National Strategy on Prevention and Control of Micronutrient Deficiencies (2015-2024)

Institute of Public Health Nutrition Directorate General of Health Services Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES, BANGLADESH (2015-2024) Cover Photo: © UNICEF/BANA2011-00749/Kiron Design: MAASCOM NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES, BANGLADESH (2015-2024) NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) D Goal, Objectives and Background 1 Institute of Public Health Nutrition Directorate General of Health Services Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES, BANGLADESH (2015-2024) December 2015 MESSAGE Micronutrient deficiencies are common in young children in developing countries with additional deleterious effects. It is also a common problem for Bangladesh as identified in the National Micronutrient Survey 2011-2012. Vitamin A deficiency increases the chances of infant and child morality, zinc deficiency reduces protection against diarrhoea and respiratory infections, and iodine deficiency curtails cognitive development in infancy. Generating political commitment and funding support to address vitamin and mineral deficiencies remains a challenge because the effects of micronutrient deficiencies in young children are not always obvious, even to parents. The Ministry of Health and Family Welfare has always been a nutrition pioneer and demonstrated commitment by addressing micronutrient deficiency problem in Bangladeshi population and developed the first ever comprehensive “National Strategy for Prevention and Control of Micronutrient Deficiencies in Bangladesh 2015-2024”. I appreciate the significant contributions of members of Expert Working Groups and other representatives from different organizations, development partners, research institute and academia for their continuous efforts to develop this very important strategy which will complement the implementation of National Nutrition Policy 2015 endorsed by the government. Finally, I wish a great success for the implementation of this strategy. Joy Bangla, Joy Bangabandhu. Long live Bangladesh. Mohammed Nasim Mohammed Nasim, MP Minister Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh MESSAGE This is my pleasure to learn that ‘National Strategy on Prevention and Control of Micronutrient Deficiencies, Bangladesh, 2015-2024’ has been developed by National Nutrition Services (NNS), Institute of Public Health Nutrition (IPHN) under the Ministry of Health and Family Welfare. Bangladesh has made a good progress and widespread in reducing malnutrition in Bangladesh though micronutrient deficiency like iron and folic acid, vitamin-A, iodine, zinc, calcium, B-12 etc. A number of micronutrient deficiency control programme like supplementation of iron and folic acid, vitamin-A, MNP sachet and zinc is being implemented by the Ministry of Health and Family Welfare in collaboration with other Ministries. At the same time Ministry of Health and Family Welfare is also providing technical support to relevant ministries to implement food fortification with iodine, vitamin-A etc through National Nutrition Services (NNS) and IPHN. I would like to congratulate Institute of Public Health Nutrition (IPHN) to take the lead in developing this national strategy and my sincere gratitude to all other concerns who were involved in formulating this. Joy Bangla, Joy Bangabandhu. Long live Bangladesh. Mr. Zahid Maleque Mr. Zahid Maleque, MP State Minister Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh MESSAGE The National Micronutrient Survey 2011-12 documented multiple micronutrient deficiencies among the population, especially younger children, school-age children and women of reproductive age in Bangladesh. Dietary inadequacy is the primary cause of vitamin A deficiency disorders, zinc deficiency and iron deficiency anaemia; while poor iodine content of soil and water due to environmental iodine deficiency is the main determinant of IDD. In Bangladesh, the National Nutrition Services (NNS) is being implemented to prevent these micronutrient malnutrition through short term supplementation like periodic mega dosing of vitamin A, distribution of iron and folic acid tablets, calcium, zinc etc and long term fortification program such as salt iodisation and Vitamin ‘A’ fortification of refined vegetable oil. Though these have been in operation for over many years, we are still facing these deficiencies due to some constraints. This “National Strategy for Prevention and Control of Micronutrient Deficiencies in Bangladesh 2015-2024” is providing detailed integrated and multi-sectoral approaches to overcome all constraints and fill up the gaps in the implementation of recommended micronutrient interventions for Bangladesh. I am confident that NNS in close collaboration with Directorate General of Health Services, Ministry of Health and Family Planning and other key stakeholders will facilitate operationalization of the strategy to combat malnutrition and micronutrient deficiencies in Bangladesh. Syed Monjurul Islam Secretary Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh FORWARD Micronutrients are essential nutrients which are required in very small amounts, but benefits human health and nutrition immensely. Vitamin ‘A’, iron, zinc, iodine, folate and B12 are among some of the important micronutrients. Deficiencies of these micronutrients are associated with morbidity, blindness, lower protection from infection, growth limitation in children, impairment of brain development and lower intelligence. Addressing micronutrient deficiencies has a bearing on individual and family health, education and income outcomes and national productivity and development. In Bangladesh, despite the significant improvements in the health and nutrition situation, the status of micronutrient deficiencies remains worrisome, particularly among vulnerable and disadvantaged population groups. Natural and human -made disasters compound the problem. Bangladesh needs to accelerate progress on key nutrition targets. A range of short, medium and long term approaches are in place in this national strategy for addressing micronutrient deficiencies. A National Micronutrient Survey was undertaken in 2011-12 and the report was released in early 2013. The survey provided a valuable opportunity for a thorough review of the country landscape in relation to Micronutrient Deficiencies. Ministry of Health and Family Welfare guided to National Nutrition Services (NNS) for review of the national micronutrient survey report and also ongoing micronutrient interventions in collaboration with development partners, international and national NGOs working in the nutrition field especially with micronutrient interventions. I appreciate the efforts made by the National Nutrition Services (NNS) for adding this national strategy in collaboration with UNICEF, MI, GAIN and other stakeholders and Ministries. My special thanks to the eminent members of Expert Working Group and also sub-groups for steering the process and providing strategic guidance to the strategy. IPHN with the support from the MoH&FW will develop a detail plan of action on implementation of the “National Strategy for Prevention and Control of Micronutrient Deficiencies in Bangladesh”. I am confident that the multi-sectoral approach to addressing micronutrient deficiencies will deliver effective and efficient programs and significantly change nutrition status in Bangladesh. Roxana Quader Additional Secretary (PH & WH) Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh. MESSAGE I am very happy to learn that National Nutrition Services (NNS), Institute of Public Health Nutrition (IPHN) has developed the first ever “National Strategy on Prevention and Control of Micronutrient Deficiencies, Bangladesh, 2015-2024”. This national strategy document was long overdue. Bangladesh possesses a huge burden of deficiencies on a range of micronutrients including Iron and Folic Acid, Vitamin A, Iodine, Zinc, Calcium, Vitamin B12 etc. Bangladesh is quite committed to address micronutrient deficiencies and working across Ministries including Health and Family Welfare, Industries, Agriculture etc. towards reducing micronutrient deficiency related problems. Directorate General of Health Services through its relevant Operational Plans has been contributing significantly to fight against the menaces of hidden hunger. I congratulate the Institute of Public Health Nutrition (IPHN) to take the lead in conducting the national survey and developing this important strategy in close cooperation with UNICEF, MI, GAIN and other key stakeholders. Let we dream for a country free from preventable menace of micronutrient deficiencies. Professor Dr. Deen Mohd. Noorul Huq Director General of Health Services Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh MESSAGE Bangladesh has been acclaimed globally for its remarkable success in health, nutrition and population control programs. However, micronutrient malnutrition still poses a significant public health problem in Bangladesh. The National Micronutrient Survey was timely undertaking at a time when the Government was willing to strengthen its nutrition programming through updated strategies. I appreciate the lead role of Institute of Public Health Nutrition and its collaborating organizations and agencies for their initiative to conduct this comprehensive National Strategy. Bangladesh has been implementing a multi-sector program targeted towards control of micronutrient deficiencies. Directorate General of Family Planning through its relevant Operational plans has also been leading the program. I am glad to know that “National Strategy on Prevention and Control of Micronutrient Deficiencies, Bangladesh, 2015-2024” is going to be published. I believe the days are not too far when we can effectively control the outcomes of essential and public health important micronutrients deficiencies. Md. Nur Hossain Talukder Director General of Family Planning Ministry of Health and Family Planning Government of the People’s Republic of Bangladesh ACKNOWLEDGEMENT I am very delighted that under the leadership of the National Nutrition Services (NNS), Ministry of Health and Family Welfare (MoH&FW); the pioneering “National Strategy on Prevention and Control of Micronutrient Deficiencies, Bangladesh, 2014-2024” has been developed. The Ministry of Health and Family Welfare, along with relevant Ministries, lead a number of micronutrient deficiency control programmes’. National Nutrition Services (NNS) is providing technical leadership to the Ministry of industries to implement food fortification programmes to reduce iodine and vitamin A deficiencies in the country. The Ministries in the food and agriculture sector actively promote cultivation and consumption of micronutrient rich foods. The Institute of public Health Nutrition (IPHN) in collaboration with UNICEF, GAIN and icddr,b conducted the National Micronutrient Survey 2011-12. This national survey provided strategic direction on the need and relevance of a national strategy. I express my sincere thanks to the member of the Expert Working Group and Technical Committee, Ministries and civil society for their valuable guidance and their continuous contribution for developing this national strategy document. Specifically, I would like to thank UNICEF to recruit a consultant Mr. Faruk Ahmed, associate professor in public health nutrition for drafting the first draft I would also like to thank MI, GAIN, icddr,b and other organizations for their technical support in developing the document. I am quite optimistic that this national strategy wills prevention and controls the micronutrient deficiencies through effective programming and multisectoral coordination and collaboration. Dr. Md. Quamrul Islam Director, Institute of Public Health Nutrition & Line Director National Nutrition Services Directorate General of Health Services Ministry of Health and Family welfare Government of the people’s Republic of Bangladesh NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 10 Table of Contents 11 List of Tables .......................................................................................................................13 List of Figures .....................................................................................................................13 List of Acronyms ................................................................................................................14 Introduction .........................................................................................................................17 Section 1 Goal, Objectives and Background .................................................................................19 1.1 Goal and Objectives ......................................................................................................20 1.1.1 Goal ..................................................................................................................20 1.1.2 Objectives .........................................................................................................20 1.2 Background ....................................................................................................................20 1.2.1 Global Context ..................................................................................................20 1.2.2 Micronutrient Deficiency Situation in Bangladesh .............................................21 1.2.3 Policy and Strategy Background .......................................................................23 1.2.4 Rationale for Micronutrient Deficiency Control Strategy ...................................24 Section 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors, Current Interventions ........................................................................................................25 2.1. Dietary Diversification ....................................................................................................26 2.1.1. Infant Young Child Feeding (IYCF) Practices ...................................................26 2.1.2. Promotion of Diversified Food Rich in Micronutrients ......................................27 2.1.2.1. Review of intake of micronutrient rich foods .....................................27 2.1.2.2. Current Interventions ........................................................................28 2.2. Vitamin A Deficiency ..................................................................................................... 29 2.2.1. Situation Analysis ..............................................................................................29 2.2.2. Current Interventions ........................................................................................29 2.2.2.1. Vitamin A supplementation in children aged 6-59 months ................29 2.2.2.2. Vitamin A supplementation in postpartum women ............................30 2.2.2.3. Fortification of foods with vitamin A ..................................................30 2.3. Iodine Deficiency Disorders ...........................................................................................31 2.3.1. Situation Analysis ..............................................................................................31 2.3.2. Current Interventions ........................................................................................32 2.3.2.1. Universal salt iodization programme ................................................32 Table of Contents NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 12 2.4. Anaemia and Iron Deficiency .........................................................................................33 2.4.1. Situation Analysis ..............................................................................................33 2.4.2. Current Interventions ........................................................................................35 2.4.2.1. Iron-folic acid supplementation programme for pregnant women ....35 2.4.2.2 Iron-folic acid supplementation programme for NPNL women and adolescent girls ..........................................................................36 2.4.2.3. Anaemia control programme for children age 6-59 months .............36 2.4.2.4. Micronutrient Powder (MNP) supplementation for young children ...37 2.5. Zinc Deficiency ..............................................................................................................37 2.5.1. Situation Analysis ..............................................................................................37 2.5.2. Current Interventions ........................................................................................38 2.5.2.1. Treatment with zinc during diarrhoea management for young children ..................................................................................38 2.5.2.2. Zinc supplementation through MNP and rice fortification .................39 2.6. Vitamin B12 Deficiency ..................................................................................................39 2.6.1. Situation Analysis ..............................................................................................39 2.6.2. Current Interventions ........................................................................................39 2.7. Vitamin D Deficiency ......................................................................................................39 2.7.1. Situation Analysis ..............................................................................................39 2.7.2. Current Interventions ........................................................................................40 2.8. Calcium Deficiency ........................................................................................................40 2.8.1. Situation Analysis ..............................................................................................40 2.8.2. Current Interventions ........................................................................................41 Section 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies ...............................................................................................43 3.1. Strategic Areas ..............................................................................................................44 3.1.1. Strategic Area 1: Policy, Guidelines and Legislation .........................................45 3.1.2. Strategic Area 2: Micronutrient Intervention Programmes ................................46 3.1.3. Strategic Area 3: Partnership & Coordination ...................................................51 3.1.4. Strategic Area 4: Capacity Building ..................................................................51 3.1.5. Strategic Area 5: Advocacy and Communication ..............................................52 3.1.6. Strategic Area 6: Monitoring, Evaluation and Research ...................................54 3.2. Strategic Implementation Plan .......................................................................................56 3.3. Indicator Matrix ..............................................................................................................72 References ...........................................................................................................................74 Annexes Annex 1: Strategy Development Process ........................................................................79 Annex 2: Expert Working Group: List of Members ...........................................................80 List of Tables & List of Figures 13 List of Tables Table 1 Strategic Areas for Prevention and Control of Micronutrient Deficiencies with Key Objectives ...................................................................................................................44 Table 2 Priority Focus Areas of Policy, Guidelines and Legislation for NSPCMD by Micronutrients ............................................................................................... 45 Table 3.1 Recommended Dietary Diversification Programmes Strategies, with Micronutrient (s) of Interest, Target Group (s) and Priority Areas ...................................... 47 Table 3.2 Recommended Fortification Programmes Strategies, with Micronutrient (s) of Interest, Target Group (s) and Priority Areas ...................................... 49 Table 3.3 Recommended Supplementation Programmes Strategies, with Micronutrient (s) of Interest, Target Group (s) and Priority Areas ...................................... 50 Table 4 Priority Areas of Partnership and Coordination .................................................................. 51 Table 5 Priority Areas for Capacity Building.................................................................................... 52 Table 6 Priority Areas for Advocacy and Communication .............................................................. 53 Table 7 Priority Areas for Monitoring, Evaluation and Research .................................................... 54 Table 8 Implementation Plan Framework for Strategic Area 1: Policy, Guidelines and Legislation ..........................................................................................................................56 Table 9 Implementation Plan Framework for Strategic Area 2: Micronutrient Intervention/ Programme (Dietary Diversification) ............................................................ 58 Table 10 Implementation Plan Framework for Strategic Area 2: Micronutrient Intervention/Programme (Fortification) ............................................................................. 