

Abstract

Micronutrient deficiencies affect growth and development and are critical for maintaining health at all ages. Their critical role in exacerbating complications of infections and chronic diseases continues to impact morbidity, mortality, and quality of life for many. Raising awareness and advocating for micronutrient deficiencies in Latin America is urgent to reduce this preventable burden. Globally, an estimated 372 million preschool-aged children and 1.2 billion non-pregnant women of reproductive age suffer deficiency from 1 or more micronutrient. Data is limited and often old, and the true burden of problem in the region remains unclear. There are also limited data on dietary intake and on the double burden of malnutrition. Latin America has been a leader in the design and implementation of innovative and effective actions to reduce excess energy intake and curb the consumption of unhealthy Actions to address deficiency have been implemented in many countries in the region over the years, but current evidence suggests that micronutrient deficiencies have fallen off the public health agenda in Latin America. Effective programming can be developed / appropriately adapted only with knowledge of the current burden. Such data can also help guide and predict future areas of risk and priorities to missing upcoming nutrition issues in the population. Renewed commitment to quantify and monitor micronutrient deficiencies in the region is essential. Abundant evidence and guidance exist to inform effective program selection, design and implementation to address this public health problem.

Do Micronutrient Deficiencies Really Pose a Threat to Public Health?

Vitamins and minerals coming from the food we eat, are essential, and there has been consensus for many decades on their role in supporting growth and development and maintaining health and fundamental body functions.^1,2 Many factors contribute to micronutrient deficiencies including poor diet quality and/or quantity (reduced intake), increased requirements, malabsorption and/or losses, impaired vitamin synthesis and activation, and/or decreased vitamin storage (except for water soluble vitamins that have no body storage) result in micronutrient deficiencies.^3–8 In populations with high prevalence, insufficient dietary intake of nutrients is a primary contributor.

Micronutrient deficiencies can impair metabolic processes at the cellular and biochemical level even before clinical and physical alterations are seen. ⁹ Many micronutrient deficiency-specific diseases are now eliminated at population level (eg, scurvy) or concentrated in specific population groups at high risk (eg, goiter and cretinism).^10,11 However, the critical role of deficiencies in exacerbating complications of infections, such as measles, tuberculosis, and diarrheal diseases, as well as chronic diseases, such as cancers and HIV/AIDS, continues to impact morbidity, mortality, and quality of life for many.^12–17 Deficiencies cause irreversible harm particularly in early life, with enormous consequences for survival and health (eg, folic acid and neural tube defects), growth (eg, vitamin D and rickets), and brain development (eg, iron).^18–22 Most, if not all of this burden to healthy quality of life, and ultimately communities and societies is preventable!

How Big Is the Issue, Globally and in Latin America?

The mostly “silent epidemic” of vitamin and mineral deficiencies affects people of all genders and ages, with its particularly high burden among women of reproductive age and children well-documented. Recent global estimates suggest that approximately 56% of preschool-aged children, and 69% of all nonpregnant women of reproductive age (NPWRA) globally suffer deficiency of at least one of three micronutrients. ²³ This is equivalent to 372 million (95% UI 319-425) preschool-aged children and 1.2 billion (1.0-1.4) NPWRA. Regional estimates based on available data from five Latin American countries shows a burden only slighter lower than the global estimate (63% among NPWRA and 48% among preschool-aged children), with wide variations within and between countries. ²³ Limited data on dietary intake from men and women 15 to 65 years of age in 32 urban cities in the region showed that the prevalence of inadequate intakes ranges from 0.4% to 98.2%, depending on the micronutrient, particularly among overweight/obese, men, and low socioeconomic status participants (see Monge-Rojas et al, in this supplement). Importantly, micronutrient deficiency is not something that disappears as the nutrition transition progresses. Indeed, its critical existent as part of the “multiple burdens of malnutrition” is well-documented. ²⁴ Similarly, limited data on the double burden of malnutrition (DBM) in LA region highlighted the need for further data on micronutrient deficiencies as a component of DBM and for more information on understudied population groups. ²⁵

Have Micronutrient Deficiencies Fallen off the Public Health Agenda in Latin America?

There is now overwhelming evidence from the region on the nutrition transition and its effects on diets. Countries across the region record diets with increasing consumption of energy-dense and ultraprocessed foods and decreasing consumption of nutrient-dense foods such as whole grains, fruit, vegetables, dairy among other fresh, and minimally processed foods.^26–28 A reduction in dietary diversity, one characteristic of healthy diets (see below) and a proxy measure for nutrient adequacy in the diet is also decreasing among all genders and ages in the region (see Gomez et al in this supplement).

