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Iron and zinc deficiencies in China: what is a feasible and cost-effective strategy?

  • Guansheng Ma (a1) (a2), Ying Jin (a1), Yanping Li (a1) (a2), Fengying Zhai (a1), Frans J Kok (a2), Evert Jacobsen (a2) and Xiaoguang Yang (a1)...

In order to prioritise interventions for micronutrient deficiencies in China, the populations affected by iron and zinc deficiencies were assessed based on data from the 2002 China National Nutrition and Health Survey. The costs and cost-effectiveness of supplementation, food diversification and food fortification were estimated using the standard World Health Organization ingredients approach. Results indicated that 30% of children (<2 years), adults (>60 years), pregnant and lactating women, and 20% of women of reproductive age were anaemic, some 245 million people. Approximately 100 million people were affected by zinc deficiency (zinc intake inadequacy and stunting), the majority living in rural areas. Among interventions on iron and zinc deficiency, biofortification showed the lowest costs per capita, I$0.01 (international dollars), while dietary diversification through health education represented the highest costs at I$1148. The cost-effectiveness of supplementation, food fortification and dietary diversification for iron deficiency alone was I$179, I$66 and I$103 per disability-adjusted life-year (DALY), respectively. Data for biofortification were not available. For zinc deficiency, the corresponding figures were I$399, I$153 and I$103 per DALY, respectively. In conclusion, iron and zinc deficiencies are of great public health concern in China. Of the two long-term intervention strategies, i.e. dietary diversification and biofortification with improved varieties, the latter is especially feasible and cost-effective for rural populations. Supplementation and fortification can be used as short-term strategies for specific groups.

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1Bryce, J, Boschi-Pinto, C, Shibuya, K, Black, RF. WHO estimates of the causes of death in children. Lancet 2005; 365: 11471152.
2World Health Organization (WHO). World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002.
3United Nations Administrative Committee on Coordination, Sub-committee on Nutrition (ACC/SCN). Fourth Report on the World Nutrition Situation. Geneva: ACC/SCN & International Food Policy Research Institute, 2000.
4Prasad, AS. Zinc deficiency has been known for 40 years but ignored by global health organizations. British Medical Journal 2003; 356: 422424.
5Pollitt, E. Iron deficiency and cognitive function. Annual Review of Nutrition 1993; 13: 521537.
6Walter, T, De Andraca, I, Chadud, P, Perales, CG. Iron deficiency anemia: adverse effects on infant psychomotor development. Journal of Pediatrics 1989; 84: 717.
7Soewonde, S, Husaini, M, Pollitt, E. Effects of iron deficiency on attention and learning processes on preschool children: Bandung, Indonesia. American Journal of Clinical Nutrition 1989; 50: 675686.
8Lozoff, B. Behavioral alterations on iron deficiency. Advances in Pediatrics 1988; 35: 331360.
9Levin, HM, Pollitt, E, Galloway, R, McGuire, J. Micronutrient deficiency disorders. In: Jamison, DT, Mosley, WH, eds. Disease Control Priorities in Developing Countries. New York: Oxford University Press/World Bank, 1993.
10Ross, J, Chen, C, He, W, Gu, G, Wang, Y, Fu, Z, et al. Effects of malnutrition on economic productivity in China as estimated by PROFILES. Biomedical and Environmental Sciences 2003; 16: 195205.
11Gibson, RS. Zinc: the missing link in combating micronutrient malnutrition in developing countries. Proceedings of the Nutrition Society 2006; 65: 5160.
12United Nations Children’s Fund/United Nations University/World Health Organization (WHO). Iron Deficiency Anaemia: Assessment, Prevention, and Control. A Guide for Programme Managers. WHO/NHD/01.3. Geneva: WHO, 2001.
13Willett, W. Nutritional Epidemiology, 2nd ed. New York: Oxford University Press, 1998.
14Tatala, S, Svanberg, U, Mduma, B. Low dietary iron availability is a major cause of anemia: a nutrition survey in the Lindi District of Tanzania. American Journal of Clinical Nutrition 1998; 68: 171178.