61 Table 11 Implementation Plan Framework for Strategic Area 2: Micronutrient Intervention Programme (Supplementation) ..................................................................... 63 Table 12 Implementation Plan Framework for Strategic Area 3: Partnership and Coordination ............................................................................................ 66 Table 13 Implementation Plan Framework for Strategic Area 4: Capacity Building ......................... 67 Table 14 Implementation Plan Framework for Strategic Area 5: Advocacy and Communication ..................................................................................................................68 Table 15 Implementation Plan Framework for Strategic Area 6: Monitoring, Evaluation, and Research .................................................................................................. 70 Table 16 Indicators (Impact level) .................................................................................................... 72 Table 17 Indicators (Outcome level) ................................................................................................ 73 List of Figures Figure 1 Micronutrient deficiencies among children aged 6-59 months ........................................... 21 Figure 2 Micronutrient deficiencies among school-aged children aged 6-14 years ......................... 22 Figure 3 Micronutrient deficiencies among NPNL in Bangladesh .................................................... 23 Figure 4 Prevalence of vitamin A deficiency (serum retinol <0.70 µmol/l) ....................................... 29 Figure 5 Prevalence of iodine deficiency (UIE<100 µg/L) in school-aged children and women in 1996, 2004-5 and 2011-12 ............................................................ 32 Figure 6 Prevalence of zinc deficiency............................................................................................. 37 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 14 List of Acronyms ANC Antenatal Care BBF Bangladesh Breastfeeding Foundation BCC Behaviour Change Communication BDHS Bangladesh Demographic and Health Survey BMS Breast-Milk Substitutes BRRI Bangladesh Rice Research Institute BSCIC Bangladesh Small and Cottage Industries Corporation BSTI Bangladesh Standards and Testing Institution CHT Chittagong Hill Tract CIP Country Investment Plan CSO Civil Society Organisations DAE Department of Agriculture Extension DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DNA Deoxyribonucleic Acid DoF Department of Food DoL Department of Livestock DPs Development Partners EBF Exclusive Breastfeeding GAIN Global Alliance for Improved Nutrition GoB Government of Bangladesh H&FWC Health and Family Welfare Centre HFP Homestead Food Production HH Household HKI Helen Keller International HPNSDP Health, Population and Nutrition Sector Development Programme ICCIDD International Council for the Control of Iodine Deficiency Disorders icddr, b International Centre for Diarrhoeal Disease Research, Bangladesh IDA Iron Deficiency Anaemia IDD Iodine Deficiency Disorders IEC Information, Education and Communication IFA Iron-folic Acid IMCI Integrated Management of Childhood Illnesses IMCI&N Corners Integrated Management of Childhood Illnesses & Nutrition Corners IPHN Institute of Public Health Nutrition List of Acronyms 15 IQ Intelligence Quotient IYCF Infant and Young Child Feeding M&E Monitoring and Evaluation MI Micronutrient Initiative MMN Multiple Micronutrients MNP Micronutrient Powder MOHFW Ministry of Health and Family Welfare MOLGRDC Ministry of Local Government and Rural Development and Cooperatives MOWCA Ministry of Women and Children Affairs NFP National Food Policy NGO Non-Government Organization NHSDP NGO Health Service Delivery Project NMS National Micronutrient Survey NNS National Nutrition Services NPNL Non-pregnant and Non-lactating NSP Nutrition Surveillance Project NSPCMD National Strategy on Prevention and Control of Micronutrient Deficiencies NVAC National Vitamin A Plus Campaign ORS Oral Rehydration Salts PNC Post-natal Care PoA Plan of Action PSAC Preschool Children QA Quality Assurance QC Quality Control SAC School-aged Children SUZY Scaling Up Zinc for Young Children UIC Urinary Iodine Concentration UN United Nations UNHCPSDP Unqualified Health Care Providers Skills Development Project UNICEF United Nations Children’s Fund USI Universal Salt Iodization VAC Vitamin A Capsule VAD Vitamin A Deficiency VGD Vulnerable Group Development VGF Vulnerable Group Feeding WFP World Food Programme WHO World Health Organization NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 16 Introduction 17 Introduction Although Bangladesh has made significant progress in reducing undernutrition and is one of the countries likely to achieve the nutrition Millennium Development Goal, micronutrient deficiency remains prevalent at a high level and is a major public health problem. While several strategies have been implemented over the past decades in response to the on-going high prevalence of micronutrient deficiencies, it was felt this was the time to revisit those strategies and develop a comprehensive strategy. The most recent National Micronutrient Survey (NMS), conducted in 2011-12, reported that the vast majority of young children and women in the country are still suffering from various micronutrient deficiencies. Thus, the Institute of Public Health Nutrition (IPHN), under the Ministry of Health and Family Welfare (MOHFW) and other stakeholders in this field, strongly felt the need to review current strategies and interventions in place. Following extensive consultation with various stakeholders, including relevant ministries, the National Strategy on Prevention and Control of Micronutrient Deficiencies (NSPCMD) was developed. This NSPCMD document provides a comprehensive and coordinated intervention plan to prevent and control micronutrient deficiencies in the country. The purpose of the NSPCMD is to provide guidance on interventions and actions for a coordinated and comprehensive approach to prevent and control micronutrient deficiencies among the Bangladeshi population, with an emphasis on vulnerable population groups, including children under five years of age, school-age children, adolescent girls, and pregnant and lactating women. The strategy document will be the guide to the priority strategies the country will focus on for a period of ten years. It will be used by policy makers; stakeholders, including government; civil society and private sectors/corporate implementers; researchers; and UN and development partners, all of whom are involved in designing, implementing, monitoring and evaluating micronutrient-related programmes at the national, regional and community levels. The strategy is divided into three main sections, as follows: Section 1: Provides a brief overview of the problem of micronutrient deficiencies in global and Bangladesh contexts. This will also provide an overview of current policies and mandates, followed by the overall goal and objectives. Section 2: Provides an insight into the current situation of micronutrient status among different population groups in the country, including trend analysis, possible causes and risk factors. It also presents existing intervention programmes for alleviating micronutrient deficiencies in the country, followed by an in-depth analysis of the strengths, weaknesses, opportunities and threats of the current micronutrient deficiency control programmes in the country. Section 3: Highlights the recommended micronutrient deficiency prevention and control strategies to be executed in the next ten years, based on evidence, best practices and lessons learned. It also outlines the implementation plan for the recommended strategies and indicators for monitoring impact and the progress of implementation of the strategy through multiple and diversified modalities. NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 18 Section 1 19 1.1 Goal and Objectives 1.2 Background 1.2.1 Global Context 1.2.2 Overall Micronutrient Deficiency Situation in Bangladesh 1.2.3 Policy and Strategy Background 1.2.4 Rationale for National Strategy on Prevention and Control of Micronutrient Deficiencies Section1 Goal, Objectives and Background NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 20 Goal, Objectives and Background 1.1 Goal and Objectives 1.1.1 Goal The overall goal of the National Strategy on Prevention and Control of Micronutrient Deficiencies (NSPCMD) is to improve the overall health, nutritional status, survival, growth, development and productivity of the population by preventing and alleviating micronutrient deficiencies. 1.1.2 Objectives � To provide guidelines on interventions and actions for improved access and affordability to micronutrients through increased consumption of micronutrient rich foods, fortified foods and supplements and compliance to micronurient guidelines and regulations � To provide a common platform for resource mobilization for the implementation of the national micronutrient deficiency prevention and control programmes � To promote efficient implementation and programme delivery of micronutrient interventions that can create impact among the marginalised through improved planning, capacity development, monitoring, coordination and collaboration of partners in the country � To improve knowledge, awareness and utilisation of micronutrient deficiency control interventions through advocacy, social mobilisation and behaviour change communication � To strengthen research and monitoring and evaluation of National Micronutrient Deficiency Prevention and Control programmes in the country 1.2 Background 1.2.1 Global Context Micronutrients are vitamins and essential minerals required in minute amounts by the body for survival, health and development. The consequences of micronutrient deficiencies are far reaching, as they not only increase the risk of mortality but also compromise quality of life and impact development and productivity. In addition to the more obvious clinical manifestations, micronutrient deficiencies are responsible for a wide range of non-specific physiological impairments, resulting in compromised resistance to infections, reduced nutrient uptake and delayed or impaired physical, mental and psychomotor development. Micronutrient deficiency is one of the most prevalent global public health problems, affecting more than 2 billion people worldwide (UNICEF and MI 2004). Examples of the effects of micronutrient can be seen with vitamin A, iodine and iron deficiencies, as shown below. Vitamin A deficiency (VAD) is the leading cause of preventable childhood blindness. It also places young children at a 23 per cent greater risk of death. Based on World Health Organization (WHO) estimates of vitamin A deficiency in preschool children and pregnant women for 1995-2005, globally 33.3 per cent of preschool children, or 90 million, are estimated 1 Goal, Objectives and Background 21 to have subclinical vitamin A deficiency and 15.3 per cent of pregnant women, or 19.1 million, have deficient serum retinol concentrations (WHO 2009a). Major strategies to address these deficiencies include improving food security, vitamin A supplementation, food fortification and dietary diversification. Since coverage of the last two interventions has not been systematically assessed, vitamin A supplementation is the primary programme indicator monitored at the global level. The 2013 Lancet series on maternal and child nutrition informed that globally 28.5 per cent of the world’s population, or 1.9 billion individuals, is iodine deficient. While this figure largely repre sents those with mild deficiencies (defined as urinary iodine concentration of 50–99 ug/L), about 50 million people have some degree of mental impairment caused by iodine deficiency (WHO 2011c). In 2012, nearly 34 million newborns were unprotected from the lifelong consequences of brain damage associated with iodine deficiency (UNICEF Data). For the last 30 years, universal salt iodization has been the most widely used strategy to control and eliminate iron deficiency disorders (IDDs). The international target for universal salt iodization aims for more than 90 per cent of households worldwide to consume adequately iodized salt (WHO et al. 2007). However, the United Nations Children’s Fund (UNICEF) estimates that globally only 76 per cent of all households consumed adequately iodized salt in 2012 (UNICEF Data). Further, about 1.62 billion people are anaemic mainly due to iron deficiency (WHO 2008). The magnitude of the problem is much greater in developing countries, where multiple micronutrient deficiencies often occur concurrently, as a result of consuming diets of poor bio-availability and limited micronutrient content (Huffman et al. 1999). Micronutrient deficiencies are common throughout the lifespan, but especially in children and pregnant and lactating women, who experience increased micronutrient demands to support growth and reproduction. 1.2.2 Micronutrient Deficiency Situation in Bangladesh In Bangladesh, the usual diets consumed are typically deficient in one or more micronutrients, notably vitamin A, iron, iodine and/or zinc (Jahan and Hossain 1998). Bioavailability of micronutrients, especially iron, zinc and vitamin A, in food usually eaten by the poor is low, because most of the food consumed is plant based. It is poor dietary quality, rather than quantity, that is considered to be the key determinant of impaired micronutrient status in this population. Young children and pregnant and lactating women are at particular risk of developing micronutrient deficiencies. Figure 1: Micronutrient deficiencies among children aged 6-59 months 21 11 7 45 40 24 19 9 6 49 38 27 21 12 10 30 45 16 38 27 14 52 48 16 Vitamin A deficiency Iron deficiency Iron deficiency anaemia Zinc deficiency Vitamin D deficiency Calcium deficiency National Rural Urban Slums 1 Source: National Micronutrient Survey 2011-12 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 22 The National Micronutrient Survey (NMS) 2011-12 revealed that a significant proportion of preschool children live with multiple micronutrient deficiencies (see Figure 1); for example, one in five preschool children is living with vitamin A deficiency1. The burden of zinc deficiency is high, with 44 per cent of preschool children suffering from zinc deficiency2, while two in five preschool children live with vitamin D deficiency3. The prevalence of calcium deficiency4 among preschool children is 24.4 per cent and a further one-third of preschool children are suffering from anaemia5, with 7.2 per cent having iron deficiency anaemia6. Amongst school-age children, the current prevalence of iodine deficiency7 is as high as 40 per cent (see Figure 2). Further, one in five school-age children also suffer from vitamin A deficiency and anaemia, while over 40 per cent of school-age children are living with vitamin D deficiency and about 20 per cent with calcium deficiency. For non-pregnant and non-lactating (NPNL) women, Figure 3 shows that 42 per cent are suffering from iodine deficiency. About one in four NPNL women are also living with anaemia and vitamin B12 and calcium deficiencies, and large majority suffer from zinc deficiency (57 per cent) and vitamin D deficiency (71.5 per cent). While the prevalence of vitamin A deficiency is only about 5 per cent among NPNL women, nearly one-third are living with mild vitamin A deficiency8. Figure 2: Micronutrient deficiencies among School-aged children aged 6-14 Years 20 .9 3. 9 1. 3 40 45 .5 17 .620 .2 4. 1 1. 1 40 .8 41 .2 15 .5 22 .1 3. 6 2. 1 39 .3 54 .2 21 .52 7. 1 3. 4 1. 3 27 .4 66 .5 28 National Rural Urban Slums Vitamin A deficiency Iron deficiency Iron deficiency anaemia Zinc deficiency Vitamin D deficiency Calcium deficiency 1 Vitamin A deficiency is defined as serum retinol level <0.70 µmol/L (WHO/IVACG). 2 Zinc deficiency is defined as serum zinc level <9.9 mmol/l in preschool children and <10.1 mmol/l in NPNL women (International Zinc Nutrition Consultative Group (IZiNCG) ). 3 Vitamin D deficiency is defined as serum vitamin D level cut-off <50.0 nmol/L, as suggested by the Institute of Medicine (Ross AC et al. 2011). 4 Calcium deficiency is defined as total serum calcium level <8.8 mg/dL in preschool children and school-aged children and <8.4 mg/dL in NPNL women (Nelson Textbook of Paediatrics, 18th Edition, 2008). 5 Anaemia is defined as haemoglobin level <11.5 gm/dl in children 6-11 years old and <12.0 gm/dl in children 12-14 years old. (WHO/UNICEF/UNU 2001) 6 Iron deficiency is defined as serum ferritin level<15.0 ng/ml (WHO 2001). 7 Urinary Iodine Concentration <100.0 µg/l. (WHO 2013) 8 Mild vitamin A deficiency is defined as serum retinol >= 0.7 - <1.05 µmol/L (ICDDRB et al. 2014). 1 Source: National Micronutrient Survey 2011-12 Goal, Objectives and Background 23 Figure 3: Micronutrient deficiencies among NPNL in Bangladesh 5. 4 7. 1 4. 8 42 .1 71 .5 26 .3 6. 1 9. 1 57 .3 5. 4 6. 7 5 44 .7 70 .6 26 .5 5. 7 8. 6 57 .5 4. 9 8. 7 4. 1 33 .3 72 .4 25 .2 7. 5 11 .4 54 .5 6. 9 7. 4 4. 1 33 .5 83 .1 26 .2 6. 5 7. 9 66 .4 V ita m in A de fic ie nc y Ir on d ef ic ie nc y Ir on d ef ic ie nc y an ae m ia Io di ne d ef ic ie nc y V ita m in D de fic ie nc y C al ci um de fic ie nc y V ita m in B 12 de fic ie nc y F ol at e d ef ic ie nc y Z in c d ef ic ie nc y National Rural Urban Slums There is no recent national estimate of the prevalence of micronutrient deficiencies among pregnant and lactating women, nor amongst the adolescent population, especially adolescent girls in the country. However, previous studies have indicated that the prevalence of micronutrient deficiency is also quite high in these population groups. Overall, the prevalence of these micronutrient deficiencies is highest among populations living in slums and among lower socio-economic groups. Overall, the major underlying causes of micronutrient deficiencies in all segments of the population are identified as household food insecurity, along with poor quality diet (predominantly plant-based foods and with minimum amount of animal foods); poor dietary diversity; lack of knowledge about food value and food diversity; intra- and inter-household disparity; gender inequality and inequity; and lack of social positioning of vulnerable and marginalised population. In addition, the predominant risk factors are identified as increase of rural to urban migration and population density, accompanied by a lack of basic living standards (water, sanitation, etc.); being a slum dweller or rural resident; poor knowledge about micronutrient-rich foods; lack of affordable diversified foods, especially animal food sources; and lack of awareness about the consequences of deficiencies and of the health benefits of adequate micronutrient intake. 1.2.3 Policy and Strategy Background The Government committed itself to addressing malnutrition among children and women in the VISION 2021 and the Sixth Five-Year Plan 2011-2015. In the Sixth Five-Year Plan, the Government of Bangladesh (GoB) addressed the problem of micronutrient deficiencies and provided strategic guidance for addressing the deficiencies, notably VAD, IDD and iron deficiency anaemia (IDA). Under the Health, Population and Nutrition Sector Development Programme 2011-2016 (HPNSDP), the mainstreamed nutrition programme aims to deliver nutrition services country wide through the existing Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP). The Government has placed the institutional home for nutrition with the Institute of Public Health Nutrition (IPHN) of DGHS. The National Nutrition Service (NNS) is an operational plans under the HPNSDP and implemented 1 Source: National Micronutrient Survey 2011-12 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 24 by IPHN to ensure implementation of the mainstreaming of nutrition. The NNS operational plan includes a number of programmes to control micronutrient deficiencies in the country. These are programmes for the control of VAD and for the prevention and control of anaemia, IDD and other micronutrient problems of public health importance (zinc, vitamin D, calcium, etc.). The Government of Bangladesh has endorsed National Nutrition Policy 2015 (MOHFW 2015). This strategy will complement the National Nutrition Policy 2015 for implementation of micronutrient intervention. Commitments at the government level are also seen through other policies implemented by different ministries, such as the National Food Policy (NFP) 2006 and its Plan of Action (PoA) 2008-2015 (FPMU 2006) and the Bangladesh Country Investment Plan (CIP), in which micronutrient deficiency control strategies are on the priority list (FPMU/Food Division 2011). The NFP places micronutrient deficiency prevention and control strategies in the context of a life-cycle framework and identifies three main approaches to be used in order to successfully address micronutrient deficiencies for the people at different stages of the life cycle: (1) dietary diversification, including nutrition education, food fortification and supplementation; (2) awareness campaigns; and (3) using multiple inclusion of pro-poor targeted and market-based interventions. 