Micronutrient deficiencies and gender: social and economic costs1–3

Ian Darnton-Hill, Patrick Webb, Philip WJ Harvey, Joseph M Hunt, Nita Dalmiya, Mickey Chopra, Madeleine J Ball,
Martin W Bloem, and Bruno de Benoist

ABSTRACT health, and welfare of women will be critical (3). Women com-
Vitamin and mineral deficiencies adversely affect a third of the prise the majority of the world’s poor (4). In poor households,
world’s people. Consequently, a series of global goals and a serious women play a critical role in ameliorating the effects of poverty,
amount of donor and national resources have been directed at such especially for infants and young children. Clearly, the reduction
micronutrient deficiencies. Drawing on the extensive experience of of micronutrient deficiencies, given that they have an impact on
the authors in a variety of institutional settings, the article used a infant and child mortality; maternal morbidity and mortality; and
computer search of the published scientific literature of the topic, development, growth, and economic and social well-being,
supplemented by reports and published and unpublished work from needs to be aggressively tackled, not least to reflect the legal

Downloaded from www.ajcn.org by on September 19, 2009

the various agencies. In examining the effect of sex on the economic human right of women and children to adequate nutrition, in-
and social costs of micronutrient deficiencies, the paper found that: cluding micronutrients.
(1) micronutrient deficiencies affect global health outcomes; (2) However, given the emphasis particularly by most donor
micronutrient deficiencies incur substantial economic costs; (3) countries on economic rationalization of the past recent decades,
health and nutrition outcomes are affected by sex; (4) micronutrient there has also been a consistent call to demonstrate the cost
deficiencies are affected by sex, but this is often culturally specific; benefit of programs addressing micronutrients, especially com-
and finally, (5) the social and economic costs of micronutrient de- pared with other health and nutrition programs. The assumption
ficiencies, with particular reference to women and female adoles- that such interventions are cost-effective has heavily relied on
cents and children, are likely to be considerable but are not well statements from the World Bank which suggested that the cost of
quantified. Given the potential impact on reducing infant and child micronutrient deficiencies might be up to 5% gross national
mortality, reducing maternal mortality, and enhancing neuro- product (GNP) whereas interventions might only cost 0.3% of
intellectual development and growth, the right of women and chil-
the GNP (5). A recent report, the “Copenhagen Consensus” re-
dren to adequate food and nutrition should more explicitly reflect
sulted from economists setting priorities among a series of pro-
their special requirements in terms of micronutrients. The positive
posals for confronting ten major global challenges, by prioritiz-
impact of alleviating micronutrient malnutrition on physical activ-
ing the use of a hypothetical $50 billion made available to
ity, education and productivity, and hence on national economies
governments in developing countries. Providing micronutrients
suggests that there is also an urgent need for increased effort to
through a combination of public health and private sector pro-
demonstrate the cost of these deficiencies, as well as the benefits of
grams was ranked second, after control of human immunodefi-
addressing them, especially compared with other health and nutri-
ciency virus/acquired immunodeficiency syndrome (HIV/
tion interventions. Am J Clin Nutr 2005;81(suppl):
AIDS) (6).
1198S–1205S.
This article explores the overall social and economic impact of
KEY WORDS Micronutrients, micronutrient deficiencies, micronutrient deficiencies by identifying and systematically
vitamins, minerals, vitamin and mineral deficiencies, cost- bringing together available information on: (1) micronutrient
effectiveness, cost-benefits, gender, sex, women, children deficiencies and health outcomes; (2) micronutrient deficiencies
1
From the UNICEF Nutrition Section & Institute of Human Nutrition,
Columbia. University, New York (IDH, ND); the World Food Program
INTRODUCTION (PW), Rome, Italy; MOST, the USAID Micronutrient Program/Johns Hop-
Micronutrient deficiencies are so important to public health kins Bloomberg School of Public Health (PWJH); the John Guggenheim
outcomes, particularly in the developing world, that a series of Memorial Foundation (Nutrition and Economics) (JMH); the University of
global goals have been established, and significant amounts of the Western Cape, South Africa (MC); Human Life Sciences, University of
Tasmania, Launceston, Australia (MJB); Helen Keller International, Singa-
donor and national funds have been directed at them. A recent
pore (MWB), Micronutrients Unit, World Health Organization, Geneva,
report highlights the magnitude of the problem and attempts to
Switzerland (BdB).
demonstrate the economic and health costs of vitamin and min- 2
Presented at the conference “Women and Micronutrients: Addressing the
eral deficiencies through a series of country-specific reports (1). Gap Throughout the Life Cycle,” held in New York, NY, June 5, 2004.
It also demonstrates the cost-effectiveness of known micronu- 3
Address reprint requests and correspondence to I Darnton-Hill, UNICEF
trient interventions and the need for greater funding. To achieve Nutrition Section, 3 U.N. Plaza, Nutrition Section (7th floor), New York,
the Millennium Development Goals (2), improving the status, New York 10017. E-mail: [email protected].