15Ruel, MT. Operationalizing dietary diversity: a review of measurement issues and research priorities. Journal of Nutrition 2003; 133: 3911S3926S.
16White, PJ, Broadley, MR. Biofortifying crops with essential mineral elements. Trends in Plant Science 2005; 10: 586592.
17Allen, LH. Interventions for micronutrient deficiency control in developing countries: past, present and future. Journal of Nutrition 2003; 133: 3875S3878S.
18Wang, L. Report of China Nationwide Nutrition and Health Survey 2002 (1): Summary Report. Beijing: People’s Medical Publishing House, 2005; 18–45.
19Yang, X, Kong, L, Zhai, F, Ma, G, Jin, S. The 2002 China National Nutrition and Health Survey. Chinese Journal of Epidemiology 2005; 26: 471474.
20Piao, J, Zhang, J, Zhao, W, You, Y, Yang, X. The 2002 China Nutrition and Health Survey: quality control. Chinese Journal of Epidemiology 2005; 26: 474478.
21National Bureau of Statistics of China. China Statistical Yearbook 2002. Beijing: China Statistics Press, 2000; 8(1).
22Zhang, Q. Iron nutritional status of young female workers in Shanghai First Silk Factory. Chinese Journal of Preventive Medicine 1987; 2: 8789.
23Cai, M, Yan, WY. Study on iron nutritional status in adolescence. Biomedical and Environmental Sciences 1990; 3: 113119.
24Wang, W, Wang, JM, Bian, L, Song, J, Yang, W. Studies on iron deficiency anemia of primary school children in a rural area of Beijing. Journal of Hygiene Research 1990; 19: 3132.
25He, Y, Wang, H, Hu, Z, Lin, Y. Study on nutritional anemia in students of 7 nationalities in Xinjiang autonomous. Xinjiang Hygiene and Prevention 1994; 12: 16.
26 World Health Organization (WHO). Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Geneva: WHO, 1995.
27WHO Working Group. Use and interpretation of anthropometric indicators of nutritional status. Bulletin of the World Health Organization 1986; 64: 929941.
28Yang, Y, Wang, G, Pan, X. China Food Composition Table 2002. Beijing: Beijing Medical University Publishing House, 2002.
29Food and Agriculture Organization of the United Nations (FAO)/World Health Organization (WHO). Human Vitamin and Mineral Requirements. Report of a Joint FAO/WHO Expert Consultation. Rome: FAO, 2002.
30Ma, G, Jin, Y, Piao, J, Kok, JF, Bonnema, G, Jacobsen, E. Phytate, calcium, iron and zinc contents and their molar ratio in foods commonly consumed in China. Journal of Agricultural and Food Chemistry 2005; 53: 1028510290.
31Ma, G, Li, Y, Jin, Y, Zhai, F, Kok, FJ, Yang, X. Phytate intake and molar ratios of phytate to zinc, iron and calcium in the diets of people in China. European Journal of Clinical Nutrition 2007; 61: 368374.
32Ma, G, Li, Y, Jin, Y, Du, S, Kok, FJ, Yang, X. Assessment of zinc intake adequacy and food source of people in China. Public Health Nutrition 2007; 10: 845854.
33Block, G, Dresser, CM, Hartman, AM, Carroll, MD. Nutrient sources in the American diet: quantitative data from the NHANES II survey. American Journal of Epidemiology 1985; 122: 1326.
34Murray, CJ, Evans, DB, Acharya, A, Baltussen, RM. Development of WHO guidelines on generalized cost-effectiveness analysis. Health Economics 2000; 9: 235251.
35 World Health Organization. CHOosing Interventions that are Cost Effective (WHO-CHOICE) [online]. Available at Accessed 18 March 2005.
36Murray, CJ, Lauer, JA, Hutubessy, RC, Niessen, L, Tomijima, N, Rodgers, A, et al. Effectiveness and cost of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003; 361: 717725.
37Bouis, HE. Micronutrient fortification of plants through plant breeding: can it improve nutrition in man at low cost? Proceedings of the Nutrition Society 2003; 62: 403411.