1.2.4 Rationale for National Strategy on Prevention and Control of Micronutrient Deficiencies The National Micronutrient Survey 2011-12 was the first-ever-created benchmark in Bangladesh for some important micronutrients, such as zinc, iron, B12, folate, vitamin D, and calcium. It also updated the status of vitamin A and iodine nutrition among the Bangladeshi population. The survey documented multiple micronutrient deficiencies among the population, especially younger children, school-age children and women of reproductive age. Addressing multiple micronutrient deficiencies requires clear policies, comprehensive strategies, actions and investment. At present the Health, Nutrition and Population Sector Programme (HNPSP) 2011-16, NNS-Operational Plan 2011-2016, the National Strategy for Anaemia Prevention and Control in Bangladesh 2007, and the Infant and Young Child Feeding (IYCF) Strategy 2007 only provide strategic directives for control and prevention of vitamin A, iron and iodine. Thus, the Institute of Public Health Nutrition and other stakeholders felt the need to review the current strategies and develop a comprehensive national micronutrient deficiency control strategy. This NSPCMD seeks to provide a comprehensive and coordinated strategy for preventing and controlling micronutrient deficiencies in Bangladesh. It will also provide an outline for an implementation plan, with clear strategies and actions for the next ten years, so that the policy makers and stakeholders who are involved in designing, implementing and evaluating micronutrient-related programmes at national, regional and community levels can implement the programme effectively. 1 Goal, Objectives and Background 25 Section 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors, Current Interventions 2.1 Dietary Diversification 2.2 Vitamin A Deficiency 2.3 Iodine Deficiency Disorders 2.4 Anaemia and Iron Deficiency 2.5 Zinc Deficiency 2.6 Vitamin B12 Deficiency 2.7 Vitamin D Deficiency 2.8 Calcium Deficiency NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 26 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors, Current Interventions 2.1 Dietary diversification 2.1.1 Infant Young Child Feeding (IYCF) Practices In infants and young children, proper breastfeeding and complementary feeding, which together comprise Infant Young Child Feeding (IYCF), will meet all micronutrient requirements. The global recommendation for optimum infant feeding from birth to 24 months of age is i) initiation of breastfeeding within is one hour of birth; ii) exclusive breastfeeding up to 6 months; iii) appropriate complementary feeding from 6 months; and iv) continued breastfeeding up to 2 years (WHO and UNICEF 2003). Promotion of breastfeeding Breastfeeding is the gold standard of infant feeding.1 Breast milk contains over 200 components, characteristics of many which are yet to be known. The impact of breastfeeding within one hour of birth reduces 31 per cent of neonatal mortality (Lawn et al. 2005); exclusive breastfeeding up to six months reduces infant mortality by 13 per cent (Jones et al. 2003). Breast milk of a healthy mother contains all the micronutrients necessary for an infant. The iron in breast milk is better absorbed than that from other sources. As well, the vitamin C and high lactose levels in breast milk aid in iron absorption. Healthy, full-term babies have enough iron and other micronutrients stores in their bodies. The current research indicates that a baby’s iron stores should last between six and twelve months.2 Current status of breastfeeding practice up to 2 years In Bangladesh, 47 per cent of newborns receive breastfeeding within one hour of birth, 64 per cent are exclusively breastfed up to 6 months of age and 90 per cent of children continue breastfeeding up to 2 years of age, according to the Bangladesh Demographic and Health Survey (BDHS) 2011 (Mitra 2011). Promotion of complementary feeding: It is recommended that complementary foods be introduced at six months of age, with a variety of nutrient-rich foods to meet nutrient needs. When the desired nutrients densities from complementary feeding were compared with the actual nutrient densities of the typical complementary food diets consumed in various population of the world, iron, zinc and vitamin B6 were found to be deficient (WHO 1998, and Dewey and Brown 2001). “Problem nutrients” as they are termed by the Pan American Health Organization (PAHO), include certain nutrients that are in short supply in some populations, such as niacin, thiamine, calcium, vitamin A and vitamin C. 1 Bangladesh Journal of Child Health > Vol 35, No 3 (2011) 2 Is Iron-Supplementation Necessary? AUGUST 2, 2011. Posted in: VITAMINS/ SUPPLEMENTS 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 27 Vitamin C is likely to be a particular problem in the complementary food of children in Bangladesh. Others such as vitamin E, iodine and selenium may also be problem nutrients in certain settings. To promote appropriate complementary feeding, it is preferable to develop population-specific dietary guidelines for complementary foods based on the food composition of locally available foods (PAHO, 2003). The answer to the issue of “problem nutrients” is to diversify food production in the country and diversify food intake by infants and young children, as well as all members in the family. It is best if infants and young children receive all their nutrients through a balanced diet of food, rather than micronutrient supplementation. A complete diet needs to be ensured for the infants and young children to cure and prevent micronutrient malnutrition. Promotion of breastfeeding and homemade complementary feeding are crucial for the prevention of micronutrient deficiency. Current status of complementary feeding In Bangladesh, 62 per cent of children start complementary feeding at 6 to 8 months of age, but only 21 per cent receives a minimum acceptable diet while under 2 years of age (Mitra 2011). Even in the highest wealth quintile families, only 30 per cent of children receive appropriate complementary feeding. Accordingly, the promotion of IYCF is a priority component of Bangladesh’s nutrition programmes. 2.1.2 Promotion of Diversified Food Rich in Micronutrients Improving dietary diversification by increasing the variety and consumption of micronutrient rich foods through the increased production of agriculture, horticulture, livestock and fisheries and supported by comprehensive nutrition education strategies has been shown to be effective in many settings (Darnton-Hill I et al., 2005 and Bushamuka VN et al., 2005). 2.1.2.1 Review of intake of micronutrient rich foods Based on the 2010 Household Income and Expenditure Survey, 35 per cent of the population have mean dietary diversity scores of less than 6 out of 12 food groups and are therefore considered to be at risk of micronutrient deficiency (Ezzati et al. 2004). Quantification of dietary micronutrient intakes among young children and their mothers in rural Bangladesh show an overall mean prevalence of micronutrient inadequacy for children at 43 per cent and for women at 26 per cent. For children, the prevalence of adequate intakes for each of 11 micronutrients ranged from a mean of 0 for calcium to 95 per cent for vitamin B6 (Arsenault et al.2013). The per capita dietary intake of four selected micronutrients (notably folic acid, vitamin A, iron and calcium) was found to be no more than 60 per cent of the reference nutrient intakes. There are also inadequate iron and folic acid intakes, which are linked with an anaemia prevalence. The degree of micronutrient inadequacy is primarily explained by diets low in energy and with little diversity of foods. In order to scale up nutrition-sensitive agriculture (horticulture, fisheries and livestock), the availability of nutritious, diversified foods need to be promoted through better inputs for its production – supplies, tools, technologies – and more sustainable livelihood opportunities for rural women. At the same time, there needs to be better knowledge on nutrition and changes in behaviour to use the new knowledge, especially with regards to infant and young children feeding. Integrated agriculture, including household farming interventions, needs to be increased to promote sustainable diets and nutrition. Extensive household gardening and fish, poultry and cattle farming which address access issues to nutritious foods should be encouraged to ensure adequate supplies of protein, calcium, iron, vitamin A, vitamin C, and other essential nutrients. Training on agricultural practices and ensuring high yielding varieties 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 28 of seeds, fertilisers, pesticides, irrigation and machinery at reasonable price are central to these efforts. In rural areas, 75 per cent of the households have a homestead garden [Khan 2011]. In 2011/12, Food Security and Nutrition Surveillance Project estimated 42 per cent of households have both homestead gardens and backyard poultry, 14 per cent have only homestead gardens, 20 per cent have only backyard poultry and 24 per cent have neither (JPGSPH and HKI 2012). The Integrated Horticulture and Nutrition Development Programme implemented by the Department of Agriculture Extension (DAE) demonstrated significant improvements through community-based nutrition programmes, which led to major improvements in nutritional knowledge, skills and technologies of rural communities across 15 districts. A Dietary Impact Assessment showed substantially higher energy, protein and micronutrient intake among project households. Schools provide a setting for introducing the community to nutrition information and technologies, leading to community advocacy of nutrition improvement policies and services. Girls, in particular, reached through schools will benefit from good nutrition, which is also beneficial later during pregnancy, lactation and nourishment of children. 2.1.2.2 Current interventions The Bangladesh Country Investment Plan (CIP) is the investment arm of the National Food Policy–2006 (NFP-2006) and its Plan of Action (PoA, 2008-2015) and is a road map towards investment in agriculture, food security and nutrition. The CIP has identified twelve investment programmes to ensure implementation of the PoA (FPMU/Food Division 2011). Some of the CIP investment programmes include sustainable and diversified agriculture, fisheries and aquaculture development; livestock development, with a focus on poultry and dairy production; and community-based nutrition programmes and services. The CIP, under the community based nutrition programmes and services, supports community-based homestead gardening, the rearing of small livestock and aquaculture and awareness building, which complement the national nutrition programme of Bangladesh. These programmes aim to increase household access to food in general, but especially to micronutrient-rich foods, and also generate income from the sale of the products. These programmes generally focus on women, recognizing their critical role in ensuring household food security and their tendency to invest in their children’s health, nutrition and education. To optimize the potential of these programmes to deliver micronutrient interventions, improvements are needed in targeting, monitoring outcomes, including identifying additional interventions, and improving the quality of implementation of the nutrition education component of the programme. Bangladesh has already implemented health education as part of health promotion and protection. The Bureau of Health Education, under the Director General of Health Services, is implementing the Health Education and Promotion Operational Plan, while the Director General of Family Planning (DGFP), through its Operational Plan for Information, Education and Motivation, under the HPNSDP, is carrying out comprehensive behaviour change communication (BCC) to target populations at all levels. The NNS has implemented a mass media campaign, social mobilization and BCC activities at the national and sub-national levels. In addition to traditional BCC tools (TV, radio, sports venues, posters, etc.), they have introduced digital health tools. There is a need to valorise the role of national applied nutrition institutions in BCC programmes (e.g., Bangladesh Institute of Research and Training on Applied Nutrition (BIRTAN), Bangladesh Agricultural Research Institute (BARI), Institute of Nutrition and Food Sciences (INFS) and Bangladesh Agricultural University (BAU) ) to strengthen the on-going initiatives under the Ministry of Agriculture. Finally, in order to make the BCC strategy more effective, it is essential that providers and staff are well trained and highly motivated. To this end there is a need to enhance the capacity for nutrition knowledge and leadership for implementation, along with strengthening the interface at the national, sub-national and union levels. 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 29 2.2. Vitamin A Deficiency 2.2.1. Situation Analysis Vitamin A deficiency had been documented as a public health problem in Bangladesh since the 1960s. Although the severity of the problem has declined remarkably, the prevalence of sub-clinical VAD (serum retinol level <0.70 µmol/L) has not changed much over the past decade, especially among preschool children (PSAC) (6-59 months) and school aged children (SAC). Currently one in five children is living with subclinical VAD1 (see Figure 4) (ICDDR et al. 2014). The prevalence is highest among children living in slums. Subclinical VAD among severely acute malnourished children is 80 per cent (Sattar et al. 2012), while there is a lack of information on the burden of VAD among moderately acute malnourished children. Also, while the current prevalence of night blindness is not available, night blindness in children under five years reduced from 3.76 per cent in 1983 (IPHN and HKI 1985) to 0.04 per cent in 2005 (IPHN and HKI 2005) and is being maintained well below the WHO-recommended one per cent threshold level. According to the National Micronutrient Survey 2011-12, only 5.4 per cent of non-pregnant and non- lactating women have low serum retinol concentrations (ICDDR et al. 2014), which is similar to what was reported in 1997-98 National Vitamin A Survey. The survey in 2011 12 also reported about 34 per cent of NPNL women have inadequate vitamin A status (Serum retinol <1.05 µmol/L), an increase from 29 per cent in 1997 98 (IPHN and HKI 1999). There is no current data on the prevalence of VAD among adolescent girls, pregnant and lactating women. 2.2.2. Current interventions 2.2.2.1. Vitamin A supplementation in children aged 6-59 months In 1973, the Government of Bangladesh commenced the Nutritional Blindness Prevention Programme with the distribution of vitamin A capsules (VAC) to children 6 to 72 months old 1 Vitamin A is important for promoting growth and development, and maintenance of immune function. VAD is associated with visual impairment (night blindness) and/ or increase the risk of morbidity and mortality from childhood infections such as measles and those causing diarrhoea (Sommer and West 1996, Villamor and Fazwi 2000). National Rural Urban Slums 20 .5 20 .9 5. 4 19 .4 20 .2 5. 4 21 .1 22 .1 4. 9 38 .1 27 .1 6. 9 Pre SAC SAC NPNL Figure 4: Prevalence of Vitamin A deficiency Associated Risk Factors of vitamin A Deficiency • Poor household expenses, lack of awareness • Low intake of animal sources of vitamin A, specially by households with severe food insecurity • Predominant share of plant –based vitamin A with low bioavailability • Burden of vitamin A deficiency is higher among the food insecure and slum populations • Lack of mother’s knowledge about vitamin A-rich food and/or their health benefits associated with the intake of dietary vitamin A in children 2 Source: National Micronutrient Survey 2011-12 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 30 during routine service and domiciliary visits1. In 1995, the distribution of VAC among children 12 to 59 months old was linked with the National Immunization Days for polio at over 120, 000 fixed sites in the country. This change in strategy resulted in an increase in coverage from 56 per cent in 1993 (Mitra 1993) to 80 per cent in 1999 (Mitra 1999). Since 2011, the Government of Bangladesh has been implementing a National Vitamin A plus Campaign, covering all children 6 to 59 months old. This programme provides VAC (100, 000 IU retinol equivalent) to children 6 to 11 months of age and VAC (200, 000 IU) to children 12 to 59 months of age. Global evidence suggests that vitamin A reserves in individuals with VAD can fall below optimal levels in three to six months following a high-dose vitamin A supplementation; however, dosing at four to six-month intervals is considered sufficient to prevent serious consequences of VAD (WHO 2011b). Indicators are that this strategy has been effective, as the coverage rate of VAC distribution has increased to more than 90 per cent since 2006 (DGHS 2006). While the major strength of the programme is a very good distribution system, there are still indications of poor recording and monitoring of VAC distribution coverage. Consequently, although national VAC distribution maintains a high coverage rate, there appears to be some discrepancy in coverage rates by level of urbanization, food insecure category and wealth status of the households (JPGSPH/HKI 2012). The IPHN is also implementing Hard-To-Reach strategy to reach vulnerable groups of children in 36 sub-districts of nine low performing districts. The only source of vitamin A for exclusively breastfed infants aged 6 months is breast milk. The Government of Bangladesh endorsed the Infant and Young Child Feeding Strategy 2007 to improve the early initiation of breastfeeding (start breastfeeding within one hour of birth) 2and exclusive breastfeeding (EBF) from birth to six months of age (IPHN 2007). EBF for the first six months has increased from 43 per cent in 2007 (Mitra 2007) to 64 per cent in 2011 (Mitra 2011). Bangladesh has adopted paid maternity leave for 6 months in the public sector, but most in the private sector are not usually following the government policy, and there are often no crèches in work places. 2.2.2.2. Vitamin A supplementation in postpartum women In 1995, the Government initiated the postpartum supplementation policy. As per this policy, a single dose of vitamin A (200, 000 IU) was to be provided to all post-partum women within two weeks of delivery. Because of high rates of home delivery (> 90 per cent), it was very difficult for Health Assistants and Family Welfare Assistants to contact all the new mothers at home within two weeks of delivery. In 2001, the Government revised the policy to allow supplementation within 6 weeks (42 days) after delivery, providing wider opportunity of supplementation. Despite this change, the coverage of post-partum vitamin A supplementation in 2012 was only 36 per cent, having remained steady since 2005 (DGHS 2012). While WHO guidelines does not recommend vitamin A supplementation in post-partum women as a public health intervention3 (WHO 2011b), the Bangladesh government continues providing post-partum vitamin A supplementation within 6 weeks of delivery, in consideration of the health benefits to the mothers in absence of any Bangladesh-specific evidence to the contrary. 2.2.2.3. Fortification of foods with vitamin A Bangladesh has made a breakthrough in the fortification of edible oil with vitamin A, which it launched in December 2011, with the aim to reduce subclinical VAD among vulnerable groups 1 Vitamin A supplementation in children 6 to 59 months of age living in developing countries is associated with a reduced risk of all-cause mortality and a reduced incidence of diarrhoea (Imdad et al. 2010). 2 The Lancet series in 2003 estimated that 13 per cent of all deaths of children under 5 years of age could be prevented through universal coverage of appropriate breast feeding (Jones et al. 2003). 3 Recent evidence on the impact of post-partum vitamin A supplementation showed no significant changes in maternal mortality, maternal morbidity and cause specific infant mortality and morbidity. (WHO 2011) 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 31 of the population1. Through the fortification project, Government supported sixteen edible oil refineries to establish fortification plants and produce vitamin-A-fortified edible oil. It is expected that with edible oils fortified with vitamin A at 15-30 ppm levels, the population, irrespective of age and socio-economic status, will receive maximum 20 per cent of the daily estimated average requirement of vitamin A. As a medium- to long-term strategy, this is to provide a sustainable solution for the whole population. With the passage by Parliament of the ‘National Edible Oil Fortification Law 2013’, 100 percent refined edible oil are to be fortified with vitamin A. Now the challenge is to ensure all groups in society consume adequate amounts of fortified oil, especially by the poorest of the poor groups. While the National Micronutrient Survey 2011-12 showed per capita edible oil consumption is 24.4 gm/day, rural populations and food insecure household members consume much lesser amounts of the oil (16.4 gm/capita/day) than members of food secure households (ICDDR et al. 2014). In addition to the need for adequate consumption, there is a need to develop a central quality control and assurance system. In another strategy to fortify foods with micronutrients in 2013, the Bangladesh Government, with technical support from World Food Programme (WFP) conducted an acceptability trial for rice fortification, with six micronutrients – vitamins A, B1 and B12, zinc, folic acid and iron – and using existing government social safety net programmes in two Sadar upazilas in Satkhira and Kurigram districts. The government safety net programmes include the Vulnerable Group Development (VGD) and the Vulnerable Group Feeding (VGF) programmes implemented by the Ministry of Women and Children Affairs (MOWCA) and Ministry of Disaster Management and Relief. In general, the report indicated a high level of acceptability of fortified rice by the programme participants. In January 2014, the Ministry of Women and Children Affairs started distributing fortified rice among VGD households and reached around 60,000 beneficiaries in five upazilas. The objective of rice fortification is to improve access by the poorest of the poor to essential micronutrients. The poorest of the poor live with multiple micronutrient deficiencies and without access to other sources of micronutrient-rich food or fortified food. The MOWCA has planned to gradually expand fortified rice distribution among VGD beneficiaries, using Government funds. In 2015, the Government expands fortified rice distribution to five more upazilas. 