1198S Am J Clin Nutr 2005;81(suppl):1198S–1205S. Printed in USA. © 2005 American Society for Clinical Nutrition
 MICRONUTRIENT DEFICIENCIES AND GENDER 1199S

Downloaded from www.ajcn.org by on September 19, 2009

FIGURE 1. Global distribution of disease burden by leading risk factors [World Health Report, WHO 2002 (55)].

and economic costs; (3) health and nutrition outcomes and sex; global burden of disease (8), iron deficiency ranks ninth overall,
(4) micronutrient deficiencies and sex; and finally, (5) the social zinc deficiency is eleventh, and vitamin A deficiency, is thir-
and economic costs of micronutrient deficiencies, with particular teenth (Figure 1).
reference to women and female adolescents and children. Con- Iron deficiency remains a public health challenge despite its
clusions are then proposed along with policy and programmatic long-recognized negative impact on the health and productivity
implications. The background information was drawn from the of women (and of adult men). Its role in impairing the cognitive
experience and information available to the authors, various development in infants and young children has provoked a re-
reports, especially from multilateral agencies and by literature newed interest in treating and preventing iron deficiency, al-
reviews using the key phrases micronutrients, vitamins, sex, though questions of effective and safe delivery remain (9). Iron
women, socioeconomic status and cost. Most of the informa- deficiency in the 6 –24 mo age group is impairing the mental
tion comes from lower income country data, with limited development of 40%– 60% of the developing world’s children
information from socially disadvantaged populations in more (1). Widespread iron deficiency negatively impacts on national
affluent countries. productivity with losses of up to 2% of the gross domestic prod-
uct (GDP) in worst affected countries (1). Iodine deficiency in
MICRONUTRIENT DEFICIENCIES AND HEALTH pregnancy is causing as many as 20 million babies per year to be
OUTCOMES born mentally impaired. This has been estimated to lower the
average IQ of those born in iodine-deficient areas by 10 –15 IQ
The adverse effects of micronutrient deficiencies and excesses
points, which then adversely affects school performance, de-
in children up to reproductive age and beyond are well known and
well documented, although some questions inevitably remain. creases productivity, and results in an enormous economic bur-
The adverse effects include both functional and health outcomes den to nations (1, 10). Vitamin A is recognized as a major factor
involving growth and development, mental and neuromotor per- in reducing excess mortality from infectious diseases in devel-
formance, immunocompetence, physical working capacity, mor- oping countries, while deficiency remains the commonest cause
bidity, mortality, and overall reproductive performance and risk in some countries of preventable childhood blindness (11). Its
of maternal death (7). Affecting the size of the health impact are importance in public health terms has become more apparent in
nutrient-to-nutrient interactions of micronutrients, age, sex, and terms of a likely role in women’s health (12) and its elimination
other host and environmental conditions such as pregnancy, ge- is a major 2010 UN goal (13). Zinc has recently been established as
netics, overall nutrition, infections, and social conditions such as both important for the treatment of diarrhea but likely to have a role,
economic status. For the purposes of this article, it is only nec- along with other micronutrients, in prevention of both diarrhea and
essary to point to the extensive evidence base of established respiratory diseases (14). Folate has long been known to be impor-
reviews. All the micronutrients of public health importance have tant in the etiology of neural tube defects and anemia, but the role of
also undergone re-positioning with regard to their public health folic acid has now been expanded to the prevention of cardiovascu-
impact over the last several decades. The Global Burden of Dis- lar disease, and as an essential component of flour fortification in
ease estimates showed that among the 26 major risk factors of the most countries with fortification (15).
1200S DARNTON-HILL ET AL

FIGURE 2. Percentage of estimated loss in gross national product (GNP) due to iron deficiency [Ross & Horton 1998 (24), Horton 1999 (56)].