Understandably, many innovative policies and actions have been implemented in several countries in the region to shift dietary patterns, focused primarily on curbing the high consumption of unhealthy foods, some as part of more comprehensive actions to curb the increase in overweight/obesity and related burden of NCDs. Many of these have been accompanied by rigorous research and evaluation, documenting important success.^29,30 With these approaches, the region has been a global leader in the design and implementation of effective actions to reduce excess energy intake and curb the consumption of unhealthy foods. These actions are providing global examples of option to favor two of four principles of what constitutes a healthy diet (FAO/WHO forthcoming)—moderation in the consumption of unhealthy foods, nutrients and dietary components, and balance in the consumption of energy and its sources. Healthy diets can be achieved however, only with if these are accompanied by a similar level of commitment and innovation to address the other two components of a healthy diet—diversity among and within food group, and adequacy of nutrients aligned with needs for age and life stage.

Achieving healthy diets—moderate, balanced, diverse, adequate—would simultaneously address a variety of public health concerns across the region, including overweight, obesity, and related noncommunicable disease, but also micronutrient deficiency with its multiple impacts on health, growth, and development. Unfortunately, as now, healthy diets are unaffordable for approximately 3 billion people globally, with some of the highest rates occurring in countries in the Latin American region. ³¹ Actions to address food availability and affordability must begin at the root of food production, realigning agriculture and trade policies, incentives, and disincentives to shift food supplies. ³² Food-based dietary guidelines (FBDG) are a powerful and underutilized tool to inform those needed changes. Food-based dietary guidelines translate the four principles of healthy diets into contextually appropriate dietary patterns, identifying exactly what types of foods are needed to enable every to consume a healthy diet. Several countries in the region have recently or are in the process of updating FBDG, ³³ considering also environmental sustainability of food production, presenting an enormous opportunity to influence food systems at all levels. Accompanied by well-designed, motivational demand creation for healthy diets can shift dietary patterns. ³⁴

What About Micronutrient Deficiency as These Changes Emerge?

The process of changing food systems to enable healthy diets and to enable and motivate all to consume them, however, will not happen overnight, and while we drive these changes, millions of women, children, adolescents, and others suffer the effects of micronutrient malnutrition. Where needed and appropriate, combinations of agricultural (eg, biofortification), population-based (eg, large-scale food fortification), and targeted actions (eg, multiple micronutrients for pregnancy and lactating women) are proven to prevent deficiency and associated health and other impacts. ³⁵ Despite documented progress in some countries in the region^36–39 still lack explicit policies to address micronutrient deficiency, ⁴⁰ and others have suffered from inconsistency of political and fiscal commitment.

To achieve long-term improvements in all dimensions of diet-related health and other impacts, strategies must begin with strengthening agricultural production and trade, aligning incentives and policies to enable populations to access healthy diets, appropriate to local preferences, and dietary traditions. This must be accompanied with policy continuity for primary health care for women and children, including continual supply of micronutrient interventions if needed, accompanied by effective behavior-focused actions that support adherence to recommendations. Continuous monitoring and evaluation to strengthen existing actions and adjust when needed is vital^41–43 but has been absent in many countries. Importantly, actions must be informed by local and up-to-date data and evidence in context, including but not limited to measuring the burden of micronutrient deficiency in the population (see Fernández et al in this supplement). Effective programming can be developed not only with knowledge of the current burden but can also help guide and predict future areas of risk and priorities to missing upcoming nutrition issues in the population (see Soloms in this supplement).

First and foremost, strong national leadership and policy continuity is essential to achieve healthy diets, and to ensure that those at risk of micronutrient malnutrition receive effective actions. Abundant evidence and guidance exist to inform effective program selection, design, and implementation in this regard. For example, for food fortification and biofortification, private sector commitment is essential. ⁴⁴ National mandatory fortification policies and effective monitoring and enforcement “level the playing field” for industry, ensuring essential nutrients reach those at risk.

Supplementation, fortification, and biofortification are not the solution to unhealthy diets—they do not address the underlying issue of unaffordability and unavailability of nutritious food as part of healthy diets. When well-designed and effectively implemented however, they can enhance equity given those at risk of deficiency, particularly women and children the opportunity to realize their potential, unhindered by the health and developmental burden of micronutrient deficiency.

There is urgent need to quantify and monitor micronutrient deficiencies in the region to provide insights into the magnitude and heterogeneity of the public health issue to international agencies, countries’ governments, and funding organizations, that can also guide future research, and support decision-making and investments to improve LAC's health and development.