2.3 Iodine Deficiency Disorders 2.3.1. Situation Analysis In Bangladesh, iodine deficiency disorders have been recognized as a public health problem for several decades, but it is difficult to get an accurate picture. The national prevalence of iodine deficiency, measured by using mean urinary iodine concentration (UIC) below 100 μg/L, in school-age children is as high as 40 per cent (see Figure 5) (ICDDR et al. 2014), a prevalence that has remained essentially unchanged since 1999. However, while there is no data on the current prevalence of severe iodine deficiency (goitre rates) in school-age children, previous surveys indicated a substantial decrease in goitre prevalence from 50 per cent in 1993 (Dhaka University et al. 1993) to 6.3 per cent in 2004-05 (Yusuf et al. 2007). The National Micronutrient Survey 2011-12 reported a fairly high median UIC in school-age children2 (145.7 µg/L) with the only exception being among the poorest segment of the population (ICDDR et al. 2014). Thus, while at a population level, Bangladesh may have adequate iodine intake, a significant proportion of school-age children are still at risk of developing iodine deficiency. Iodine deficiency in children is associated with poor growth and impaired intelligence quotient 1 For the majority of many populations, the fortification of foods with micronutrients has been shown to be a technologically, programmatically and economically effective method of increasing micronutrient intakes in populations (Darnton-Hill 1998). 2 The median UIC in school age children has been used to assess approximate iodine status of the general population in the countries where iodized salt is the primary vehicle for iodine consumption (WHO et al. 2007) 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 32 (IQ) and cognitive functions (Hetzel 1983). There is no national-level data on iodine deficiency in adolescent girls. The National Micronutrient Survey 2011-12 reported a 42 per cent prevalence of iodine deficiency in NPNL women, a rate which was 45.6 per cent in 1999 (Dhaka University et al. 1999) and 38.6 per cent in 2004-5 (Yusuf et al. 2007). The national survey of IDD in 2004-05 reported goitre rates of 11.7 per cent and 14.6 per cent in NPNL women and pregnant women, respectively (Yusuf et al. 2007). Moderate to severe iodine deficiency in pregnant women is linked with impaired mental development and growth retardation of the offspring, a condition called cretinism, and mild iodine deficiency is associated with impaired foetal neurological development (Bielsalski 2013). Further, the National Micronutrient Survey 2011-12 reported a median UIC of 122.6 µg/L for NPNL women (ICDDR et al. 2014), while it was 111.5 µg/L in 1999 (Dhaka University et al. 1999) and 139.9 µg/L in 2004-5 (Yusuf et al. 2007). Overall, in comparing the prevalence of the risk of iodine deficiency and median UIC of the NPNL women, the situation has not changed significantly since 1999. As for iodized salt, the most recent estimates show that the coverage of adequately iodized salt at the household level (defined as ≥15 ppm) is 57.6 per cent overall, with rural, urban and slum levels at 51.8 per cent, 75.4 per cent and 76.9 per cent, respectively (ICDDR et al. 2014). Currently about a quarter of the households buy open salt; 84 per cent of these households do not buy iodized salt packets due to their higher prices, and about one fourth of them do not buy salt packets because they are not available. Further, only 27.5 per cent of the retailers know about the salt law; of this percentage, 20 per cent do not know about the punishment for violating the salt law (ICDDR et al. 2014).Overall, there appears to be an absence of mass level awareness of the universal salt iodization (USI) programme; more attention to an iodized salt marketing strategy could play an important role in alleviating the IDD problem in the Bangladeshi population. 2.3.2. Current interventions 2.3.2.1. Universal salt iodization programme The Government of Bangladesh adopted the Universal Salt Iodization Strategy in 1989 and endorsed the Salt Iodization Act 1989, making it mandatory for edible salt to be iodized. Accordingly, during 1995, under the Ministry of Industries, the Bangladesh Small and Cottage Industries Corporation (BSCIC) initiated the Control of Iodine Deficiency Disorders through a USI project and focused on establishing salt iodization plants in all salt factories in the country with the financial assistance of UNICEF. In 1998, salt iodization regulation was endorsed and substantial investments were made for the development of infrastructure for salt iodization. An evaluation survey of USI in 1999 reported that nearly 99 per cent of the edible salts at the factory level were iodized; however not all salts were adequately iodized (IPHN et al. 1999). Addressing IDD is a national priority, and the government has established a National Salt Committee, with district and sub-district level entities. However, there are gaps and challenges 42 .5 33 .8 40 45 .8 38 .6 42 .1 1999 2004-5 2011-12 Children NPNL Figure 5: Prevalence of iodine deficiency (UIE <100ug/L) in school aged children and women in 1996, 2004-5 and 2011-12 2 Source: National Micronutrient Survey 2011-12 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 33 in the existing strategies to prevent and control IDD in Bangladesh. While modern iodized salt industries cover at least 60 per cent of the salt market, the current national coverage of adequately iodized salt at the retailer’s level (≥20 ppm) is 66.4 per cent (ICDDR et al. 2014). Although quality assurance (QA) /quality control (QC) monitoring systems, including testing laboratories, are established, there are inadequate technical personnel in laboratories at the production level. The USI project has a strong potential to alleviate IDD in the country; however, its effectiveness is limited by several weaknesses. First, the National Salt Law 1989 did not include the use of iodized salt in the food industries and/or for livestock. According to WHO and UNICEF’s definition, USI refers to “the iodization of all human and livestock salt, including salt used in the food industry” (WHO et al. 2007). When one of these three types of salt is non-iodized, it can leak into the market for direct human consumption relatively easily, as all are food-grade salts. Second, the lack of information on the actual production of edible and industrial salts, a weak monitoring system and insufficient law enforcement at all levels (factory, retail and community levels), higher prices for iodized salt and the availability of low quality crude salt all contribute to non-compliance. Third, there was inadequate preparation for transforming the USI project into a national programme and a lack of commitment and engagement at the regional level. Finally, there is an inadequate use of mass communication, leading to poor consumer awareness that they should demand iodized salt. Other challenges include controlling fraud entrepreneurs packaging industrial salt in the guise of edible salt, controlling the importation of iodized salt, preventing syndicate and monopoly business of bigger industries, and law enforcement at the retailer level. 2.4. Anaemia and Iron Deficiency 2.4.1. Situation Analysis Studies on the levels of anaemia in Bangladesh report levels that range widely, but all indicate actions still need to be taken. According to the National Micronutrient Survey 2011-12, anaemia affects 33 per cent of preschool children, 19.1 per cent of children aged 6 to 11 years, 17 per cent of children aged 12 to 14 years and 26 per cent of NPNL women1 (ICDDR et al. 2014), with rural predominance. When compared with previous surveys conducted by the Nutrition Surveillance Project of Helen Keller International (HKI) in 2001 (IPHN and HKI 2002) and 2004 (Haas and T Brownlie 2001), there appears to be a significant reduction in the prevalence of anaemia among preschool children and NPNL women in the country over the past decade. However, the Bangladesh Demographic and Health Survey (BDHS) conducted in 2011 (Mitra 2011) found a 51 per cent prevalence of anaemia in preschool children and 40 per cent in NPNL women. The National Micronutrient Survey 2011-12 and BDHS 2011 were conducted within one year, thus the differences in prevalence between the two surveys might be largely attributed to the methodological differences and emphasizes the difficulties in comparing prevalence 1 Anaemia has been found to be associated with increased maternal and peri-natal mortality (Ezzati et al. 2004). Associated Risk Factors of lodine Deficiency • In Bangladesh, soil has been deprived of iodine because of the leaching effects of heavy rainfall and floods • Household food insecurity, high cost of iodized packet salt • Lack of awareness about health benefits of iodine/iodized salts, preservation of iodized salts at household level • Use of industrial salt (non-iodized) as edible salt • Low quality crude salts and importing edible salt without quality checking • Lack of law enforcement and monitoring at retailers level • Lack of internal quality control at factory level 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 34 across different surveys. However, it is important to recognize that at least one in every three preschool children and one in every four NPNL women is still anaemic, and this warrants a review and perhaps change in the existing public health programmes and strategies. There is no recent data on the prevalence of anaemia among adolescent girls. However, previous surveys have indicated 30-40 per cent prevalence of anaemia in this segment of the population (IPHN and HKI 2002 and 2006). Further, the National Micronutrient Survey in 2011-12 did not include pregnant and lactating women. According to BDHS in 2011, nearly half of pregnant (49.6 per cent) and lactating (48 per cent) women were anaemic (Mitra 2011). In 2004, the prevalence of anaemia in pregnant women was 39 per cent (IPHN and HKI 2006), but it was 47 per cent in 2001 (IPHN and HKI 2002). The National Micronutrient Survey 2011-12 revealed that the current national prevalence of iron deficiency, based on serum ferritin concentration, is only 10.7 per cent in preschool children and 7.1 per cent in NPNL women. Further, the prevalence of IDA1 is 7.2 per cent in preschool children and 4.8 per cent in NPNL women. In school-aged children, prevalence of IDA is even lower, indicating that iron deficiency may not be the primary cause of anaemia in Bangladeshi population. Current evidence suggests that iron deficiency still contributes to anaemia in Bangladesh, although it may not be the largest contributor. The cause of anaemia in Bangladesh needs further investigation. The National Micronutrient Survey 2011-12 reported that dietary iron provides only 41 to 82 per cent of the recommended daily allowance across different population groups. Although consumption of animal-source foods has increased in the country (Bangladesh Bureau of Statistics 2010), it constitutes only a small share of the total dietary iron (ICDDR et al. 2014). Further, the survey reported that there is no association between serum ferritin levels (reflects body iron store) and dietary iron consumption, while it has shown a significant association with ground water iron levels2 in areas of residence of the study participants. The same survey also reported a significantly higher mean serum ferritin level in all the studied population groups living in areas with high ground water iron. Further analysis of the National Micronutrient Survey 2011-12 data revealed that the serum ferritin levels3 of NPNL women living in areas with low ground water iron ranged from 4.9 to 256.9 μg/dL, with 4.6 per cent having iron overload (a threshold of >150 µg/l for a serum ferritin concentration is used to define iron load for women (WHO et al. 2001) ). For women living in areas with high ground water iron, it ranged from 4.9 to 269.3 μg/dL, with 10.5 per cent of the women having iron overload (ICDDR et al. 2014).During pregnancy, iron requirements increase significantly and an increase in body water results in haemodilution. Thus it is very unlikely 1 Iron deficiency anaemia is associated with poor growth and cognitive impairment in children, and increased susceptibility to infection, loss of productivity from impaired work capacity (Haas and T Brownile 2001), which also exerts a substantial economic burden (Horton et al. 2003). 2 Iron content in groundwater appears to be high in some parts of Bangladesh (Merrill et al., 2010), and it is pre-dominantly in ferrous (Fe2+) form, which is more bioavailable then ferric form (Merrill et al., 2010 and Hallberg 1991). 3 3After excluding the subjects with infection or inflammation based on high CRP and AGP level (NMS 2011-2012 Raw data analysis, Unpublished). Associated Risk Factors of Anemia and lron Deficiency • Household food insecurity along with poor quality diet (predominantly plant-based food and with minimum amounts of animal food) • Lack of knowledge about food value and food diversity • Poor literacy, being a female and slum dweller • Infectious morbidity and worm infestations • Poor caring practice, including poor breastfeeding inappropriate weaning and low quality complementary foods • Low coverage and compliance of IFA supplementation • Weak monitoring and lack of coordination of IFA supplementation programme 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 35 that by giving routine iron-folic acid (IFA) supplements, these pregnant women will suffer from haemoconcentration and/or iron over load. On the other hand, without IFA supplements, a large majority of these women may not sustain normal iron status. Folic acid is also required to prevent neural tube defects during pregnancy. Therefore, further research is required before recommending any change in the IFA supplementation policy and programme. Since 90 to 95 per cent of anaemia cases could not be explained by iron deficiency, it is crucial to examine further other possible causes of anaemia in this population1. The National Micronutrient Survey in 2011-12 reported a significant positive association of haemoglobin with serum ferritin, retinol and zinc in preschool children and a negative association with household food insecurity after controlling for potential confounders. Similarly, in NPNL women, serum ferritin, serum folate, serum retinol and the dietary intake of animal source iron are positively associated with haemoglobin, while household food insecurity is negatively associated with haemoglobin (ICDDR et al. 2014). These findings reinforce the role of other haematopoietic micronutrients in anaemia control and prevention. The risk of malaria is low in Bangladesh, being restricted to hilly areas, so is probably not a factor. While there is no national data on thalassemia prevalence, it is possible that a part of the anaemia problem may be due to genetic disorders2. 2.4.2. Current interventions 2.4.2.1. Iron-folic acid supplementation programme for pregnant women In Bangladesh, an IFA supplementation programme3 for pregnant women has been implemented for several decades. The current IFA supplementation programme has several potentials, which include a government-approved national anaemia strategy and IFA supplementation guidelines, functionally integrated health and family planning wings under the NNS operational plan, increased coordination and utilization of public and private facilities, and a good supply chain system, along with service delivery network. The IPHN, under the MOHFW, developed national guidelines for the prevention and treatment of IDA in 2001 (IPHN 2001), when IFA supplementation, dietary improvement, food fortification and parasite control in preschool children, school-aged children, adolescent girls, and women of reproductive age were recommended. However, anaemia prevention and control activities only focused on IFA supplementation and have not paid adequate attention to address the other causes of anaemia. In 2007, the MOHFW developed and approved the National Strategy for Prevention and Control of Anaemia (WHO et al. 2001), in which the IFA supplementation programme was identified as a critical intervention needed to address anaemia in pregnant women. Under the current policy, pregnant women are provided IFA supplements, with a daily dose of 60 mg of elemental iron and 400 µg folic acid throughout pregnancy and onwards until 90 days after delivery4. The IFA supplementation is one of the components of the NNS operational plan of HPNSDP and is implemented by the DGHS and DGFP as part of the antenatal care services. Since July 2011, the NNS is responsible for the iron supplementation programme for the whole country under HPNSDP. The most recent report indicates that 37 per cent of women never received IFA 1 Besides iron deficiency, anaemia is caused by malaria, worm infestation, chronic infections, genetic disorders (haemoglobinopathies) and deficiencies of vitamins B-6, B-12, A, and C, folic acid, and riboflavin (Mejia et al. 1992, Powers et al. 1983, Leklem 1997, Fishman et al. 2000, Dreyfuss et al. 2000, Jansson et al. 1986, and Linpisarn et al. 1996). 2 A study among women in a northern rural Bangladeshi area reported 28 per cent prevalence of thalassemia and found an association between the prevalence of thalassemia and risk of anaemia (Merrill et al. 2012). 3 Daily IFA supplementation is strongly recommended for pregnant women as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency (WHO 2012). 4 In settings where anaemia in pregnant women is a severe public health problem (>40 per cent), such as it is in Bangladesh, a daily dose of 60 mg elemental iron instead of a low dose (30 mg) and 400 μg folic acid is recommended (WHO 2012). 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 36 supplements during pregnancy. Among those who took the IFA supplements, more than half started taking them in the third trimester and only 16 per cent took them during first. Further, coverage rates vary widely by divisions and regions and by level of urbanization. Adherence to IFA supplements is also related to the wealth and education level of pregnant women (JPGSPH and HKI 2012). Ensuring nutrient needs in the early stage of pregnancy is critical. It has been known for decades that adequate folate status during pregnancy is essential in preventing neural tube defects. While antenatal care (ANC) coverage increased dramatically from 31 per cent in 1993 (Mitra 1993) to 77 per cent in 2011 (JPGSPH and HKI 2012), only 26 per cent of pregnant women obtained at least four ANC visit in 2011. Inadequate and irregular supplies of IFA tablets at the ANC service centres result in inadequate distribution of IFA tablets to the pregnant women who visit ANC clinics. Because there is a lack of harmonization between the policy on ANC and IFA timing, women do not receive adequate dosage through ANCs. Further, for each ANC service centre, IFA supplies are fixed and are not based on local targets or estimations of need. In addition, weak monitoring and supervision, lack of awareness among service providers about the need of IFA, and inadequate training of the service providers are also evident. Among the beneficiaries, the level of education, lack of awareness about the benefits of IFA supplements and absence of adequate counselling are some of the key contributing factors to the low coverage rate. Further, existing programmes do not encompass all of the high-risk target groups. For example, children aged less than five years are not routinely given any interventions to prevent and control anaemia, and adolescent girls and NPNL women are not included in nationwide efforts. Some of the key challenges identified for the current programme include increasing political commitments, ensuring regular supplies of IFA tablets by reducing its procurement process time and reducing central dependency, reaching vulnerable groups in hard-to-reach areas and reducing public misconception. 2.4.2.2. Iron-folic acid supplementation programme for NPNL women and adolescent girls In population groups where the prevalence of anaemia among women of reproductive age is above 20 per cent and mass fortification programmes of staple foods with iron and folic acid are not in place, WHO recommends weekly IFA supplementation as a strategy to prevent iron deficiency, improve pre-pregnancy iron reserves and improve folate status in some women (WHO 2009b). In Bangladesh, the national guidelines for the prevention and treatment of IDA recommend weekly supplementation with two tablets, each having 60 mg elemental iron and 400 µg folic acid, for adolescent girls and NPNL women (IPHN 2001). From 2005 to 2010, a programme ran for adolescent girls where once-weekly IFA capsules were distributed to those students of government and non-government schools of selected areas outside Dhaka city. However, this programme was limited to only those districts that had school health clinics. In addition, the NNP, in its programme areas, also provided IFA supplements and anthelmintic treatment to adolescent girls, newly wed women and post-partum women through their Community Nutrition Promoters. The NNP ended in 2011 and was replaced by the NNS. Currently, there is no nation-wide IFA supplementation programme for NPNL women and adolescent girls. However, the current NNS programme does recommend weekly IFA supplementation, with a dose of two tablets, each having 60 mg elemental iron and 400 μg folic acid, for adolescent girls. 