Downloaded from www.ajcn.org by on September 19, 2009

Given that single micronutrient deficiencies rarely occur in which was mainly economically determined. In pregnant women
isolation, the public health importance of other micronutrients in rural Tamil Nadu, women’s intakes leading to low micronu-
such as vitamin B12, riboflavin, and the role of multi- trient intakes were most affected by eating customs and socio-
micronutrient formulations are receiving increasing attention economic status (23). Poor people are more likely than others to
(16). 앒70% of US pregnant women take multi-micronutrients as suffer from micronutrient malnutrition, but micronutrient intake
recommended medical practice, and there seems no clear reason does not necessarily improve in step with increasing income (5).
why women in low- and medium-income countries should be However, with increasing improvement in the quality of the diet,
denied the presumed benefits of this, especially if the dosage is micronutrient status will generally improve.
given at no more than one recommended daily allowance (RDA). As part of the development of the “PROFILES” package, Ross
Higher doses need further investigation, especially in high HIV- and Horton (24) developed algorithms for estimating the eco-
endemic areas (17, 18), but may well have a role in delaying nomic costs of anemia due to cognitive delays in children, lower
progression of HIV infection to AIDS (17). productivity among adults, and premature births. The analysis
suggested that the median value of productivity losses due to iron
deficiency was about $4 per capita or 0.9% of GDP (24). On a per
MICRONUTRIENT DEFICIENCIES AND ECONOMIC
capita basis, losses are greatest in rich countries, where wages are
COSTS
higher, even though iron deficiency is less widespread. Never-
Developing countries are emphasized in this article because theless, the estimated cost to South Asia, where the prevalence of
vitamin and mineral deficiencies are both highly prevalent in anemia is highest, was estimated to be around $5 billion annually
developing countries and because such deficiencies have major (Figure 2). The dominant effect for all countries is the loss
negative biomedical outcomes. However, there is also evidence associated with cognitive deficits in children (24). Horton, using
that vitamin and mineral deficiencies are still highly prevalent in
an econometric model, estimates that just 3 types of
developing nations (such as China, Indonesia and Vietnam)
malnutrition—protein-energy malnutrition, iron deficiency and
where the availability of staple foods (and thus energy defi-
iodine deficiency—are responsible for 3%– 4% of GDP loss in
ciency) are no longer problems. Some evidence shows vitamin
Pakistan in any given year and 2%–3% of GDP loss in Vietnam.
and mineral deficiencies continue to be prevalent among lower
income population groups in developed countries, such as the Maternal anemia is responsible for 20%–22% of maternal deaths
United States (19) and Europe (20). Karp (19), points out that, of due to complications of pregnancy and unsafe birthing situations
the over 13 million children in the United States whose families (25). Productivity of adult anemic agricultural workers (or other
live below the poverty level, 앒10% have overt micronutrient heavy manual labor) is reduced by 1.5% for every 1% decrease
malnutrition. in hemoglobin (Hb) concentration below the established thresh-
In developing countries, intakes of expensive animal-derived old for safe health (26) (see Figure 2).
foods are often not accessible to the poor and this substantially The World Bank summarized the benefits of micronutrients in
reduces intake of vitamins and minerals (21), whereas in indus- terms of cost per life saved and productivity gained per program
trialized countries, the poor diets in lower socioeconomic groups (Table 1). For saving lives at least cost, targeted supplementation
affect micronutrient intake more through low intakes of fruits and to at-risk groups (pregnant mothers for iron, under-fives for vi-
vegetables (20). In the Philippines, Bouis (22) showed that vita- tamin A) is more cost-effective than fortification, although the
min A deficiency was associated more strongly with a lack of latter is a more sustainable solution in the long run as incomes rise
knowledge than with low income, in contrast to iron deficiency, and households gain access to higher-quality primary health
 MICRONUTRIENT DEFICIENCIES AND GENDER 1201S
TABLE 1 ratios (29). Depending on the assumptions made, the benefit-to-
Costs and benefits of micronutrient interventions: returns on nutrition cost ratio is from 40 to 400:1 (10). The mortality risk associated
investments1 with iodine deficiency is the least well-known; limited results
Discounted Value Cost per indicate a possible 8% benefit in child mortality reduction (30).
Cost per of productivity DALY
life saved gained per program gained
Vitamin A
Deficiency/Remedy (US$) (US$) (US$)
Meta-analyses of field trials of mass vitamin A supplementa-
Iron deficiency
tion to children 6 to 59 mo of age have indicated an overall
Supplementation of pregnant 800 25 13
women only reduction in child mortality by 25%–35%, despite less consis-
Fortification 2,000 84 4 tency in the rates of reduction in morbidity, with greater reduc-
Iodine deficiency tion in severity than incidence of illness (31). Impacts on mor-
Supplementation (repro-aged 1,250 14 19 bidity are also mediated by presence or absence of other
women only) deficiencies such as iron and zinc. In contrast to low birth weight,
Supplementation (all people 4,650 6 37 the benefits from the productivity gains over decades of work
under 60) (from preventing blindness) are relatively small in comparison to
Fortification 1,000 28 8 benefits from reducing early mortality. A series of careful coun-
Vitamin A deficiency
try studies on costs of vitamin A supplementation programs for
Supplementation (under 5 325 22 9
under-5-year-old (Ghana, Guatemala, Nepal, Peru, and Philip-
only)
Fortification 1,000 7 29 pines), revealed that the unit costs of the vitamin A supplement
Nutrition Education 238 ($0.04 per child for 2 doses) represent 5% of the delivery costs