38 Ministry of Agriculture of the People’s Republic of China. Planting area and output of staple crops in China [online]. Available at Accessed 20 March 2006.
39World Bank. Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries. Development in Practice Series. Washington, DC: World Bank, 1994.
40Horton, S. The economics of food fortification. Journal of Nutrition 2005; 136: 10681071.
41The Micronutrient Initiative/United Nations Children’s Fund (UNICEF). Vitamin & Mineral Deficiency: A Global Progress Report. Ottawa/New York: The Micronutrient Initiative/UNICEF, 2003.
42Hallberg, L, Rossander, L. Improvement of iron nutrition in developing countries: comparison of adding meat, soy protein, ascorbic acid, citric acid, and ferrous sulphate on iron absorption from a simple Latin American-type of meal. American Journal of Clinical Nutrition 1984; 39: 577583.
43Suharno, D, West, CE, Muhilal, , Karyadi, D, Hautvast, JG. Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia. Lancet 1993; 342: 13251328.
44Ridwan, E, Schultink, W, Dillon, D, Gross, R. Effects of weekly iron supplementation on pregnant Indonesian women are similar to those of daily supplementation. American Journal of Clinical Nutrition 1996; 63: 884890.
45 Brown K, Peerson JM, Allen LH. Effects of zinc supplementation on children’s growth. In: Sandström B, Walter P, eds. Role of Trace Elements for Health Promotion and Disease Prevention [special issue]. Bibliotheca Nutritio et Dieta 1998; 54: 76–83.
46McGuire, J. Addressing micronutrient malnutrition. SCN News 1993; 9: 110.
47Yip, R. Iron deficiency: contemporary scientific issues and international programmatic approaches. Journal of Nutrition 1994; 124: 1479S1490S.
48Stoltzfus, R, Dreyfuss, M. Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. The International Nutrition Anemia Consultative Group (INACG). Washington, DC: ILSI Press, 1998; 39 pp.
49Mertz, W. Food fortification in the United States. Nutrition Reviews 1997; 55: 4449.
50Honein, MA, Paulozzi, LJ, Mathews, TJ, Erickson, JD, Wong, LY. Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects. JAMA: Journal of the American Medical Association 2001; 285: 29812986.
51Ray, JG, Meier, C, Vermeulen, MJ, Boss, S, Wyatt, PR, Cole, DE. Association of neural tube defects and folic acid food fortification in Canada. Lancet 2002; 360: 20472048.
52Allen, LH. New approaches for designing and evaluating food fortification programs. Journal of Nutrition 2006; 136: 10551058.
53Haas, JH, Miller, DD. Overview of experimental biology 2005 symposium: food fortification in developing countries. Journal of Nutrition 2006; 136: 10531054.
54Chen, J, Zhao, X, Zhang, X, Yin, S, Piao, J, Huo, J, et al. Studies on the effectiveness of NaFeEDTA-fortified soy sauce in controlling iron deficiency: a population-based intervention trial. Food and Nutrition Bulletin 2005; 26: 177186.
55 Copenhagen Consensus. Copenhagen consensus – vision and facts [online], 2004. Available at Accessed 28 February 2005.
56Zhai, F, He, Y, Ma, G, Li, Y, Wang, Z, Hu, Y, et al. Study on the current status and trend of food consumption among Chinese population. Chinese Journal of Epidemiology 2005; 26: 485488.
57Haas, JD, Beard, JL, Murray-Kolb, L, del Mundo, A, Felix, A, Gregorio, G. Iron-biofortified rice increase body iron in Filipino women. Journal of Nutrition 2005; 135: 28232830.
58Bouis, HE. Global efforts to breed for more nutritious crops. In: Roos, N, Bouis, HE, Hassan, H, Kabir, KA, eds. Alleviating Malnutrition Through Agriculture in Bangladesh. Washington, DC: International Food Policy Research Institute, 2004; 2834.
59Welch, RM. Biotechnology, biofortification, and global health. Food and Nutrition Bulletin 2005; 26: 419421.
60Caballero, B. Fortification, supplementation, and nutrient balance. European Journal of Clinical Nutrition 2003; 57: S76S78.
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