2.4.2.3. Anaemia control programme for children aged 6 to 59 months Nationwide, children aged less than five years old are not routinely given any intervention to prevent and control anaemia. Inadequate attention is given to parasitic disease control, dietary improvement and food fortification. De-worming of children aged 24-59 months with Albendazole, as part of the country’s anaemia control programme, is included during the semi 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 37 annual National Vitamin A Plus Campaign (NVAC). In 2011, the national coverage rate for de-worming was 77 per cent (JPGSPH and HKI 2012).To combat anaemia, children in some of the Dhaka urban slums and Chittagong Hill Tract (CHT) also received multiple micronutrient powder (MNP), with UNICEF support. More recently, under the Maternal and Young Child Nutrition Security Initiative in Asia supported by UNICEF, the DGHS and DGFP have been implementing IYCF and MNP supplementation in children aged 6 to 23 months of age to reduce anaemia in that age group in selected sub-districts. The MNP powder contains five nutrients, including iron and folic acid. 2.4.2.4. Micronutrient Powder (MNP) supplementation for young children The National Strategy for Prevention and Control of Anaemia has recommended the use of MNP1 in the diet of 6- to 23-months-old children and for children 24 to 59 months of age, if resources are available, to prevent anaemia and other micronutrient deficiencies (IPHN 2007). In settings where anaemia in children under two or under five years of age is 20 per cent or higher, one sachet of MNP containing 12.5 mg of elemental iron (preferably as encapsulated ferrous fumarate), 300 µg of retinol (vitamin A) and 5 mg of elemental zinc (preferably as zinc gluconate) is recommended daily. In addition to iron, vitamin A and zinc, MNP may contain other vitamins and minerals at RDA doses for the target population (WHO 2011a); however, evidence of the effectiveness of multiple (more than five) micronutrients in MNP is still lacking. In 2011, MOHFW, with technical support from UNICEF, started implementing MNP supplemen tation for children 6 to 23 months old in 18 upazilas in seven districts and later expanded to a few more upazilas. 2.5. Zinc Deficiency 2.5.1. Situation Analysis Zinc is an essential component of a large number of enzymes and plays a crucial role in food intake regulation and nutrient metabolism, Deoxyribonu cleic acid (DNA) and protein synthesis, growth and development, and immune functions. The National Micronutrient Survey in 2011-12 provided for the first time nationally representative data on zinc status, based on serum zinc concentration2, but only in preschool children and NPNL women (ICDDR et al. 2014). As shown in Figure 6, the prevalence of zinc deficiency in pre school children3 is 44.6 per cent, with the highest rate being among children living in slums. While there is no na 1 WHO has strongly recommended home fortification of foods with MNP for infants and children 6-23 months of age for improving iron status and reducing anaemia (WHO 2011). 2 Serum zinc level is a reasonable indicator of the relatively severe state of zinc deficiency and is commonly used for population assessment (WHO & FAO 2006). 3 Zinc deficiency increases the risk of diarrhoea, pneumonia and malaria in children (Walker and Black 2004, Sazawal et al. 2007 and Brooks et al. 2004). National Rural Urban Slums 44 .6 57 .3 48 .6 57 .5 29 .5 54 .5 51 .7 66 .4 Pre-school age children NPNL Figure 6: Prevalence of Zinc deficiency 2 Source: National Micronutrient Survey 2011-12 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 38 tional level data on the prevalence of zinc deficiency in infants1, a study in a rural community in Bangladesh found 50 per cent prevalence of zinc deficien cy in infants (Eneroth et al. 2010). The national prevalence of zinc deficiency in NPNL women is 57.3 per cent, with the highest rate being for women living in slums. While there is no national-lev el data on the prevalence of zinc defi ciency in pregnant women, a study in a rural sub-district reported 55 per cent prevalence of zinc deficiency in preg nant women2 (Lindström et al. 2011). According to the National Micronutrient Survey 2011-12, the median daily consumption of zinc by preschool children is 2.67 mg for those living in slums and is 3.23 mg in urban areas, while the RDA for zinc is 3-5 mg for this age group. Overall, nearly 39 per cent of children aged 2-3 years and only 11.5 per cent of children aged 4-5 years met the RDA. In NPNL women, mean consumption of zinc is 54.7 per cent and 47.0 per cent of RDA in the urban and slum areas respectively. Further, a large majority of dietary zinc is from plant source foods which are poorly bio-available. It is worth noting that mean animal source zinc consumption varies with levels of urbanization, wealth and food security; it is lowest among people living is slums and in poor and food-insecure households (ICDDR et al. 2014). 2.5.2 Current interventions 2.5.2.1 Treatment with zinc during diarrhoea management for younger children In 2004, WHO and UNICEF recommended the use of oral rehydration saline (ORS) for the correction and prevention of dehydration and 10–20 mg of zinc for 10–14 days as treatment for all episodes of diarrhoea (Lindström et al. 2011).The MOHFW, with the help of two governmental committees, developed a policy for a zinc therapy programme during diarrhoea for young children3that was approved by the Government in 2006. The MOHFW, in collaboration with International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b) and Acme Laboratories, Bangladesh, conducted the Scaling Up Zinc for Young Children (SUZY) Programme in the same year, which is one of the first national efforts to expand zinc treatment coverage for childhood diarrhoea in the world. In addition, the MOHFW revised the national Integrated Management of Childhood Illnesses (IMCI) guidelines to include zinc therapy for diarrhoea. While the zinc supplementation programme has now been incorporated into the NNS and is using health service delivery facilities in both rural and urban areas, the current coverage rate is only 34 per cent. Lack of awareness, inadequate production by pharmaceutical companies (due to inadequate demand), inadequate supply in the mainstream, and poor monitoring systems are some of the weaknesses of the programme. Although social marketing campaigns have led to early successes of the programme, it is still suffering from a range of challenges. One of the key challenges is weak consumer awareness of zinc tablets for treating diarrhoea. More worryingly, there appears to be lack of demand for zinc by health care providers. 1 Zinc deficiency in early childhood is believed to be a cause for developmental disorders (Cole and Lifshifz 2008). 2 Zinc supplementation in pregnancy showed a 14 per cent reduction in the risk of preterm delivery among supplemented women (Chaffee and King 2012). 3 Zinc supplementation during an episode of diarrhoea in children can reduce the duration and severity of the episode and lower the incidence of diarrhoea in the following 2–3 months (Baqui et al. 2002 and Bhutta et al. 2000). Associated Risk Factors of Zinc Deficiency • Household food insecurity, low socio economic status • Low intake of animal sources of zinc and high intake of plant sources of zinc • Consume a diet with a very high content of phylate, an inhibitor of zinc absorption • Drinking tube well water containing high level of iron is found to be negatively associated with zinc status in preschool children • Zinc and iron interact with each other if appropriate iron to zinc ratio is not maintained 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 39 2.5.2.2. Zinc supplementation through MNP and rice fortification As mentioned in the previous discussion on home fortification with MNP, Government is implementing an area-based programme for MNP supplementation, containing 5 mg zinc, among children aged 6 to 23 months, integrated with IYCF counselling. At the same time rice fortification will contain zinc, which will be distributed among the poorest of the poor groups of the population through VGF and VGD. However, both of these programmes will still not cover all groups of people living with zinc deficiency in Bangladesh. WFP has also supported the implementation of atta fortification in the past and is continuing to distribute biscuit fortification, which also contain zinc, for school children. 2.6 Vitamin B12 Deficiency 2.6.1. Situation Analysis Vitamin B12 is needed for synthesis of DNA, and hence, cell division, and normal function of nervous tissue. Its deficiency affects rapidly dividing cells, such as those forming red blood cells1. To date, there is no data available on national level estimates of vitamin B12 deficiency among infant and children. However, a study in a rural community in Bangladesh reported 31 per cent prevalence of vitamin B12 deficiency in infants2 (Eneroth et al. 2010). According to the National Micronutrient Survey in 2011-12, one in four NPNL women suffers from some degree of vitamin B12 deficiency (ICDDR et al. 2014).Maternal vitamin B12 status is strongly associated with the vitamin B12 status of newborns (Bjørke Monsen et al. 2001).There is no current data on vitamin B12 deficiency among pregnant and lactating women3, but a study in a rural sub-district in Bangladesh reported 46 per cent prevalence of vitamin B12 deficiency in women at their early pregnancy (Lindström et al. 2011). 2.6.2 Current interventions Currently there is no national strategy or programme for preventing vitamin B12 deficiency among high-risk population groups in the country. 2.7 Vitamin D Deficiency 2.7.1. Situation Analysis Vitamin D plays important roles in our bodies by maintaining normal levels of calcium and phosphate in the blood, which in turn facilitates bone mineralization, contraction of muscles, nervous system activities and cellular functions (WHO 2004). The National Micronutrient Survey 2011-12 provided for the first time nationally representative data on vitamin D status, based on serum vitamin D concentration, but only in preschool children, school-age children and NPNL 1 Vitamin B12 deficiency can cause macrocytic anaemia (Fishman et al. 2000). 2 Vitamin B-12 deficiency can cause cognitive impairment and memory loss (Allen et al. 1999). 3 Infants fed with breast milk from vitamin B12-deficient mothers exhibits a failure to thrive, poor brain development and, in some cases, mental retardation (Allen 2002). Associated Risk Factors of Vitamin B12 Deficiency • Poor dietary intake • Low intake of animal source, where products from herbivorous animals (i.e. meat, eggs, milk) are the only source of vitamin B12 for humans • Low socio-economic status and household food insecurity 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 40 women. The prevalence of vitamin D deficiency, based on serum vitamin D level <50.0 nmol/L, is 39.6 per cent in preschool children and 45.5 per cent in school-age children1, with the highest rate among children living in slums. When a more stringent cut-off is used to define for vitamin D deficiency2, 7.5 per cent of preschool children and 6.5 per cent of school-age children are found to be vitamin D deficient. Further, female school-age children appear to have higher burden of the problem than the boys, although the difference is not statistically significant. In preschool children, the prevalence of vitamin D deficiency is highest among the poorest and the severe food insecure households. On the contrary, for school-age children it is highest among the richest and the food secure households (ICDDR et al. 2014). Further, the National Rickets Survey in 2008 reported a one per cent prevalence of rickets among children aged between 1 and15 years, with the highest rate, 62 per cent, among the rachitic cases were children aged under five (ICDDR 2009). According to the National Micronutrient Survey 2011-12, nearly three-quarters (71.5 per cent) of NPNL women are vitamin D deficient3, based on serum vitamin D level <50.0 nmol/L. Using a stricter cut-off to define for vitamin D deficiency, serum vitamin D level <25 nmol/L, 21.0 per cent of NPNL women are found to be vitamin D deficient (ICDDR et al. 2014). There is no national level data on the prevalence of vitamin D deficiency in pregnant women, although maternal vitamin D status during pregnancy is important for the vitamin D status of the child during early childhood (Hollies and Wagner 2004). 2.7.2. Current interventions At present, there is no national strategy or programme for preventing vitamin D deficiency among the high-risk population groups in the country. Several opportunities are identified for possible interventions, including Government’s willingness to work with stakeholders, enough sunlight across the country, adequate water bodies to culture fish, a homogenous society, the presence of common fortification food vehicles, women’s empowerment and a prospective school feeding programme. However, for improving population-level vitamin D status, strong political commitment is required. It is important to note that currently vitamin D supplementation during pregnancy, as part of routine antenatal care, is not recommended by the WHO (WHO 2012b). 2.8 Calcium Deficiency 2.8.1 Situation analysis In addition to its role in maintaining bone health, calcium is involved in a large number of metabolic processes, including blood clotting, muscle contraction, hormone release, and cellular proliferation and differentiation. According to the National Micronutrient Survey 2011 1 Vitamin D deficiency is associated with rickets in children and in areas where vitamin D deficiency is endemic, rickets are diagnosed soon after birth (ICDDR 2009). 2 The cut-off to define vitamin D deficiency were serum vitamin D level <25 nmol/L used by UK National Diet and Nutrition Surveys (Gregory et al,. 2000; Henderson et al., 2002). 3 In adults, vitamin D deficiency is associated with osteomalacia and bone fracture, and chronic diseases, such as diabetes and heart disease (Gröber et al., 2013) Associated Risk Factors of Vitamin D Deficiency • Poor dietary intake of vitamin D rich foods along with high of phylate • Limited outdoor exposure conditioned to modern life style and urbanization • Lack of adequate research and lack of national strategy on vitamin D • Poor antenatal vitamin D status in mother adversely affecting the young infant • Lack of access to information on vitamin D 2 Micronutrient Deficiencies: Situation Analysis, Associated Risk Factors,Current Interventions 41 12, one in four preschool children and nearly one in five school-age children in Bangladesh are suffering from calcium deficiency1 (ICDDR et al. 2014). The national prevalence of calcium deficiency among NPNL women is 26.3 per cent. The problem is equally prevalent across the residential strata and socio-economic status categories. There is no national level data on the prevalence of calcium deficiency in pregnant women2. 2.8.2. Current intervention The current WHO recommendation for all pregnant women (particularly those are at risk of gestational hypertension) is to supplement with calcium tablets, with a total daily dosage of 1.5 to 2.0 g elemental calcium/day, divided into three doses, from 20 weeks of gestation (WHO 2013). At present, no population-based intervention to address calcium deficiency is in place. Several opportunities are identified for possible interventions, including government’s willingness to work with stakeholders, adequate water bodies to culture fish, presence of common fortification food vehicles, women’s empowerment and a prospective school feeding programme. However, there are challenges, such as ensuring equity, reaching the hard-to-reach, addressing people’s cultural taboos, and mobilising resources for fortification: finances, technology, skills, and a sustainable and effective marketing model. 1 Calcium deficiency was defined as total serum calcium level <8.8 mg/dL in preschool children and school-aged children and <8.4 mg/dL in NPNL women (Nelson Textbook of Pediatrics, 18th Edition, 2008). 2 Calcium supplementation during pregnancy is associated with a reduction in risk of gestational hypertension, pre eclampsia, preterm delivery and increase in birth weight (Imdad and Butta 2012). Associated Risk Factors of Calcium Deficiency • Poor dietary intake of calcium rich foods, along with high intake of phylate • Lack of awareness of need for calcium and how to get it • Lack of adequate research and national strategy/intervention 2 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 42 Goal, Objectives and Background 43 Section3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 3.1. Strategic Areas 3.2. Strategy Implementation Plan 3.3. Indicator Matrix NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 44 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 3.1 Strategic Areas This section focuses both on improving and reviewing the existing strategies and on developing new strategies for alleviating and preventing various micronutrient deficiencies. To ensure that the recommended strategies are comprehensively laid out, six strategic areas are identified with key objectives as described in Table 1. Table 1: Strategic Areas for Prevention and Control of Micronutrient Deficiencies with Key Objectives Strategic Area Objective 1. Policy, Guidelines & Legislation To ensure that relevant policies, guidelines and legislation are developed or revised and enacted for improving the micronutrient status of the population by 2016. 2. Intervention Programme To implement appropriate long-term (dietary diversification and modification), medium-term (Fortification) and short-term (supplementation), intervention programmes for preventing and controlling micronutrient deficiency through pro-poor targeted and market-based interventions. Depending on the intervention, Total Quality Management (TQM) will be applicable, 3. Partnership & Coordination To promote efficient implementation and effective coverage of various intervention programmes through improved planning, monitoring, coordination and collaboration among policy makers, GoB, civil society organisations (CSO), the United Nations (UN), researchers and private sectors. 4. Capacity Building To improve knowledge, technical and service delivery skills of health care managers and frontline workers on micronutrient deficiency control. To improve knowledge, technical and monitoring skills of relevant government institutes responsible for monitoring and enforcement of mandatory and voluntary food fortification programmes 5. Advocacy and Communication To increase awareness and demand by targeted populations for micronutrient deficiency control programmes and to ensure that evidence is disseminated and used to inform nutrition policy making. 6. Monitoring, Evaluation & Research To strengthen institutional frameworks, guidelines and the reporting of monitoring and evaluation of micronutrient deficiency control activities at all levels. To increase new knowledge and review current programme through operational research. 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 45 3.1.1. Strategic Area 1: Policy, Guidelines and Legislation This strategic area focuses on the development and/or modification of specific policies, guidelines and legislation that are necessary to provide the framework for implementation of evidence-based and effective NSPCMD programmes. The focus areas of actions are outlined in Table 2. Table 2: Priority Focus Areas of Policy, Guidelines and Legislation for NSPCMD by Micronutrients Micronutrient Priority Areas of Action Vitamin A 1. Strengthening VAC supplementation strategy for children aged 6-59 months, especially those living in hard-to-reach areas and moderately malnourished children. 2. Revisiting existing policy for post-partum VAC supplementation programme in the context of recent WHO recommendation. 3. Reinforcing compliance by private sectors as key players in the vitamin A fortification program. Iodine 1. Revising existing Salt Law to implement the use of iodized salt in livestock and processed food. 2. Declaring USI as a programme of national importance and intervening in a mission mode (Salt Mission). 3. Transforming USI project into a sustainable programme and mainstreaming USI activities within NNS. 4. Initiating a Market Intervention Operation (MIO) to determine the right price for consumers. 5. Introducing iodized salt into safety net programmes. 6. Taking strong administrative action against non-performing mills. 7. Imposing restriction on import of refined edible salt, with proper quality checks and with the exception of emergency situations. Iron 1. Reviewing policy on IFA supplementation guidelines for adolescent girls and NPNL women; consider adding other micronutrients to supplements. 2. Considering policy on multiple micronutrient supplementation during pregnancy. 3. Need based targeted MNP supplementation programme for young children aged 6-23 months. Zinc 1. Developing and implementing policy on rice fortification with zinc as one of the multiple micronutrients for the poorest group through government safety net programmes and other groups (open market sale, rationing, etc.). 