Downloaded from www.ajcn.org by on September 19, 2009

Nutrition education and 252 when the full program is costed (32). Though additional thera-
maternal literacy peutic benefits have regularly been noted in clinical settings, e.g.
the now standard practice of providing vitamin A to children
1
DALY ҃ disability-adjusted life year.
suffering from measles and the use of vitamin A to treat clinical
signs of xerophthalmia, the estimation concentrated on the ben-
efits from the prophylactic provision of vitamin A. The world-
care. Nevertheless, properly targeted supplementation is justi- wide average is now estimated to be $1.50 for 2 doses of vitamin
fied while fortification programs are in the early stage and ex- A per child per year, highly cost-effective given the role of
panding coverage, as long as the targeting principles reflect risk vitamin A deficiency as a primary risk factor in infant and child
assessment and are consistently applied. Food-based interven- mortality. Eliminating vitamin A deficiency would save 16% of
tions have the potential to be the most sustainable interventions the global burden of disease in children (30).
for micronutrient deficiencies, although they are unlikely to be
sufficient in the short term in poverty and emergency settings.
The multiple benefits of food-based approaches are clear but Iron
rarely factored in. They include increases in intake of many The estimation of the benefits of reducing iron deficiencies
nutrients, improved food security, female empowerment, and must incorporate the fact that iron deficiency anemia can affect
increased cash incomes that are likely to be spent on children’s adult worker productivity directly, as well as through its impair-
nutrition and girls’ education. An observational study in rural ment of child development. Behrman and Rozenweig (28) as-
India found that the micronutrient-rich food consumption by sumed a 5% across the board loss of labor productivity due to
pregnant women, specifically that of milk, green-leafy vegeta- current anemia in addition to the gains through reducing low birth
bles, and fruits, were independently associated with the size of weight. However, increased benefits come at increased costs,
the infant at birth (23). because to obtain these additional ongoing productivity gains,
In addressing the returns on investments to reduce micronu- there must be continued interventions over the work life in ad-
trient deficiencies, Hunt (27) has concluded the following for the dition to the one-time intervention to reduce the number of low
4 micronutrients of public health interest. birth weight infants being born by antenatal supplementation to
mothers. Eliminating severe anemia in pregnancy is estimated to
Iodine potentially reduce the maternal disease burden by some 13%.
By eliminating iodine deficiency in previously iodine-
deficient areas, the average economic gain produced by the in- Zinc
crease in cognitive development is similar to the average eco-
Daily supplementation with zinc at home has been shown to
nomic gain in preventing a low birth weight child, with a benefit-
reduce infant mortality by 70% and it is now recommended
cost ratio, per deficient women, of greater than one (28). Studies
treatment for diarrhea, along with oral rehydration therapy (14,
from Germany, India, Latin America, and the United States have
33). There is little reported experience on delivery mechanisms
shown the benefits of different interventions to reduce iodine
suitable for large scale interventions (except, perhaps, with mul-
deficiency (10). In Ecuador, people with moderate deficiency
tiple fortification).
were consistently paid less for agricultural work (Greene 1977
cited in 26). More recently, WHO looked at the cost- Noting that potential investments appear under-resourced,
effectiveness and benefit-to-cost ratios of micronutrient inter- Behrman and Rozenweig have also noted the high rates of
ventions, especially fortification and salt iodization programs; benefit-to-cost ratios and that the ‘gains appear to be particularly
both of which were identified as having very high benefit-to-cost large for reducing micronutrient deficiencies in populations in
1202S DARNTON-HILL ET AL

which prevalences are high’ (28). The portion of the global bur- It has been pointed out— eg, by the UN Secretary General—
den of disease (mortality and morbidity, 1990 figures) in devel- that women are being particularly severely impacted by the HIV/
oping countries that would be removed by eliminating malnutri- AIDS epidemic as they are biologically, socially, and culturally
tion is estimated by Mason, Musgrove, and Habicht as 32% (30). more HIV-susceptible than men. HIV rates are 20% higher than
This includes the effects of malnutrition on the most vulnerable men in sub-Saharan Africa, and much higher in younger age
groups’ burden of mortality and morbidity from infectious dis- groups, with nearly 60% of those living with HIV/AIDS in sub-
eases only. This is therefore a conservative figure, but nonethe- Saharan Africa being women (40). They are also less likely to
less much higher than previous estimates, mainly due to now avail themselves of health services for the treatment of opportu-
including micronutrient malnutrition (30). Seen in relation to the nistic infections and more likely to forego food consumption in
overall disease burden (all population groups, all causes, all their household than men (41).
developing countries), eliminating micronutrient malnutrition In settings that experience little nutrition improvement despite
(in children plus anemia in reproductive age women) would save economic growth, social discrimination against women is com-
18% of the global burden of disease, with eliminating child mon (42). In Pakistan, for example, widespread discrimination
underweight an additional 15% (30). against girls and women is high and child malnutrition rates are
among the highest in the world, as is the proportion of low birth
weight infants, at 25%. Meanwhile in Thailand, where nutrition
has improved remarkably in the last 2 decades, women have very
HEALTH AND NUTRITION OUTCOMES AND SEX high literacy, high participation in the labor force, and a strong
Women and young girls are disadvantaged in health outcomes place in social and household-level decision-making. Within
in the developing world whereas this may not be the case in the India, women have similarly better relative status in Kerala com-
more industrialized world where women routinely outlive men. pared with other states, and Kerala has better health, social and

Downloaded from www.ajcn.org by on September 19, 2009

This does not preclude the possibility of social disadvantage, and nutrition indicators, and not coincidently, the highest levels of
an excess of some diseases such as depression (4). In most af- female education (42).
fluent countries, being a single mother is a strong risk factor for
poverty or socioeconomic disadvantage. Globally, being a single
mother or widow, and thus heading a female-headed household, MICRONUTRIENT DEFICIENCIES AND SEX
almost invariably results in reduced income and increased like- As previously noted, the evidence that infant, young child,
lihood of living in poverty (34). In their sample of South African adolescent, and adult females have significantly worse health
female-headed households though, Lemke et al found that this and nutrition is strong, while this depends on the region con-
did not necessarily mean they were less likely to have adequate cerned and social and status factors (35). There is surprisingly
food (34). little information on micronutrient deficiencies and their relation
That many women are systematically discriminated against, or to sex, although assumptions of sex discrimination are common.
that a lower value is placed on women in many societies, is A recent review noted that while it is important to recognize that
indisputable based on routine statistical indicators such as important differences do exist in prevalence rates for various
female-to-male life expectancy, and literacy (3) and with evi- micronutrient deficiencies by sex, physiology also plays a role in
dence, especially from South Asia, that they have less control the expression of deficiencies, but such differences are not easily
over economic resources, than women in Norway or even Latin generalized (43). For example, 3 broadly accepted “facts” are
America (35). Regional differences in low birth weights may also often repeated in the micronutrient literature. The first is that
reflect women’s status. This is important because low birth boys are “at greater risk of xerophthalmia (night blindness and
weight is the best single predictor of malnutrition (and likely Bitot’s spot) than are girls” (11, 44). The second is that women of
some key limiting micronutrients) because it is associated with reproductive age suffer a higher prevalence of iron deficiency
poor growth in infancy and throughout childhood (36), and in- than men do (45). The third is that “girls have a higher prevalence
creased subsequent mortality. Low birth weight may also lead to [of iodine deficiency] than boys,” especially from adolescence
increased obesity and noncommunicable disease morbidity and onward (46).
mortality later in life (37). Maternal mortality ratio is a shocking There certainly is evidence to support such claims. Vitamin A
50 and 80 times higher in South Asia and sub-Saharan Africa than deficiency is commonly reported to be up to 10 times more
in the United States or Europe (38). common in males than females (44). Similarly, there is a well-
Sex disparities are reflected throughout the life course. Where documented higher risk of anemia in women of reproductive age
antenatal sex identification is increasingly performed, as in due to menstruation and repeated pregnancies (45), with preg-
China and South Asia, there is a striking imbalance in male-to- nant women at greater risk of being iron deficient when anemia
female birth ratios (3, 39), presumed to be due to female feticide. is identified as a clinical manifestation (25). That said, few recent
The differences in ratios of girls to boys having primary educa- studies confirm empirically that the vitamin A status of boys is
tion are well documented and vary strongly across countries. The significantly lower than that of girls, but that seems to depend on
adult literacy rate in South Asia for women as a percentage of the environmental, epidemiologic, and disease profiles of com-
those for men is 62%, compared with 72% in the Middle East and munities, as does iron deficiency anemia among men and chil-
North Africa and in sub-Saharan Africa (13, 36). Across differ- dren between 5 and 18 y of age (43). Indeed, most studies tend to
ences in wealth, not only is it harder for a girl living in impov- assess micronutrient status of children without disaggregating by
erished circumstances to get primary education, but even if she the sex of child, and focus on the status of mothers without
does receive it, it is likely to be of shorter duration. She is more considering the status of fathers or sons. The undifferentiated
likely to be pulled out of school for family needs, and less likely, aggregation of people into broad categories of “children” or
in most countries, to go onto higher education (3). “women” can obscure wide variation in conditions as individuals
 MICRONUTRIENT DEFICIENCIES AND GENDER 1203S
proceed through the life cycle in different socioeconomic, cul- when cost savings have been factored in, had saved the govern-
tural, and agro-ecological contexts. ment $1.5 million or annually $167 000 (50). Cost-effectiveness
Examples of micronutrients linked to sex disadvantage in- studies undertaken on the national vitamin A distribution pro-
clude the significantly higher risk of mortality among night-blind grams in Ghana and Zambia found the costs per death averted
women compared with non-night-blind women even after the were $277 and $162 respectively (51, 52).
end of the pregnancy and the resolution of night blindness (38). There are also major costs of micronutrient deficiencies asso-
Anemia affects 50%–70% of women during pregnancy and in ciated with humanitarian crises. Women are typically overrep-
severe forms will increase the risk of maternal mortality by up to resented in terms of negative impacts of today’s complex emer-
20% (1, 9). In a review on iron intake from India, it was reported gencies—roughly 70% of refugees and people displaced inside
that the intake of iron was 쏝50% of the RDA for children 1– 6 y their own countries by armed conflict are women and children.
old. For pregnant and lactating women, the intake was 37% and Wherever crises have resulted in compromised access to food,
49% of RDA respectively (47). In South Asia, and other areas the threat of acute micronutrient deficiencies rises; if a popula-
where portions of the population are living in poverty, multiple tion is already deficient in vitamins and minerals when an emer-
micronutrient deficiencies coexist (16). It has been noted that gency unfolds, the impact is worse than if preexisting conditions
even when females [in Asia] are apparently meeting energy and had been satisfactory. In Bangladesh, for example, a higher in-
protein needs, they may still be at risk of micronutrient malnu- take of vitamin A was associated with a lower risk of severe
trition due to lower intakes of more expensive animal foods, malnutrition among children directly affected by floods (53). In
fruits, and treats of higher nutrient density (23). Nevertheless, the Indonesia, although the drought and economic crisis of the late
recent review by Webb et al (43) suggests that generalizations are 1990s did not have a significant impact on child anthropometry
not possible due to an enormous geographic and cultural varia- (weight-for-age), child iron status deteriorated sharply during the
tion, even for India. crisis and still had not recovered to its precrisis level 5 y later (21).