2. Considering bio-fortification of rice with zinc for mass populations. Vitamin B12 1. Considering possibility of adding animal source foods in appropriate form for vulnerable groups through safety net and food security programme. This can also increase consumption of other micronutrients, such as vitamins A, D, B12, iron and zinc. Vitamin D and Calcium 1. Developing and implementing policy on food fortification with vitamin D (such as edible oil – consider double fortification). 2. Strengthening calcium supplementation during pregnancy, as per WHO guideline. 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 46 3.1.2. Strategic Area 2: Micronutrient Intervention Programmes This strategic area focuses on the key interventions that are recommended for controlling micronutrient deficiencies in the country. Some of these interventions have been implemented for many years, and mainly require strengthening, while other interventions are new in the country and require adaptation to the country context and systems development. These interventions are divided into three broad categories: • First, supplementation as a short-term approach. However, some of these supplementation programmes hardly merit being seen as short-term, and many would argue that the need will be there for many years yet, such as for a vitamin A supplementation programme in the country. • Second, food fortification with micronutrients as a medium- to long-term approach. Probably the most cost-effective food-based approach to improving nutrient availability and accessibility is fortification, with the provision that the fortified foods must reach those who most need them. • Third, improving dietary diversification as a long-term approach through increasing the variety and frequency of MN-rich food sources through homestead food production (HFP), nutrition education and horticultural approaches (crop diversification, bio-technology and bio-fortification). Tables 3.1, 3.2 and 3.3 outlines the focus areas for each of the intervention strategies including target population and target micronutrient (s). Of the six recommended supplementation intervention programmes (Table 3.3), five programmes have been already running for years at variable scales: VAC distribution; IFA supplementation for pregnant women; weekly IFA supplementation for adolescent girls and NPNL women; MNP supplementation for young children; and zinc therapy with ORS in management of diarrhoea for young children at variable scales. Targeted supplementation of calcium through multiple micronutrient supplementation programmes are the new intervention recommended. Among the five recommended fortification programmes (Table 3.2), two programmes are already in place: fortification of edible oil with vitamin A and USI. Four new fortification programmes have been recommended, such as rice fortification with zinc, bio fortification of rice with zinc, and adding vitamin D in edible oil fortification. For dietary diversification and modifications, several innovative programmes are recommended (Table 3.1), such as strengthening policies on nutrition-sensitive agriculture and food systems, strengthening integrated household farming systems; promoting animal foods, livestock and fisheries; and promoting nutrition-specific programmes, including home-based traditional practices for improving micronutrient intake through the bio-fortification of zinc and micronutrient fortification through crop processing. 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 47 3 Ta bl e 3. 1: R ec om m en de d D ie ta ry D iv er si fic at io n P ro gr am m es S tr at eg ie s, w ith M ic ro nu tr ie nt (s ) o f I nt er es t, Ta rg et G ro up (s ) a nd P ri or ity A re as In te rv en tio n S tr at eg y M ic ro nu tr ie nt (s ) Ta rg et G ro up P ri or ity A re as o f A ct io n S tr en gt he n in fa nt a nd yo un g ch ild fe ed in g pr om ot io n, p ro te ct io n an d su pp or t a ct iv iti es A ll es se nt ia l W ho le po pu la tio n • Q ua lit y co un se lli ng a t f ac ili tie s an d co m m un iti es • S up po rt in g br ea st fe ed in g at w or k pl ac es • E ns ur in g m at er ni ty p ro te ct io n in th e pu bl ic a nd p riv at e se ct or s • E nf or ci ng B re as t M ilk S ub st itu te s (B M S ) La w S tr en gt he n po lic ie s on n ut rit io n se ns iti ve ag ric ul tu re a nd fo od sy st em s V ita m in A , v ita m in D , i ro n, z in c, ca lc iu m , v ita m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g fo od s ec ur ity a nd a gr ic ul tu re p ol ic ie s to e nh an ce a va ila bi lit y, af fo rd ab ili ty , d iv er si ty a nd q ua lit y, in cl ud in g fo od s af et y • S up po rt in g nu tr iti on o rie nt ed a gr ic ul tu re r es ea rc h on c ro ps , l iv es to ck a nd pr od uc tio n sy st em s • R es ea rc hi ng a nd p ro m ot io n of n ut rie nt d en se p ro du ct d ev el op m en t, fo od t o fo od e nr ic hm en t, pr oc es si ng a nd tr an sp or t • S ca lin g up h om es te ad a nd s ch oo l g ar de ns S tr en gt he ni ng in te gr at ed ho us eh ol d fa rm in g sy st em s V ita m in A , v ita m in D , i ro n, z in c, ca lc iu m , v ita m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • S tr en gt he ni ng H F P p ro gr am m e an d in te gr at ed fa rm in g sy st em s by im pr ov ed in pu ts a nd e nh an ce d te ch no lo gy tr an sf er to e ns ur e ad eq ua te s up pl y of a v ar ie ty of s af e an d nu tr iti ou s fo od s • In cr ea si ng c ro p an d fo od d iv er si ty th ro ug h ag ric ul tu re ( e. g. , m ix ed c ro pp in g, ra is ed b ed s sy st em s) • P ro m ot in g th e gr ow in g of m ic ro nu tr ie nt r ic h ho rt ic ul tu re , s m al l l iv es to ck a nd fis he rie s pr od uc e P ro m ot io n of a ni m al fo od s, li ve st oc k an d fis he rie s V ita m in A , v ita m in D , i ro n, z in c, ca lc iu m , v ita m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g an im al s ou rc es o f f oo ds fo r pr eg na nt a nd la ct at in g w om en th ro ug h A N C a nd P N C s er vi ce s • P ro m ot in g an im al s ou rc es o f f oo d fo r ch ild re n th ro ug h IY C F c ou ns el lin g • P ro m ot in g th e pr od uc tio n an d co ns um pt io n of s m al l fi sh a s so ur ce o f c al ci um an d vi ta m in A • P ro m ot in g th e co ns um pt io n of o ily fi sh a s a so ur ce o f v ita m in D • C om m on m es sa gi ng a cr os s se ct or s on th e co ns um pt io n of d iv er si fie d di et s, fo cu si ng o n th e fir st 1 , 0 00 d ay s of li fe , s ho ul d be d el iv er ed th ro ug h th e ex te ns io n se rv ic es o f c or e se ct or s • E nh an ci ng th e fo od b as ke t t o in cl ud e a w id er r an ge o f f oo ds ( e. g. , e gg s) th ro ug h th e sa fe ty n et p ro gr am m es , p ar tic ul ar ly fo r vu ln er ab le g ro up s NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 48 3 In te rv en tio n S tr at eg y M ic ro nu tr ie nt (s ) Ta rg et G ro up P ri or ity A re as o f A ct io n H om e ba se d tr ad iti on al pr ac tic es fo r im pr ov in g M ic ro nu tr ie nt In ta ke V ita m in A , v ita m in D , i ro n, z in c, ca lc iu m , v ita m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g so ak in g pr ac tic e fo r st ap le fo od s uc h as r ic e an d pu ls es • P ro m ot in g ro as tin g an d so ak in g fo r su ch fo od s lik e ric e an d le nt ils • E xp lo rin g th e av ai la bi lit y of lo ca l a nd /o r in di ge no us fo od s ric h in m ic ro nu tr ie nt s th ro ug ho ut th e co un ty , w ith a fo cu s on c oa st al a nd C H T re gi on s an d co ns id er in g fa ct or s of s ea so na lit y an d cl im at e • E nh an ci ng n ut rit io n aw ar en es s th ou gh n at io n w is e B C C c am pa ig n, in cl ud in g m as s m ed ia B io f or tifi ca tio n of z in c Z in c, v ita m in A W ho le po pu la tio n • C on si de r cr os s br ee di ng o f h ig h zi nc c on ta in in g m eg a va rie ty o f r ic e w ith in di ge no us v ar ie tie s • E st ab lis hi ng q ua lit y co nt ro l f or fe rt ili ze rs in te rm s of z in c co nt en t a nd m in im iz in g ad ul te ra tio n of Z n fe rt ili ze rs • P ro m ot in g th e pr od uc tio n an d co ns um pt io n of h ig h β ca ro te ne c on ta in in g sw ee t po ta to ( ko m ol a su nd ar i) • P ro m ot in g a ne w v ar ia nt o f z in c en ric he d ric e de ve lo pe d in B an gl ad es h Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 49 Table 3.2: Recommended Fortification Programmes Strategies, with Micronutrient (s) of Interest, Target Group (s) and Priority Areas Strategy Target Group Priority Areas of Action Fortification of edible oil with vitamin A Whole population • Ensuring adequate consumption of fortified oil, especially by the vulnerable groups • Increasing awareness through mass communication to increase demand • Ensuring quality production of vitamin A-fortified edible oil through strengthening regulatory monitoring and enforcement Strengthen USI programme Whole population • Strengthening production by upgrading the technology for both crude and iodized salts • Ensuring registration of all salt brands by name to control fake brands and introducing different colour packaging for iodized and non-iodized salts • Introducing reward system for best performing salt mills. Encouraging the transformation of small salt mills into medium-scale mills, and medium-scale mills into large mills • Supporting affordable prices for iodized salt for all level of population • Strengthening awareness at population and retail levels to increase consumption of iodized salt • Implementing Retailer Rapid Test Kit strategy to prevent marketing of non-iodized salt for human consumption Rice fortification with micronutrient Whole / targeted population • Mainstreaming fortified rice through GoB safety net programme and others (open market sale, rationing, etc.), in addition to the diversification of food basket • Scaling up fortified rice through the Public Food Distribution System • Exploring scale up of bio-fortification of rice with zinc • Developing and endorsing standards and guidelines Food Fortification with vitamin D. Whole population • Exploring the scope for double fortification of edible oil with vitamin A and vitamin D 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 50 3 Table 3.3: Recommended Supplementation Programmes Strategies, with Micronutrient (s) of Interest, Target Group (s) and Priority Areas Strategy Target Group Priority Areas of Action VAC supplementation Children, 6-59 months • Sustaining high effective coverage of VAC supplementation • Strengthening coverage of VAC supplementation in hard-to-reach areas • Strengthening therapeutic use of VAC during measles, diarrhoea and severe acute malnutrition IFA supplementation Pregnant women • Providing IFA supplementation to newly wed women to ensure pre-pregnancy IFA status • Strengthening effective coverage of IFA during pregnancy, by providing adequate dose of IFA in ANC 1 (90 tablets – 3 months’ supply) and ANC 2 (90 tablets) and monitoring compliance in next ANC visits • Special packaging of IFA tablets to include a reminder tool and key messages for women • Ensuring systematic anaemia screening, using appropriate technology for all pregnant women at their first ANC visit • Strengthening referrals for severe cases of anaemia for treatment • Improving supply forecasting and monitoring of IFA supplies, by changing to a needs-based supply system Adolescent girls and NPNL women • Providing IFA supplementation (weekly), deworming (twice yearly) to adolescent girls 13-19 years through schools and adolescent community clubs • Strengthening partnership with Ministry of Education and Ministry of Women and Children Affairs to deliver nutrition promotion and supplementation to adolescent girls through these delivery platforms Need based targeted MNP supplementation for young children as home based food fortification Children 6-23 months • MNP supplementation and monitoring of compliance for targeted children 6-23 months • Integrating MNP programme with emergency programme Zinc supplementation with ORS in management of diarrhoea Children < 5 years • Improving coverage of ORS with zinc in management of diarrhoea, by strengthening the supply of zinc based on estimated/targeted diarrhoea case load and contingency stock for seasonal peaks of incidence • Supporting primary health care centres and satellite clinics in urban slum areas in zinc supply provision and monitoring for case management of diarrhoea • Strengthening awareness programme on zinc supplementation in management of diarrhoea Targeted Calcium supplementation Pregnant women • Implementing calcium supplementation for pregnant women through ANC as per WHO guideline Children at risk • Screening for rickets and supplementation of calcium for children in high risk areas (e.g., south-east coastal districts) Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 51 3.1.3. Strategic Area 3: Partnership & Coordination For successful implementation of all strategic areas, it is essential that there are sufficient resources and also working partnerships and coordination systems. Table 4 provides an outline of the focus action areas in partnership and coordination. Table 4: Priority Areas of Partnership and Coordination Strategy Priority Areas of Action Dietary diversification • Enhancing partnership with other relevant departments (DAE, DoF, DoL) for increasing productivity in horticulture, livestock, poultry and fisheries to contribute to sustainable diets • Ensuring coordination with other programmes, especially agriculture and fisheries sectors • Integrating nutrition in school curriculum IFA supplementation • Increasing coordination between MOHFW, other ministries and partner organizations USI programme • Strengthening coordination by mainstreaming with NNS all activities related to iodized salt • Strengthening DGHS and DGFP under MOHFW’s countrywide health service network for community awareness and monitoring of supply of iodized salt Need based targeted MNP supplementation for young children as home based food fortification • Increasing coordination between MOHFW and other organizations, including CSOs and private sectors involved Strengthen IYCF activities • Strengthening counselling services at facilities and communities • Advocating and coordinating between authorities and private organizations to implement government policy of 6 months maternity leave in private sectors • Advocating and partnering between private and public organizations for crèches in work places Zinc fortification in agriculture • Establishing inter-ministerial coordination between ministries of Health, Agriculture and Food • Establishing complementary collaborative efforts between research institutes, extension services and private sectors Vitamin D and calcium supplementation • Exploring and strengthening through multi-sector collaboration Coordination committees • Reorganizing relevant ministry and DG level committees (specific micronutrient based, e.g., vitamin A) to a generic overarching committee on micronutrients 3.1.4. Strategic Area 4: Capacity Building Capacity building is critical for successful public health nutrition intervention programmes. The NSPCMD will be implemented through health care providers at different levels – national, regional, district and community. During the next ten years, MOHFW, in collaboration with other partners, will focus on building the capacity of these health workers to ensure quality service delivery, accurate monitoring and reporting, for improved outcomes in relation to the micronutrient status of targeted groups. A list of the focus areas for capacity building are outlined Table 5. 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 52 Table 5: Priority Areas for Capacity Building Level Priority Areas of Action National • Developing high-profile communication campaigns on micronutrient prevention and control to target policy makers, stakeholders, academia, private sectors and the general population • Advocating and influencing other relevant sector policies and programmes in supporting implementation of national strategy (e.g. Ministry of Finance, Ministry of Industry, Ministry of Agriculture, etc.) • Enhancing supply chain management • Strengthening enforcement of relevant laws and regulations and quality assurance. Conduct analysis on food and pharma laws to formulate recommendations which would protect and support national strategy Regional • Providing technical support, as per agenda of each partner, to the salt manufacturing mills to improve production, QC/QA and monitoring • Building capacity of implementing and monitoring bodies, e.g.. BSCIC, IPHN, BSTI, etc. • Ensuring coordination and capacity of CSOs and private sectors for reach and compliance. District • Integrating planning and monitoring of micronutrient prevention and control interventions into district coordination • Supporting and facilitating multi-sector district coordination and joint evaluation for the implementation of the national strategy Facility • Increasing knowledge and skills of service providers through appropriate and adequate training • Equipping service providers with effective job aids, monitoring tools and communication materials Community • Increasing knowledge and awareness in populations about micronutrient deficiencies through social mobilisation involving community and religious leaders • Supporting effective community-outreach and promotion to influence behaviour change and attitudes to increase demand of micronutrient interventions and consumption of nutrient-rich, fortified foods 3.1.5. Strategic Area 5: Advocacy and Communication Increasing the demand for and use of micronutrient intervention services and improving the utilisation of recommended micronutrient supplements, fortified products and food-based approaches are the key objectives of the overall strategy. Behaviour change to improve the intake of micronutrients is an essential part of whatever intervention method is being used and requires communications, using mass media, social and political facilitation, social marketing and nutrition education. Therefore, in this strategy document, priority has been given to designing and implementing evidence-based and pro-poor interventions targeted at the general population and, in some cases, depending on the intervention needs, specific population groups, including pregnant women and under-five children. The MOHFW on a regular basis should review the current policies, legislations and enforcement measures. Based on the reviews, the Ministry shall initiate actions to develop/amend new policies and legislations that are relevant to the context. In this section, a list of focus areas for advocacy and communication are presented in Table 6. 