Downloaded from www.ajcn.org by on September 19, 2009

In Bangladesh, this sex discrimination can actually have an The damage to cognitive development and attained schooling
unexpected impact in that while girls may receive a less favored among these children is likely to be long lasting.
diet, this might mean more dark green leafy vegetables so their Studies on women’s status and childhood nutritional status,
levels of vitamin A are better than comparable boys and the levels although not addressing micronutrient status directly, have con-
of vitamin A deficiency less (43). Research from Mexico, how- cluded that there is good evidence to show that a woman’s status
ever, showed no significant sex differences in dietary quality or impacts on the nutritional status of her child. Because women
quantity in infants and preschoolers even under conditions of with higher status (relative to men) have better nutritional status
economic and demographic stress (48). Nevertheless, school themselves, they are better cared for and provide higher quality
girls consumed significantly less energy per day than boys and care to their children (35). Across countries, relative resources
less of all micronutrients examined, presumably because of controlled by women tend to increase the share spent on educa-
lower total dietary intake. The authors concluded that the lower tion (54). Educated girls and women have fewer children, seek
food intakes of girls did not appear to be due to purposeful diet medical attention sooner for themselves and their children, and
discrimination, but rather to culturally patterned sex roles involv- provide better care and nutrition for their children (3).
ing lower activity (48).
CONCLUSION
SOCIAL AND ECONOMIC COSTS OF It has been shown that: (1) micronutrient deficiencies lead to
MICRONUTRIENT DEFICIENCIES BY SEX poor health outcomes; (2) micronutrient deficiencies are respon-
There is insufficient information on the costs of micronutrient sible for economic costs at individual, community, and national
deficiencies to people as individuals and communities. Using the levels; (3) sex affects health and nutrition outcomes; (4) sex may
PROFILES software package (Academy for Educational Devel- effect micronutrient deficiencies, at least in some cultures, and
opment), estimates have been made for several countries. A that where there is a difference it is usually females who are
recent example is Sierra Leone, where it was concluded that in disadvantaged; and, (5) there are major social and economic
the absence of adequate policy and program action to reduce costs of micronutrient deficiencies, and consequently, benefits of
anemia rates in women, the monetary value of agricultural pro- addressing them. What has not been conclusively shown, al-
ductivity losses associated with anemia in the female labor force though the evidence points that way very strongly is that these
over the next 5 y would exceed $94.5 million; the present value costs— both social and economic—are greater for females.
of the future productivity losses associated with the intellectual Where it has been demonstrated, it has not been well quantified.
impairment resulting from intrauterine iodine deficiency ex- The usual quantitative approaches used in assessing health and
ceeds $42.5 million; and over 38 000 deaths of Sierra Leonean nutrition risk may miss this sort of information, as sex and intra-
children under 5 y of age will be attributable to vitamin A defi- household relations, social networks and informal sector activi-
ciency (49). ties are often not uncovered by conventional statistical methods
In an economic costing exercise in Nepal the authors identified (34, 43, 54).
that the cost of death averted by vitamin A being provided in the The 2003 Human Development report was able to conclude
country by Female Community Health Volunteers was $327 that generally, while some progress had been made, “sex inequal-
(50). Quite apart from the social benefits of empowering these ity undermines women’s capabilities in education and health”
poorly educated women, the program was identified as reducing (3). More attention to the context-specific nature of micronutri-
the incidence and severity of diarrheal diseases and measles, ent deficiencies is called for as a first step toward more reliable
which in turn reduces the need for Ministry of Health services, prevalence estimations and a more rational basis for targeting
thereby saving the Government of Nepal $1.5 million—which public health action. The countries with the worst health and
1204S DARNTON-HILL ET AL

nutrition conditions, Asia and sub-Saharan Africa, would gain 12. West KP jr. Extent of vitamin A deficiency among pre-school children
most from the broad public health benefits of better nutrition and women of reproductive age. J Nutr 2002;132:2857S– 66S.
13. UNICEF, World Fit For Children. UN General Assembly Special Ses-
(30). Because it is increasingly accepted that an integrated ap- sion on Children. New York: United Nations A/RES/S-27/2, 2002.
proach is required to tackle many vitamin and mineral deficien- 14. IZiNCG (International Zinc Consultative Group). Hotz C, Brown KH,
cies (including dietary diversification, fortification and supple- eds. Assessment of the risk of zinc deficiency in populations and options
mentation integrated into programs to control intestinal parasites for its control. IZiNCG Technical document #1. Food Nutr Bull 2004;
and malaria, as well as environmental, sanitation, and political 25(suppl):96S–203S.
15. Bishai D, Nalubola R. The history of food fortification in the United
interventions), more attention needs to be paid to the ecological, States: its relevance for current fortification efforts in developing coun-
economic, and cultural factors that influence the local consump- tries. Econ Devel Cultural Change 2002;51:37–53.
tion and absorption of nutrients by sex. 16. Huffman SL, Baker J, Shumann J, Zehner ER. The case for promoting
To achieve sustainable improvement of the nutritional status multiple vitamin/mineral supplements for women of reproductive age in
Developing countries. Linkages Project. Washington DC: Academy for
of children, women’s status should be improved in all regions,
Educational Development, 1999.
but especially in South Asia, followed by sub-Saharan Africa. 17. Fawzi WW, Msamanga GI, Spiegelman D, et al. A randomized trial of
However, women’s health must also be improved for their own multivitamin supplements and HIV disease progression and mortality.
sake so they are able to lead a productive, healthy, and vital role N Engl J Med 2004;351:23–32.
in their societies, which would, in turn, reap the economic and social 18. Friis H, Gomo E, Nyazema N, et al. Effect of multimicronutrient sup-
plementation on gestational length and birth size: a randomized,
benefits. One important way of doing this is to ensure that women placebo-controlled, double-blind effectiveness trial in Zimbabwe. Am J
and female adolescents and children achieve the various micronu- Clin Nutr 2004;80:178 – 84.
trient goals. Investing in female nutrition through long-term, com- 19. Karp R. Malnutrition among children in the United States: the impact of
prehensive life-course based programs will help break the intergen- poverty. In: Shils ME, Olson JA, Moshe S, Ross AC, eds. Modern
erational cycle of malnutrition, reduce the cost of micronutrient nutrition in health and disease. 9th ed. Baltimore: Williams & Wilkins,
1999;989 –1001.