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 53 Table 6: Priority Areas for Advocacy and Communication Target Audience Priority Areas of Action Policy makers • Developing user friendly communication and information products to inform and influence policymakers on micronutrient prevention and control • Developing communication plans, guidelines and tools on micronutrients • Amending, strengthening and enforcing laws and regulations Key ministries (Agriculture, Livestock, Fisheries, Education, Welfare, Finance, etc.) • Advocating to develop sector policies and programmes that are nutrition sensitive and support implementation of the national strategy • Developing and utilising adapted and consistent information, education and communication (IEC) materials and messages Private sector • Engaging in the ethical marketing and social marketing of micronutrients, nutritious and fortified foods • Integrating fortified food products (salt and edible oil) with other national health programmes for media publicity to create people’s demand • Motivating producers to reduce the price of fortified food products (salt and edible oil), which will lead to more sales and consumption in the community • Avoiding conflict of interest General population and communities • Improving understanding and awareness among the general population and targeted populations, including school children, through mass media and community media and inclusion in curriculums • Developing effective and innovation communication channels • Strengthening quality of and scaling up of targeted counselling and communication services to mothers and adolescent girls • Identifying creative communication platforms – through mother support networks, peer-to-peer support, community forums, etc. Service Providers • Ensuring service providers understand their role and responsibility in the implementation of micronutrient deficiency prevention and control interventions • Promoting consistent messages • Increasing public demand by providing information to physicians through medical representatives and organizing seminars/ workshops for village doctors, Shaystha Shebikas, and health workers Development partners • Mobilising resources for research for new interventions and technologies and scaling up of evidence-based interventions • Ensuring nutrition development programmes align with objectives and strategies in national micronutrient deficiency prevention and control strategy • Advocating for joint monitoring of implementation and achievement of results of the strategy 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 54 3.1.6. Strategic Area 6: Monitoring, Evaluation and Research Monitoring and evaluation (M&E) and research are critical components of the NSPCMD and necessary for the delivery of high quality intervention products through the continuous improvement of the programme. M&E and research have been identified as major weaknesses in all the existing programmes. This section outlines the focus areas of M&E which would need to run in the recommended intervention programmes (Table 7). The M&E framework will ensure standard nutrition indicators are monitored and measured periodically to assess effective coverage of these interventions. Further, a number of operation research areas have been identified to gain new knowledge and thus will help to modify the current programmes if needed. Table 7: Priority Areas for Monitoring, Evaluation and Research Micronutrient Research / M&E Priority Areas of Action VAC supplementation programme M&E • Strengthening the monitoring system to ensure quality coverage by providing training to national and sub-national level staff • Monitoring the receipt of two doses of vitamin A supplementation at individual level to ensure adequate protection IFA supplementation in pregnancy Research M&E • Operation researching to decide modification of current programme, as for example, the issue of iron intake from groundwater and its effects on anaemia and other micronutrients • Further etiological researching on anaemia • Exploring possibility of adding multiple micronutrients during pregnancy • Strengthening monitoring and supervision through adequate training of service providers • Establishing monitoring of supply chain system IFA supplementation for at-risk groups (adolescent girls, newly wed women) M&E • Establishing monitoring system and supply chain management Need based targeted MNP supplementation for young children as home-based food fortification Research M&E • Evaluating efficacy of the programme, especially for anaemia, iron and zinc, and vitamin A status • Conducting operation research on safety issues/ side effects of MNP • Strengthening M&E system Zinc supplementation with ORS in management of diarrhoea M&E • Strengthening M&E system 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 55 Micronutrient Research / M&E Priority Areas of Action USI programme M&E • Enforcing external monitoring by government regulatory bodies • Involving local government agencies, including elected public representatives (e.g., chairperson, members) in monitoring of retailers • Developing crude salt specification by BSCIC and monitoring of crude salt quality • Introducing QC labs in all salt industries Strengthen fortification of edible oil with vitamin A M&E • Strengthening the development of a strong monitoring and evaluation system in private sector and government services Fortification with zinc Research • Exploring rice and wheat flour fortification with zinc • Establishing a monitoring system on the effectiveness of rice fortification Bio-fortification of zinc Research M&E • Researching further newly developed zinc bio fortified rice varieties (such as BRRI 62) and the necessary extension initiative • Monitoring and quality control of zinc content in food Improving zinc content in food /agriculture Research • Exploring using powdered fish as a sprinkle in the food • Exploring Zn-Fertilizer • Developing foliar spraying technique • Exploring zinc enrichment of rice at the processing stage (soaking) All food fortification programmes M&E • Ensuring quality control programme is endorsed by the government regulatory body Promote diversified safe food Research • Identifying low-cost high-micronutrient containing animal sources of food • Ensuring diversified and safe food All micronutrient interventions M&E Governance • Overarching multi-sectoral committees would be in place for guiding and monitoring nutrition programmes including micronutrients in line with National Nutrition Policy. 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 56 3. 2 S tr a te g y Im p le m e n ta ti o n P la n T hi s se ct io n is d ed ic at ed t o th e im pl em en ta tio n pl an f ra m ew or k fo r th e N S P C M D f or t he n ex t te n ye ar s. T he im pl em en ta tio n pl an f ra m ew or k ou tli ne d in T ab le s 8 to 1 5 is s tr uc tu re d ac co rd in g to t he s ix s tr at eg ic a re as d es cr ib ed i n Ta bl e 1 an d in cl ud es i nt er ve nt io n, p rio rit y ar ea s, re sp on si bl e or ga ni za tio ns a nd s er vi ce d el iv er y ch an ne ls /p la tfo rm s. Ta bl e 8: Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 1: P ol ic y, G ui de lin es a nd L eg is la tio n M ic ro nu tr ie nt P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er V ita m in A 1. S tr en gt he ni ng V A C s up pl em en ta tio n st ra te gy fo r ch ild re n ag ed 6 5 9 m on th s, e sp ec ia lly th os e liv in g in h ar d to r ea ch ar ea s an d m od er at el y m al no ur is he d ch ild re n. M O H F W U N S ys te m , D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e B y2 01 6 2. R ev is iti ng e xi st in g po lic y fo r po st p ar tu m V A C su pp le m en ta tio n pr og ra m m e in th e co nt ex t o f r ec en t W H O re co m m en da tio n. M O H F W U N S ys te m , D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e B y 20 16 3. R ei nf or ci ng c om pl ia nc e by p riv at e se ct or s as k ey p la ye rs in th e vi ta m in A fo rt ifi ca tio n pr og ra m . M in is tr y of In du st rie s U N S ys te m , D ev el op m en t P ar tn er s, E di bl e O il R efi ne rie s B y 20 16 Io di ne 1. R ev is in g ex is tin g S al t L aw to im pl em en t t he u se o f i od iz ed sa lt in li ve st oc k an d pr oc es se d fo od . M in is tr y of In du st rie s M in is tr y of L aw , M O H F W B y 20 16 2. D ec la rin g U S I a s a pr og ra m m e of n at io na l i m po rt an ce a nd in te rv en in g in a m is si on m od e (S al t M is si on ). M O H F W M in is tr y of In du st rie s, M in is tr y of C om m er ce B y 20 16 3. Tr an sf or m in g U S I p ro je ct in to a s us ta in ab le p ro gr am m e an d m ai ns tr ea m in g U S I a ct iv iti es w ith in N N S . M in is tr y of In du st rie s M O H F W B y 20 17 4. In iti at in g a M ar ke t I nt er ve nt io n O pe ra tio n (M IO ) to d et er m in e th e rig ht p ric e fo r co ns um er s. M in is tr y of C om m er ce M O H F W , M in is tr y of In du st rie s B y 20 16 5. In tr od uc in g io di ze d sa lt in to s af et y ne t p ro gr am m es . M O W C A M O F, M O H F W , M in is tr y of S oc ia l W el fa re B y 20 17 6. Ta ki ng s tr on g ad m in is tr at iv e ac tio n ag ai ns t n on p er fo rm in g m ill s. M in is tr y of In du st rie s M in is tr y of L aw O n go in g 7. Im po si ng r es tr ic tio n on im po rt o f r efi ne d ed ib le s al t, w ith pr op er q ua lit y ch ec ks a nd w ith th e ex ce pt io n of e m er ge nc y si tu at io ns . M in is tr y of In du st rie s M in is tr y of L aw , M in is tr y of C om m er ce O n go in g3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 57 M ic ro nu tr ie nt P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er Ir on 1. R ev ie w in g po lic y on IF A s up pl em en ta tio n gu id el in es fo r ad ol es ce nt g irl s an d N P N L w om en ; c on si de r ad di ng o th er m ic ro nu tr ie nt s to s up pl em en ts . M O H F W U N S ys te m , D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e B y 20 16 2. C on si de rin g po lic y on m ul tip le m ic ro nu tr ie nt s up pl em en ta tio n du rin g pr eg na nc y. M O H F W U N S ys te m , D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e B y 20 16 3. N ee d ba se d ta rg et ed M N P s up pl em en ta tio n pr og ra m m e fo r yo un g ch ild re n ag ed 6 2 3 m on th s. M O H F W U N S ys te m , D ev el op m en t P ar tn er s, N at io na l N G O s O n go in g Zi nc 1. D ev el op in g an d im pl em en tin g po lic y on r ic e fo rt ifi ca tio n w ith zi nc a s on e of th e m ul tip le m ic ro nu tr ie nt s fo r th e po or es t gr ou p th ro ug h go ve rn m en t s af et y ne t p ro gr am m es a nd o th er gr ou ps ( op en m ar ke t s al e, r at io ni ng , e tc .) . M O W C A , M O F M O H F W , U N S ys te m B y 20 16 2. C on si de rin g bi o fo rt ifi ca tio n of r ic e w ith z in c fo r m as s po pu la tio ns . M O A M O H F W B y 20 18 V ita m in B 12 1. C on si de rin g po ss ib ili ty o f a dd in g an im al s ou rc e fo od s in ap pr op ria te fo rm fo r vu ln er ab le g ro up s th ro ug h sa fe ty n et a nd fo od s ec ur ity p ro gr am m e. T hi s ca n al so in cr ea se c on su m pt io n of o th er m ic ro nu tr ie nt s, s uc h as v ita m in s A , D , B 12 , i ro n an d zi nc . M O W C A M O F, M O H F W , M in is tr y of F is he rie s an d Li ve st oc k, U N S ys te m B y 20 18 V ita m in D a nd C al ci um 1. D ev el op in g an d im pl em en tin g po lic y on fo od fo rt ifi ca tio n w ith vi ta m in D ( su ch a s ed ib le o il c on si de r do ub le fo rt ifi ca tio n) . M in is tr y of in du st rie s M O H F W , E di bl e O il R efi ne rie s B y 20 17 2. S tr en gt he ni ng c al ci um s up pl em en ta tio n du rin g pr eg na nc y, a s pe r W H O g ui de lin e. M O H F W B y 20 16 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 58 3 Ta bl e 9: Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 2: M ic ro nu tr ie nt In te rv en tio n/ P ro gr am m e (D ie ta ry D iv er si fic at io n) In te rv en tio n S tr at eg y M ic ro nu tr ie nt (s ) Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er S tr en gt he n in fa nt a nd yo un g ch ild fe ed in g pr om ot io n, pr ot ec tio n an d su pp or t ac tiv iti es A ll es se nt ia l W ho le po pu la tio n • Q ua lit y co un se lli ng a t f ac ili tie s an d co m m un iti es • S up po rt in g br ea st fe ed in g at w or k pl ac es • E ns ur in g m at er ni ty p ro te ct io n in th e pu bl ic an d pr iv at e se ct or s • E nf or ci ng B re as t M ilk S ub st itu te s (B M S ) La w M O H F W M in is tr y of E du ca tio n, M oW C A , M in is tr y of In fo rm at io n, U N S ys te m , N at io na l F ou nd at io n an d A lli an ce O n go in g S tr en gt he n po lic ie s on nu tr iti on se ns iti ve ag ric ul tu re an d fo od sy st em s V ita m in A , vi ta m in D , i ro n, zi nc , c al ci um , vi ta m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g fo od s ec ur ity a nd a gr ic ul tu re po lic ie s to e nh an ce a va ila bi lit y, a ffo rd ab ili ty , di ve rs ity a nd q ua lit y, in cl ud in g fo od s af et y • S up po rt in g nu tr iti on o rie nt ed a gr ic ul tu re re se ar ch o n cr op s, li ve st oc k an d pr od uc tio n sy st em s • R es ea rc hi ng a nd p ro m ot io n of n ut rie nt de ns e pr od uc t d ev el op m en t, fo od t o fo od en ric hm en t, pr oc es si ng a nd tr an sp or t • S ca lin g up h om es te ad a nd s ch oo l g ar de ns M in is tr y of A gr ic ul tu re M in is tr y of F oo d, U N S ys te m B y 20 18 S tr en gt he ni ng in te gr at ed ho us eh ol d fa rm in g sy st em s V ita m in A , vi ta m in D , i ro n, zi nc , c al ci um , vi ta m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • S tr en gt he ni ng H F P p ro gr am m e an d in te gr at ed fa rm in g sy st em s by im pr ov ed in pu ts a nd e nh an ce d te ch no lo gy tr an sf er to en su re a de qu at e su pp ly o f a v ar ie ty o f s af e an d nu tr iti ou s fo od s • In cr ea si ng c ro p an d fo od d iv er si ty th ro ug h ag ric ul tu re ( e. g. , m ix ed c ro pp in g, r ai se d be ds sy st em s) • P ro m ot in g th e gr ow in g of m ic ro nu tr ie nt r ic h ho rt ic ul tu re , s m al l l iv es to ck a nd fi sh er ie s pr od uc e M in is tr y of A gr ic ul tu re , M in is tr y of Li ve st oc k an d F is he rie s M in is tr y of W om en a nd C hi ld re n A ffa irs , U N S ys te m B y 20 18 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 59 3 In te rv en tio n S tr at eg y M ic ro nu tr ie nt (s ) Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er P ro m ot io n of an im al fo od s, liv es to ck a nd fis he rie s V ita m in A , vi ta m in D , i ro n, zi nc , c al ci um , vi ta m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g an im al s ou rc es o f f oo ds fo r pr eg na nt a nd la ct at in g w om en th ro ug h A N C an d P N C s er vi ce s • P ro m ot in g an im al s ou rc es o f f oo d fo r ch ild re n th ro ug h IY C F c ou ns el lin g • P ro m ot in g th e pr od uc tio n an d co ns um pt io n of s m al l fi sh a s so ur ce o f c al ci um a nd v ita m in A • P ro m ot in g th e co ns um pt io n of o ily fi sh a s a so ur ce o f v ita m in D • C om m on m es sa gi ng a cr os s se ct or s on th e co ns um pt io n of d iv er si fie d di et s, fo cu si ng on th e fir st 1 , 0 00 d ay s of li fe , s ho ul d be de liv er ed th ro ug h th e ex te ns io n se rv ic es o f co re s ec to rs • E nh an ci ng th e fo od b as ke t t o in cl ud e a w id er ra ng e of fo od s (e .g ., eg gs ) th ro ug h th e sa fe ty ne t p ro gr am m es , p ar tic ul ar ly fo r vu ln er ab le gr ou ps M O H F W M in is tr y of Li ve st oc k an d F is he rie s, M oW C A , M in is tr y of F oo d B y 20 18 H om e ba se d tr ad iti on al pr ac tic es fo r im pr ov in g M ic ro nu tr ie nt In ta ke V ita m in A , vi ta m in D , i ro n, zi nc , c al ci um , vi ta m in s B 2 , B 6 & B 1 2 W ho le po pu la tio n • P ro m ot in g so ak in g pr ac tic e fo r st ap le fo od su ch a s ric e an d pu ls es • P ro m ot in g ro as tin g an d so ak in g fo r su ch fo od s lik e ric e an d le nt ils • E xp lo rin g th e av ai la bi lit y of lo ca l a nd /o r in di ge no us fo od s ric h in m ic ro nu tr ie nt s th ro ug ho ut th e co un ty , w ith a fo cu s on co as ta l a nd C H T re gi on s an d co ns id er in g fa ct or s of s ea so na lit y an d cl im at e • E nh an ci ng n ut rit io n aw ar en es s th ou gh na tio n w is e B C C c am pa ig n, in cl ud in g m as s m ed ia M in is tr y of F oo d M in is tr y of A gr ic ul tu re , M O H F W , M in is tr y of In fo rm at io n, U N S ys te m B y 20 18 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 60 3 In te rv en tio n S tr at eg y M ic ro nu tr ie nt (s ) Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er B io fo rt ifi ca tio n of zi nc Z in c, v ita m in A W ho le po pu la tio n • C on si de r cr os s br ee di ng o f h ig h zi nc co nt ai ni ng m eg a va rie ty o f r ic e w ith in di ge no us v ar ie tie s • E st ab lis hi ng q ua lit y co nt ro l f or fe rt ili ze rs in te rm s of z in c co nt en t a nd m in im iz in g ad ul te ra tio n of Z n fe rt ili ze rs • P ro m ot in g th e pr od uc tio n an d co ns um pt io n of h ig h β ca ro te ne c on ta in in g sw ee t p ot at o (k om ol a su nd ar i) • P ro m ot in g a ne w v ar ia nt o f z in c en ric he d ric e de ve lo pe d in B an gl ad es h M in is tr y of A gr ic ul tu re M in is tr y of F oo d, U N S ys te m B y 20 19 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 61 Ta bl e 10 : Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 2: M ic ro nu tr ie nt In te rv en tio n/ P ro gr am m e (F or tifi ca tio n) M ic ro nu tr ie nt Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n S er vi ce D el iv er y C ha nn el Ti m e Fr am e Le ad P ar tn er Fa ci lit y C om m un ity F or tifi ca tio n of ed ib le o il w ith vi ta m in A W ho le po pu la tio n • E ns ur in g ad eq ua te c on su m pt io n of fo rt ifi ed o il, e sp ec ia lly b y th e vu ln er ab le g ro up s • In cr ea si ng a w ar en es s th ro ug h m as s co m m un ic at io n to in cr ea se d em an d • E ns ur in g qu al ity p ro du ct io n of vi ta m in A f or tifi ed e di bl e oi l t hr ou gh st re ng th en in g re gu la to ry m on ito rin g an d en fo rc em en t M O I M oH F W , M in is tr y of In fo rm at io n, E di bl e O il In du st ry D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e, N G O s O pe n M ar ke t O pe n M ar ke t, N G O s O n go in g S tr en gt he n U S I pr og ra m m e W ho le po pu la tio n • S tr en gt he ni ng p ro du ct io n by up gr ad in g th e te ch no lo gy fo r bo th cr ud e an d io di ze d sa lts • E ns ur in g re gi st ra tio n of a ll sa lt br an ds by n am e to c on tr ol fa ke b ra nd s an d in tr od uc in g di ffe re nt c ol ou r pa ck ag in g fo r io di ze d an d no n io di ze d sa lts • In tr od uc in g re w ar d sy st em fo r be st pe rf or m in g sa lt m ill s. E nc ou ra gi ng th e tr an sf or m at io n of s m al l s al t m ill s in to m ed iu m s ca le m ill s, a nd m ed iu m sc al e m ill s in to la rg e m ill s • S up po rt in g af fo rd ab le p ric es fo r io di ze d sa lt fo r al l l ev el o f p op ul at io n • S tr en gt he ni ng a w ar en es s at po pu la tio n an d re ta il le ve ls to in cr ea se co ns um pt io n of io di ze d sa lt • Im pl em en tin g R et ai le r R ap id T es t K it st ra te gy to p re ve nt m ar ke tin g of n on io di ze d sa lt fo r hu m an c on su m pt io n M in is tr y of In du st ry an d B S C IC S al t P ro du ce rs , M O H F W , D ev el op m en t P ar tn er s, U N S ys te m , N G O s O pe n M ar ke t O pe n M ar ke t N G O s O n go in g 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 62 M ic ro nu tr ie nt Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n S er vi ce D el iv er y C ha nn el Ti m e Fr am e Le ad P ar tn er Fa ci lit y C om m un ity R ic e fo rt ifi ca tio n w ith m ic ro nu tr ie nt W ho le / ta rg et ed po pu la tio n • M ai ns tr ea m in g fo rt ifi ed r ic e th ro ug h G oB s af et y ne t p ro gr am m e an d ot he rs (o pe n m ar ke t s al e, r at io ni ng , e tc .) in ad di tio n to th e di ve rs ifi ca tio n of fo od ba sk et • S ca lin g up fo rt ifi ed r ic e th ro ug h th e P ub lic F oo d D is tr ib ut io n S ys te m • E xp lo rin g sc al e up o f b io f or tifi ca tio n of r ic e w ith z in c • D ev el op in g an d en do rs in g st an da rd s an d gu id el in es M O F, M O W C A M O I, U N S ys te m , D ev el op m en t P ar tn er s, N G O s B y 20 17 F oo d F or tifi ca tio n w ith v ita m in D . W ho le po pu la tio n • E xp lo rin g th e sc op e fo r do ub le fo rt ifi ca tio n of e di bl e oi l w ith v ita m in A an d vi ta m in D M in is tr y of In du st rie s D ev el op m en t P ar tn er s, E di bl e O il R efi ne rie s O pe n M ar ke t O pe n M ar ke t O n go in g3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 63 3 Ta bl e 11 : Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 2: M ic ro nu tr ie nt In te rv en tio n P ro gr am m e (S up pl em en ta tio n) M ic ro nu tr ie nt Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n S er vi ce D el iv er y C ha nn el Ti m e Fr am e Le ad P ar tn er s Fa ci lit y C om m un ity VA C su pp le m en ta tio n C hi ld re n, 6 59 m on th s • S us ta in in g hi gh e ffe ct iv e co ve ra ge o f V A C su pp le m en ta tio n • S tr en gt he ni ng c ov er ag e of V A C su pp le m en ta tio n in h ar d to r ea ch ar ea s • S tr en gt he ni ng th er ap eu tic u se o f VA C d ur in g m ea sl es , d ia rr ho ea an d se ve re a cu te m al nu tr iti on IP H N /N N S D G H S , D G F P, U N S ys te m , D ev el op m en t P ar tn er s, N G O s, M O LR D C / U P H C P S D P, N H S D P H ea lth C en tr es N VA C ca m pa ig ns , E P I o ut re ac h si te s, P ro m ot io n by he al th w or ke rs in c ou rt ya rd se ss io ns a nd H H v is its B y 20 16 IF A su pp le m en ta tio n P re gn an t w om en • P ro vi di ng IF A s up pl em en ta tio n to ne w ly w ed w om en to e ns ur e pr e pr eg na nc y IF A s ta tu s • S tr en gt he ni ng e ffe ct iv e co ve ra ge of IF A d ur in g pr eg na nc y, b y pr ov id in g ad eq ua te d os e of IF A in A N C 1 ( 90 ta bl et s – 3 m on th s’ su pp ly ) an d A N C 2 ( 90 ta bl et s) an d m on ito rin g co m pl ia nc e in ne xt A N C v is its • S pe ci al p ac ka gi ng o f I FA ta bl et s to in cl ud e a re m in de r to ol a nd ke y m es sa ge s fo r w om en • E ns ur in g sy st em at ic a na em ia sc re en in g us in g ap pr op ria te te ch no lo gy fo r al l p re gn an t w om en a t t he ir fir st A N C v is it • S tr en gt he ni ng r ef er ra ls fo r se ve re ca se s of a na em ia fo r tr ea tm en t • Im pr ov in g su pp ly fo re ca st in g an d m on ito rin g of IF A s up pl ie s, by c ha ng in g to a n ee ds b as ed su pp ly s ys te m IP H N /N N S D G H S , D G F P, U N S ys te m , D ev el op m en t P ar tn er s, N G O s M O LR D C / U P H C P S D P N H S D P H ea lth C en tr es (A N C /P N C ) P ro m ot io n on u se a nd co m pl ia nc e by h ea lth w or ke rs d ur in g co ur ty ar d se ss io ns a nd H H v is its B y 20 17 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 64 3 M ic ro nu tr ie nt Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n S er vi ce D el iv er y C ha nn el Ti m e Fr am e Le ad P ar tn er s Fa ci lit y C om m un ity A do le sc en t gi rls a nd N P N L w om en • P ro vi di ng IF A s up pl em en ta tio n (w ee kl y) , d ew or m in g (t w ic e ye ar ly ) to a do le sc en t g irl s 13 19 y ea rs th ro ug h sc ho ol s an d ad ol es ce nt c om m un ity c lu bs • S tr en gt he ni ng p ar tn er sh ip w ith M in is tr y of E du ca tio n an d M in is tr y of W om en a nd C hi ld re n A ffa irs to d el iv er n ut rit io n pr om ot io n an d su pp le m en ta tio n to a do le sc en t gi rls th ro ug h th es e de liv er y pl at fo rm s IP H N /N N S , D G F P, D G H S M O P M E / M oE , M O W C A , N G O s, M O LG R D C / U P H C P S D P N H S D P, D ev el op m en t P ar tn er s, U N S ys te m H ea lth C en tr es , S ch oo ls A do le sc en t cl ub s, P ro m ot io n by s ch oo l te ac he rs , he al th w or ke rs , p ee r le ad er s, e tc . B y 20 16 N ee d ba se d ta rg et ed M N P su pp le m en ta tio n fo r yo un g ch ild re n as ho m e ba se d fo od fo rt ifi ca tio n C hi ld re n 6 23 m on th s • M N P s up pl em en ta tio n an d m on ito rin g of c om pl ia nc e fo r ta rg et ed c hi ld re n 6 23 m on th s, • In te gr at in g M N P p ro gr am m e w ith em er ge nc y pr og ra m m e. D G F P, D G H S R el ev an t M in is tr ie s, U N S ys te m , D ev el op m en t P ar tn er s, N G O s H ea lth C en tr es P ro m ot io n on u se a nd co m pl ia nc e by h ea lth w or ke rs d ur in g co ur ty ar d se ss io ns a nd H H v is its , Lo ca l m ar ke ts B y 20 17 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 65 3 M ic ro nu tr ie nt Ta rg et G ro up