Downloaded from www.ajcn.org by on September 19, 2009

deficiencies; and have multiple other benefits for women, children, 20. Darmon N, Ferguson EL, Briend A. A cost constraint alone has adverse
their households, and ultimately for nations. effects on food selection and nutrient density: an analysis of human diets
by linear programming J Nutr 2002;132(12):3764 –71.
The helpful inputs or suggestions of the following people are gratefully 21. Bloem MW, de Pee S, Darnton-Hill I. Micronutrient deficiencies and
acknowledged: Dr. Victor Aguayo (UNICEF), Dr. Bruce Cogill (FANTA maternal thinness: first link in the chain of nutritional and health events
Project/AED/USAID), Professor Richard Deckelbaum (Columbia Univer- in economic crises. In: Bendich A, Deckelbaum RJ, eds. Primary and
sity). Dr Rainer Gross, (Chief, Nutrition Section, UNICEF), Professor John secondary nutrition. 2nd ed. Totowa, NJ: Humana Press, 2005:357–73.
Mason (University of Tulane, USA), Dr. Chizuru Nishida (WHO), Dr. Tina 22. Bouis H. Evaluating demand for calories for urban and rural populations
Sanghvi (BASICS II), Ms Margaret Majuk and Ms. Shannon Fitzgerald in the Philippines: implications for nutrition policy under economic
(UNICEF Library services). The collective responsibility for the article is recovery. World Devel 1990;18:281–99.
comprised as follows: conception and outline drafting (IDH and ND); sig- 23. Rao S, Yajnik CS, Kanade A, et al. Intake of micronutrient-rich foods in
rural Indian mothers is associated with the size of their babies at birth:
nificant writing contributions (PW, PWJH, JMH); intellectual contribution
Pune Maternal Nutrition Study. J Nutr 2001;131:1217–24.
and substantive text editing (MC, MB, MWB) and overall review of article 24. Ross J, Horton S. Economic consequences of iron deficiency. Ottawa:
(BdeB). None of the authors expressed a conflict of interest. The views The Micronutrient Initiative. 1998.
expressed are those of the authors, not necessarily their institutions. 25. Allen L, Gillespie S. What Works? A review of the efficacy and effec-
tiveness of nutrition interventions. Standing Committee on Nutrition of
the UN ACC/SCN Nutr Policy paper No. 19/Asian Development ADB
REFERENCES Nutr Devel Ser No. 5. Geneva: ACC/SCN, 2001.
1. Adamson P, MI/UNICEF. Vitamins & mineral deficiency: a global 26. Levin HM, Pollitt E, Galloway R, McGuire J. Micronutrient deficiency
progress report. Calculations based on: Ross J, Stiefel H. Calculating the disorders. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL,
consequences of micronutrient malnutrition on economic productivity, eds. Disease control priorities in developing countries. Washington DC:
health and survival. Ottawa: Micronutrient Initiative, 2003. World Bank, 1993.
2. SCN. 5th Report on the World Nutrition Situation: nutrition for improved 27. Hunt JM. The potential impact of reducing global malnutrition on pov-
development outcomes. UN System Standing Committee on Nutrition, erty reduction and economic development. Asia Pac J Clin Nutr 2005:
Geneva: WHO, 2004. 14(CD Supplement):10 –38.
3. UNDP. Human development report. Millennium development goals—a 28. Behrman JR, Rozenweig MR. The returns to increasing body weight.
compact among nations to end human poverty. New York: UNDP, 2003. Penn Institute for Economic Research. Philadelphia: University of Penn-
4. Doyal L. Gender and the 10/90 gap in health research. Bull World Health sylvania, 2001;PIER Working paper 01– 052:1– 41.
Org 2004;82:162. 29. Allen L, de Benoist B, Dary O, Hurrell R. Guidelines on food fortifica-
5. McGuire J, Galloway R, World Bank. Enriching lives: overcoming tion with micronutrients for the control of micronutrient malnutrition.
vitamin and mineral malnutrition in developing countries. Development Geneva: WHO, 2004.
in Practice Series. Washington DC: World Bank, 1994. 30. Mason JB, Musgrove P, Habicht JP. At least one-third of poor countries’
6. Behrman JR, Aldermann H, Hoddinott J. Hunger and malnutrition. disease burden is due to malnutrition. Bethesda, MD: Disease Control
Copenhagen Consensus— challenges and opportunities, 2004;58. Priorities Project, Fogarty International Center, NIH, 2003;DCPP Work-
7. Viteri FE, Gonzalez H. Adverse outcomes of poor micronutrient status ing paper no. 1:1–19.
in childhood and adolescence. Nutr Rev 2002;60(suppl):S77–S83. 31. Villamor E, Fawzi WW. Vitamin A supplementation: implications for
8. Ezzati M, Lopez AD, Rodgers A, Vander HS, Murray CJ. Selected major morbidity and mortality in children. J Infect Dis 2000;182:1(suppl):
risk factors and global and regional burden of disease. Lancet 2002;360: 122S–33S.
1347– 60. 32. Neidecker-Gonzalez O, Nestel P, Bouis H. Estimating the global costs of
9. INACG/WHO. Iron deficiency anemia: reexamining the nature and vitamin A capsule distribution–a review of the literature and develop-
magnitude of the public health problem. Beard J, Stoltzfus R, eds. J Nutr ment of a country-level model. Harvest Plus Challenge Program,
2001;131(suppl):564S–703S. CGIAR, 2004.
10. Hetzel BS, Delange F, Dunn JT, Ling J, Mannar V, Pandav C. Towards 33. WHO/UNICEF Joint Statement. Clinical management of acute diar-
the global elimination of brain damage due to iodine deficiency. Delhi: rhoea. World Health Organization. WHO/FCH/CAH/04.7/United Na-
Oxford University Press. 2004. tions Fund for Children UNICEF/PD/Diarrhoea/01. 2004.
11. Sommer A, West KP Jr, Olson JA, Ross CA. Vitamin A deficiency: 34. Lemke S, Vorster HH, Jansen van Rensburg NS, Ziche J. Empowered
health, survival, and vision. New York: Oxford University Press, 1996. women, social networks and the contribution of qualitative research:
 MICRONUTRIENT DEFICIENCIES AND GENDER 1205S
broadening our understanding of underlying causes for food and nutri- 46. Cobra C, Muhilal, Rusmil K, et al. Infant survival is improved by oral
tion insecurity. Publ Health Nutr 2003;6:759 – 64. iodine supplementation. J Nutr 1997;27:574 – 8.
35. Smith LC, Ramakrishnan U, Ndiaye A, Haddad L, Martorell R. The 47. Singh P, Toteja GS. Micronutrient profile of Indian children and women:
importance of women’s status for child nutrition in Developing Coun- summary of available data for iron and vitamin A. Indian Pediatr 2003;
tries. Washington DC: International Food Policy Research Institute/ 40:477–9.
Department of International Health, Emory University. IFPRI Research 48. Backstrand JR, Allen LH, Pelto GH, Chavez A. Examining the gender
Report 131, 2003. gap in nutrition: an example from rural Mexico. Soc Sci Med 1997;44:
36. Mehotra S. Child malnutrition and gender discrimination in South Asia:
1751–9.
is the worst malnutrition linked to the worst gender discrimination in the
world? In: Thakur R, ed. South Asia and the UN. Tokyo: UNU Press, 49. Aguayo VM, Scott S, Ross J on behalf of the PROFILES Study Group
2004:315–34. in Sierra Leone. Sierra Leone- investing in nutrition to reduce poverty:
37. Darnton-Hill I, Nishida C, James WPT. A life course approach to diet, a call for action. Publ Health Nutr 2003;6(7):653–7.
nutrition and the prevention of chronic diseases. Publ Health Nutr 2004; 50. Fiedler J. The Nepal Vitamin A program: prototype to emulate or donor
7(1A):101–21. enclave? Health Policy Planning 2000;15:45–56.
38. Christian P. Micronutrients and reproductive health issues: an interna- 51. Rassas B, Hottor JK, Anerkai OA, et al. Cost analysis of the national
tional perspective. J Nutr 2003;133(suppl):1969S–73S. vitamin A supplementation program in Ghana. MOST Project, Arlington
39. Khanna R, Kumar A, Vaghela JF, Sreenivas V, Piliyel JM. Community VA. ISTI Inc./USAID, March 2004.
based retrospective study of sex in infant mortality in India. Br Med J 52. Rassas B, Nakamba PM, Mwela CM, et al. Cost analysis of the national
2003;327:126 –9. vitamin A supplementation program in Zambia. MOST Project, Arling-
40. Prah Ruger J. Combating HIV/AIDS in developing countries. Br Med J ton VA: ISTI Inc./USAID, August 2003.
2004;329:121–2. 53. Choudhary A, Bhuiya A. Effects of biosocial variables on changes in
41. UNAIDS. AIDS epidemic update. December 2002. Geneva: UNAIDS, nutritional status of rural Bangladeshi children, pre- and postmonsoon
2002. flooding. J Biosocial Sci 993;25:351-7.
42. Bhutta ZA, Gupta I, de’Silva H, et al. Maternal and child health: is South
54. Quisumbing AR, Maluccio JA. Intrahousehold allocation and gender
Asia ready for a change? Br Med J 2004;328:816 –9.
43. Webb P, Nishida C, Darnton-Hill I. Intrahousehold dimensions of vita- relations: new empirical evidence from four developing countries.

Downloaded from www.ajcn.org by on September 19, 2009

min and mineral deficiencies: a review of the evidence. Publ Health Nutr Washington DC: International Food Policy Research Institute. FCND
(in press). Discussion Paper No. 84, 2000;80pp.
44. McLaren DS, Frigg M. Sight and life manual on Vitamin A deficiency 55. WHO. The World Health Report 2002: reducing risks, promoting
disorders (VADD). Basel, Switzerland: Task Force Sight & Life, 1997. healthy life. Geneva: WHO, 2002.
45. Kurz KM. Adolescent nutrition status in developing countries. Proc Nutr 56. Horton S. Opportunities for investments in nutrition in low-income Asia.
Soc 1996;55:321–37. Asian Devel Rev 1999;17:246 –73.