P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n S er vi ce D el iv er y C ha nn el Ti m e Fr am e Le ad P ar tn er s Fa ci lit y C om m un ity Z in c su pp le m en ta tio n w ith O R S in m an ag em en t o f di ar rh oe a C hi ld re n < 5 ye ar s • Im pr ov in g co ve ra ge o f O R S w ith zi nc in m an ag em en t o f d ia rr ho ea , by s tr en gt he ni ng th e su pp ly of z in c ba se d on e st im at ed / ta rg et ed d ia rr ho ea c as e lo ad a nd co nt in ge nc y st oc k fo r se as on al pe ak s of in ci de nc e • S up po rt in g pr im ar y he al th c ar e ce nt re s an d sa te lli te c lin ic s in ur ba n sl um a re as in z in c su pp ly pr ov is io n an d m on ito rin g fo r ca se m an ag em en t o f d ia rr ho ea • S tr en gt he ni ng a w ar en es s pr og ra m m e on z in c su pp le m en ta tio n in m an ag em en t of d ia rr ho ea D G H S , M O LG R D C / U P H C P S D P D G F P, U N S ys te m , D ev el op m en t P ar tn er s, In te rn at io na l R es ea rc h C en tr e, N G O s N H S D P H ea lth C en tr es P ro m ot io n on u se a nd co m pl ia nc e by h ea lth w or ke rs d ur in g co ur ty ar d se ss io ns a nd H H v is its B y 20 17 Ta rg et ed ca lc iu m su pp le m en ta tio n P re gn an t w om en • Im pl em en tin g ca lc iu m su pp le m en ta tio n fo r pr eg na nt w om en th ro ug h A N C a s pe r W H O g ui de lin e IP H N /N N S , D G F P, D G H S M O W C A , U N S ys te m , D ev el op m en t P ar tn er s, N G O s H ea lth F ac ili tie s P ro m ot io n on u se a nd co m pl ia nc e by h ea lth w or ke rs d ur in g co ur ty ar d se ss io ns a nd H H v is its B y 20 16 C hi ld re n at ris k • S cr ee ni ng fo r ric ke ts a nd su pp le m en ta tio n of c al ci um fo r ch ild re n in h ig h ris k ar ea s (e .g ., so ut h ea st c oa st al d is tr ic ts ) IP H N /N N S D G H S , D G F P H ea lth F ac ili tie s B y 20 17 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 66 Ta bl e 12 : Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 3: P ar tn er sh ip a nd C oo rd in at io n M ic ro nu tr ie nt / C oo rd in at io n C om m itt ee s P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er D ie ta ry d iv er si fic at io n • E nh an ci ng p ar tn er sh ip w ith o th er r el ev an t d ep ar tm en ts ( D A E , D oF , D oL ) fo r in cr ea si ng p ro du ct iv ity in h or tic ul tu re , l iv es to ck , p ou ltr y an d fis he rie s to co nt rib ut e to s us ta in ab le d ie ts • E ns ur in g co or di na tio n w ith o th er p ro gr am m es , e sp ec ia lly a gr ic ul tu re a nd fis he rie s se ct or s • In te gr at in g nu tr iti on in s ch oo l c ur ric ul um M O H F W M in is tr ie s of F is he rie s, A gr ic ul tu re a nd Li ve st oc k B y 20 16 IF A s up pl em en ta tio n • In cr ea si ng c oo rd in at io n be tw ee n M O H F W , o th er m in is tr ie s an d pa rt ne r or ga ni za tio ns M O H F W U N S ys te m , D ev el op m en t P ar tn er s B y 20 16 U S I p ro gr am m e • S tr en gt he ni ng c oo rd in at io n by m ai ns tr ea m in g w ith N N S a ll ac tiv iti es r el at ed to io di ze d sa lt • S tr en gt he ni ng D G H S a nd D G F P u nd er M O H F W ’s c ou nt ry w id e he al th s er vi ce ne tw or k fo r co m m un ity a w ar en es s an d m on ito rin g of s up pl y of io di ze d sa lt M in is tr y of In du st rie s N N S , D ev el op m en t P ar tn er s O n go in g N ee d ba se d ta rg et ed M N P s up pl em en ta tio n fo r yo un g ch ild re n as h om e ba se d fo od fo rt ifi ca tio n • In cr ea si ng c oo rd in at io n be tw ee n M O H F W a nd o th er o rg an iz at io ns , i nc lu di ng C S O s an d pr iv at e se ct or s in vo lv ed M O H F W D G F P, D G H S , U N S ys te m , D ev el op m en t P ar tn er s, N G O s B y 20 16 S tr en gt he n IY C F ac tiv iti es • S tr en gt he ni ng c ou ns el lin g se rv ic es a t f ac ili tie s an d co m m un iti es • A dv oc at in g an d co or di na tin g be tw ee n au th or iti es a nd p riv at e or ga ni za tio ns to im pl em en t g ov er nm en t p ol ic y of 6 m on th s m at er ni ty le av e in p riv at e se ct or s • A dv oc at in g an d pa rt ne rin g be tw ee n pr iv at e an d pu bl ic o rg an iz at io ns fo r cr èc he s in w or k pl ac es M O H F W R ig ht s ba se d O rg an is at io ns , C ha m be r of C om m er ce B y 20 17 Z in c fo rt ifi ca tio n in ag ric ul tu re • E st ab lis hi ng in te r m in is te ria l c oo rd in at io n be tw ee n m in is tr ie s of H ea lth , A gr ic ul tu re a nd F oo d • E st ab lis hi ng c om pl em en ta ry c ol la bo ra tiv e ef fo rt s be tw ee n re se ar ch in st itu te s, ex te ns io n se rv ic es a nd p riv at e se ct or s M O A M O H F W , M O F B y 20 17 V ita m in D a nd c al ci um su pp le m en ta tio n • E xp lo rin g an d st re ng th en in g th ro ug h m ul ti se ct or c ol la bo ra tio n M O A M O H F W , M O F B y 20 17 C oo rd in at io n co m m itt ee s • R eo rg an iz in g re le va nt m in is tr y an d D G le ve l c om m itt ee s (s pe ci fic m ic ro nu tr ie nt ba se d, e .g ., vi ta m in A ) to a g en er ic o ve ra rc hi ng c om m itt ee o n m ic ro nu tr ie nt s M O H F W IP H N /N N S , M oI , M oA , M oF L, M oF B y 20 163 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 67 Ta bl e 13 : I m pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 4: C ap ac ity B ui ld in g Le ve l P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er N at io na l • D ev el op in g hi gh p ro fil e co m m un ic at io n ca m pa ig ns o n m ic ro nu tr ie nt p re ve nt io n an d co nt ro l t o ta rg et p ol ic y m ak er s, s ta ke ho ld er s, a ca de m ia , p riv at e se ct or s an d th e ge ne ra l p op ul at io n • A dv oc at in g an d in flu en ci ng o th er r el ev an t s ec to r po lic ie s an d pr og ra m m es in su pp or tin g im pl em en ta tio n of n at io na l s tr at eg y (e .g . M in is tr y of F in an ce , M in is tr y of In du st ry , M in is tr y of A gr ic ul tu re , e tc .) • E nh an ci ng s up pl y ch ai n m an ag em en t • S tr en gt he ni ng e nf or ce m en t o f r el ev an t l aw s an d re gu la tio ns a nd q ua lit y as su ra nc e. C on du ct a na ly si s on fo od a nd p ha rm a la w s to fo rm ul at e re co m m en da tio ns w hi ch w ou ld p ro te ct a nd s up po rt n at io na l s tr at eg y IP H N /N N S D G H S , D G F P, D P E , U N S ys te m , D ev el op m en t P ar tn er s, IN G O & N G O O n go in g R eg io na l • P ro vi di ng te ch ni ca l s up po rt , a s pe r ag en da o f e ac h pa rt ne r, to th e sa lt m an uf ac tu rin g m ill s to im pr ov e pr od uc tio n, Q C /Q A a nd m on ito rin g • B ui ld in g ca pa ci ty o f i m pl em en tin g an d m on ito rin g bo di es , e .g .. B S C IC , I P H N , B S T I, et c. • E ns ur in g co or di na tio n an d ca pa ci ty o f C S O s an d pr iv at e se ct or s fo r re ac h an d co m pl ia nc e. IP H N /N N S D G H S , D G F P, IN G O / N G O , P riv at e S ec to r O n go in g D is tr ic t • In te gr at in g pl an ni ng a nd m on ito rin g of m ic ro nu tr ie nt p re ve nt io n an d co nt ro l in te rv en tio ns in to d is tr ic t c oo rd in at io n • S up po rt in g an d fa ci lit at in g m ul ti se ct or d is tr ic t c oo rd in at io n an d jo in t e va lu at io n fo r th e im pl em en ta tio n of th e na tio na l s tr at eg y B S C IC , I P H N / N N S B S T I, S al t M ill er s A ss oc ia tio n, U N S ys te m , D ev el op m en t P ar tn er s, O th er s O n go in g F ac ili ty • In cr ea si ng k no w le dg e an d sk ill s of s er vi ce p ro vi de rs th ro ug h ap pr op ria te a nd ad eq ua te tr ai ni ng • E qu ip pi ng s er vi ce p ro vi de rs w ith e ffe ct iv e jo b ai ds , m on ito rin g to ol s an d co m m un ic at io n m at er ia ls IP H N /N N S D G H S , D G F P, U N S ys te m , D ev el op m en t P ar tn er s, IN G O /N G O , P riv at e S ec to r O n go in g C om m un ity • In cr ea si ng k no w le dg e an d aw ar en es s in p op ul at io ns a bo ut m ic ro nu tr ie nt de fic ie nc ie s th ro ug h so ci al m ob ili sa tio n in vo lv in g co m m un ity a nd r el ig io us le ad er s • S up po rt in g ef fe ct iv e co m m un ity o ut re ac h an d pr om ot io n to in flu en ce b eh av io ur ch an ge a nd a tti tu de s to in cr ea se d em an d of m ic ro nu tr ie nt in te rv en tio ns a nd co ns um pt io n of n ut rie nt r ic h, fo rt ifi ed fo od s IP H N /N N S D G H S , D G F P, D A E , I N G O /N G O , D ev el op m en t P ar tn er s, P riv at e S ec to r O n go in g 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 68 Ta bl e 14 : Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 5: A dv oc ac y an d C om m un ic at io n Ta rg et A ud ie nc e P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er P ol ic y m ak er s • D ev el op in g us er fr ie nd ly c om m un ic at io n an d in fo rm at io n pr od uc ts to in fo rm an d in flu en ce p ol ic ym ak er s on m ic ro nu tr ie nt p re ve nt io n an d co nt ro l • D ev el op in g co m m un ic at io n pl an s, g ui de lin es a nd to ol s on m ic ro nu tr ie nt s • A m en di ng , s tr en gt he ni ng a nd e nf or ci ng la w s an d re gu la tio ns M oH F W / M in is tr y of In fo rm at io n U N S ys te m , ev el op m en t P ar tn er s 20 16 on w ar ds K ey m in is tr ie s (A gr ic ul tu re , Li ve st oc k, F is he rie s, E du ca tio n, W el fa re , F in an ce , e tc .) • A dv oc at in g to d ev el op s ec to r po lic ie s an d pr og ra m m es th at a re n ut rit io n se ns iti ve a nd s up po rt im pl em en ta tio n of th e na tio na l s tr at eg y • D ev el op in g an d ut ili si ng a da pt ed a nd c on si st en t i nf or m at io n, e du ca tio n an d co m m un ic at io n (I E C ) m at er ia ls a nd m es sa ge s M oH F W ( IP H N / N N S /D G H S /D G F P ), U P H C S D P, M in is tr y of In fo rm at io n, M in is tr y of E du ca tio n, M oW C A U N S ys te m / D P s/ IN G O s/ N G O s/ C iv il S oc ie tie s an d P P P 20 16 on w ar ds P riv at e se ct or • E ng ag in g in th e et hi ca l m ar ke tin g an d so ci al m ar ke tin g of m ic ro nu tr ie nt s, nu tr iti ou s an d fo rt ifi ed fo od s • In te gr at in g fo rt ifi ed fo od p ro du ct s (s al t a nd e di bl e oi l) w ith o th er n at io na l he al th p ro gr am m es fo r m ed ia p ub lic ity to c re at e pe op le ’s d em an d • M ot iv at in g pr od uc er s to r ed uc e th e pr ic e of fo rt ifi ed fo od p ro du ct s (s al t a nd ed ib le o il) , w hi ch w ill le ad to m or e sa le s an d co ns um pt io n in th e co m m un ity • A vo id in g co nfl ic t o f i nt er es t M in is tr y of In fo rm at io n, M in is tr y of In du st rie s, P riv at e S ec to r M O H F W , M in is tr y of C om m er ce , U N S ys te m , D ev el op m en t P ar tn er s B y 20 16 G en er al p op ul at io n an d co m m un iti es • Im pr ov in g un de rs ta nd in g an d aw ar en es s am on g th e ge ne ra l p op ul at io n an d ta rg et ed p op ul at io ns , i nc lu di ng s ch oo l c hi ld re n, th ro ug h m as s m ed ia a nd co m m un ity m ed ia a nd in cl us io n in c ur ric ul um s • D ev el op in g ef fe ct iv e an d in no va tio n co m m un ic at io n ch an ne ls • S tr en gt he ni ng q ua lit y of a nd s ca lin g up o f t ar ge te d co un se lli ng a nd co m m un ic at io n se rv ic es to m ot he rs a nd a do le sc en t g irl s • Id en tif yi ng c re at iv e co m m un ic at io n pl at fo rm s – th ro ug h m ot he r su pp or t ne tw or ks , p ee r to p ee r su pp or t, co m m un ity fo ru m s, e tc . G ov er nm en t (M oH F W / L oc al G ov er nm en t/ M in is tr y of F oo d/ M in is tr y of In fo rm at io n, M in is tr y of E du ca tio n, M oW C A ) U N S ys te m / D P s/ IN G O s/ N G O s/ S M C / P ro du ce rs 20 16 on w ar ds3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 69 S er vi ce p ro vi de rs • E ns ur in g se rv ic e pr ov id er s un de rs ta nd th ei r ro le a nd r es po ns ib ili ty in th e im pl em en ta tio n of m ic ro nu tr ie nt d efi ci en cy p re ve nt io n an d co nt ro l in te rv en tio ns • P ro m ot in g co ns is te nt m es sa ge s • In cr ea si ng p ub lic d em an d by p ro vi di ng in fo rm at io n to p hy si ci an s th ro ug h m ed ic al r ep re se nt at iv es a nd o rg an iz in g se m in ar s/ w or ks ho ps fo r vi lla ge do ct or s, S ha ys th a S he bi ka s, a nd h ea lth w or ke rs M oH F W ( IP H N / N S /D G H S /D G F P ), U P H C S D P, M O I, M O E , M oW C A F ou nd at io n/ O th er N G O s 20 16 on w ar ds D ev el op m en t pa rt ne rs • M ob ili si ng r es ou rc es fo r re se ar ch fo r ne w in te rv en tio ns a nd te ch no lo gi es an d sc al in g up o f e vi de nc e ba se d in te rv en tio ns • E ns ur in g nu tr iti on d ev el op m en t p ro gr am m es a lig n w ith o bj ec tiv es a nd st ra te gi es in n at io na l m ic ro nu tr ie nt d efi ci en cy p re ve nt io n an d co nt ro l st ra te gy • A dv oc at in g fo r jo in t m on ito rin g of im pl em en ta tio n an d ac hi ev em en t o f r es ul ts of th e st ra te gy M oH F W , Lo ca l G ov er nm en ts U N S ys te m , N G O s 20 16 on w ar ds 3 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 70 Ta bl e 15 : Im pl em en ta tio n P la n Fr am ew or k fo r S tr at eg ic A re a 6: M on ito ri ng , E va lu at io n, a nd R es ea rc h M ic ro nu tr ie nt P ri or ity A re as o f A ct io n R es po ns ib le O rg an iz at io n Ti m e Fr am e Le ad P ar tn er VA C su pp le m en ta tio n pr og ra m m e • S tr en gt he ni ng th e m on ito rin g sy st em to e ns ur e qu al ity c ov er ag e by pr ov id in g tr ai ni ng to n at io na l a nd s ub n at io na l l ev el s ta ff • M on ito rin g th e re ce ip t o f t w o do se s of v ita m in A s up pl em en ta tio n at in di vi du al le ve l t o en su re a de qu at e pr ot ec tio n M oH F W th ro ug h D G H S & D G F P, IP H N U N S ys te m , D P s, A ca de m ic In st itu te s, In te rn at io na l R es ea rc h C en tr e, N G O s B y 20 17 IF A s up pl em en ta tio n in p re gn an cy • O pe ra tio n re se ar ch in g to d ec id e m od ifi ca tio n of c ur re nt p ro gr am m e, as fo r ex am pl e, th e is su e of ir on in ta ke fr om g ro un dw at er a nd it s ef fe ct s on a na em ia a nd o th er m ic ro nu tr ie nt s • F ur th er e tio lo gi ca l r es ea rc hi ng o n an ae m ia • E xp lo rin g po ss ib ili ty o f a dd in g m ul tip le m ic ro nu tr ie nt s du rin g pr eg na nc y • S tr en gt he ni ng m on ito rin g an d su pe rv is io n th ro ug h ad eq ua te tr ai ni ng o f s er vi ce p ro vi de rs • E st ab lis hi ng m on ito rin g of s up pl y ch ai n sy st em M oH F W th ro ug h D G H S & D G F P, IP H N A ca de m ic In st itu te s, F ou nd at io ns , I nt er na tio na l R es ea rc h C en tr e, U N S ys te m , D P s B y 20 17 IF A s up pl em en ta tio n fo r at r is k gr ou ps (a do le sc en t g irl s, ne w ly w ed w om en ) • E st ab lis hi ng m on ito rin g sy st em a nd s up pl y ch ai n m an ag em en t M oH F W th ro ug h D G H S & D G F P, IP H N N A B y 20 17 N ee d ba se d ta rg et ed M N P su pp le m en ta tio n fo r yo un g ch ild re n as ho m e ba se d fo od fo rt ifi ca tio n • E va lu at in g ef fic ac y of th e pr og ra m m e, e sp ec ia lly fo r an ae m ia , i ro n an d zi nc , a nd v ita m in A s ta tu s • C on du ct in g op er at io n re se ar ch o n sa fe ty is su es / s id e ef fe ct s of M N P • m ic ro nu tr ie nt s • S tr en gt he ni ng M & E s ys te m M oH F W th ro ug h IP H N A ca de m ic In st itu te s, In te rn at io na l R es ea rc h C en tr e, F ou nd at io ns , U N S ys te m , D P s B y 20 18 Z in c su pp le m en ta tio n w ith O R S in m an ag em en t of d ia rr ho ea • S tr en gt he ni ng M & E s ys te m M oH F W th ro ug h IP H N B y 20 163 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 71 U S I p ro gr am m e • E nf or ci ng e xt er na l m on ito rin g by g ov er nm en t r eg ul at or y bo di es • In vo lv in g lo ca l g ov er nm en t a ge nc ie s, in cl ud in g el ec te d pu bl ic re pr es en ta tiv es ( e. g. , c ha irp er so n, m em be rs ) in m on ito rin g of re ta ile rs • D ev el op in g cr ud e sa lt sp ec ifi ca tio n by B S C IC a nd m on ito rin g of cr ud e sa lt qu al ity • In tr od uc in g Q C la bs in a ll sa lt in du st rie s M oI , C ID D , B S C IC L G D , I P H N , B S T I, IF S T, IN F S , F B C C I (in cl ud in g sa lt pr od uc er s an d re ta ile rs ), U N S ys te m , D P s, N G O s B y 20 17 S tr en gt he n fo rt ifi ca tio n of e di bl e oi l w ith v ita m in A • S tr en gt he ni ng th e de ve lo pm en t o f a s tr on g m on ito rin g an d ev al ua tio n sy st em in p riv at e se ct or a nd g ov er nm en t s er vi ce s M in is tr y of In du st rie s U N S ys te m , D ev el op m en t P ar tn er s B y 20 16 F or tifi ca tio n w ith z in c • E xp lo rin g ric e an d w he at fl ou r fo rt ifi ca tio n w ith z in c • E st ab lis hi ng a m on ito rin g sy st em o n th e ef fe ct iv en es s of r ic e fo rt ifi ca tio n M in is tr y of F oo d M O W C A , A ca de m ic In st itu te s, In te rn at io na l R es ea rc h C en tr e, U N S ys te m , D ev el op m en t P ar tn er s B y 20 16 B io f or tifi ca tio n of zi nc • R es ea rc hi ng fu rt he r ne w ly d ev el op ed z in c bi o fo rt ifi ed r ic e va rie tie s (s uc h as B R R I 6 2) a nd th e ne ce ss ar y ex te ns io n in iti at iv e • M on ito rin g an d qu al ity c on tr ol o f z in c co nt en t i n fo od M in is tr y of A gr ic ul tu re M in is tr y of F oo d, M oH F W (I P H N ), M oI ( B S T I) , U N S ys te m , D P s, R B R R I a nd In te rn at io na l R es ea rc h C en tr e B y 20 16 O n go in g Im pr ov in g zi nc co nt en t i n fo od / ag ric ul tu re • E xp lo rin g us in g po w de re d fis h as a s pr in kl e in th e fo od • E xp lo rin g Z n F er til iz er • D ev el op in g fo lia r sp ra yi ng te ch ni qu e • E xp lo rin g zi nc e nr ic hm en t o f r ic e at th e pr oc es si ng s ta ge ( so ak in g) M O F L, M oA M O H F W , M in is tr y of F oo d, U N S ys te m , D ev el op m en t P ar tn er s, IN G O s B y 20 17 A ll fo od fo rt ifi ca tio n pr og ra m m es • E ns ur in g qu al ity c on tr ol p ro gr am m e is e nd or se d by th e go ve rn m en t re gu la to ry b od y M in is tr y of F oo d (p ro po se d F oo d S af et y A ut ho rit y) M oA , M oH F W , M in is tr y of In du st rie s, M oF L, IP H N , B S T I, U N S ys te m , D ev el op m en t P ar tn er s, N G O s B y 20 16 P ro m ot e di ve rs ifi ed sa fe fo od • Id en tif yi ng lo w c os t h ig h m ic ro nu tr ie nt c on ta in in g an im al s ou rc es o f fo od • E ns ur in g di ve rs ifi ed a nd s af e fo od M O F L, M in is tr y of F oo d M oH F W B y 20 17 A ll m ic ro nu tr ie nt in te rv en tio ns • O ve ra rc hi ng m ul ti se ct or al c om m itt ee s w ou ld b e in p la ce fo r gu id in g an d m on ito rin g nu tr iti on p ro gr am m es in cl ud in g m ic ro nu tr ie nt s in lin e w ith N at io na l N ut rit io n P ol ic y M oH F W / IP H N M in is tr y of In du st rie s, M in is tr y of F oo d, M in is tr y of A gr ic ul tu re , M in is tr y of W om en & C hi ld re n A ffa irs , M O I, B y 20 16 3 1 Vitamin A deficiency is defined as serum retinol level <0.7 mmol/l (WHO/IVACC). 2 Iron deficiency is defined as serum ferritin level <12.0 mg/ml in preschool age children (WHO, 2001). 3 Iodine deficiency is defined as urinary iodine concentration<100.0 µg/l in school age children and NPNL (WHO 2013). 4 Zinc deficiency is defined as S. Zinc level <9.9 mml/l in preschool age children and 10.1 mmol/l in NPNL women (International Zinc Nutrition Consultative Group (IZiNCG) 2004). 5 Vitamin D deficiency is defined as serum vitamin D level <50.0 nmol/L, as suggested by the Institute of Medicine (Ross AC et al. 2011) 6 Prevalence of calcium deficiency is defined as serum calcium level <8.8 mg/dL for preschool and school age children and <8.4 mg/dL for NPNL women. NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 72 3.3 Indicator Matrix Table 16: Indicators (Impact level) Indicator Target Group Baseline (year) Target by 2019 (reduction by 15%) Target by 2024 (reduction by 25%) Means of Verifications Impact level 1 Prevalence of Vitamin A deficiency1 Preschool-age children (6-59 months) 20.5% (NMS 2011-12) 17% 15% National Micronutrient Survey School-age children (6-14 years) 20.9% (NMS 2011-12) 18% 16% 2 Prevalence of Iron deficiency2 Preschool-age children (6-59 months) 10.7% (NMS 2011-12) 9% 8% National Micronutrient Survey 3 Prevalence of Iodine deficiency3 School-age children (6-14 years) 40% (NMS 2011-12) 34% 30% National Micronutrient Survey NPNL women (15-49 years) 42.1% (NMS 2011-12) 36% 32 National Micronutrient Survey 4 Prevalence of Zinc Deficiency4 School-age children (6-14 years) 44.6% (NMS 2011-12) 38% 33% National Micronutrient Survey NPNL women (15-49 years) 57.3% (NMS 2011-12) 49% 43% 5 Prevalence of Vitamin D deficiency5 Preschool-age children (6-59 months) 39.6% (NMS 2011-12) 34% 30% National Micronutrient Survey NPNL women (15-49 years) 71.5% (NMS 2011-12) 61% 54% 6 Prevalence of Calcium Deficiency6 Preschool-age children (6-59 months) 24.4% (NMS 2011-12) 21% 18% National Micronutrient Survey NPNL women (15-49 years) 26.3% (NMS 2011-12) 22% 20% 3 3 Recommended Strategy for Prevention and Control of Micronutrient Deficiencies 73 Table 17: Indicators (Outcome level) Indicator Target Group Baseline (year) Target by 2019 Target by 2025 Means of Verifications Outcome level indicators 1 % of children 6-59 months receiving at least one dose of vitamin A supplementation within six months Children aged 6-11 months 83% (2012, EPI CES 2013) >90% >95% EPI Coverage Evaluation Survey National Micronutrient Survey Children aged 12-59 months 92% (2012, EPI CES 2013) >92% >95% 2 % of woman who consumed at least 100 IFA tablets during pregnancy Pregnant women 15% (IPHN/HKI 2006) >50% >75% Food Security Nutrition Surveillance Project 3 % of children 6-23 months receiving micronutrient powders within last 24 hours Children aged 6-23 months 1.3% (NMS 2011-12) 15% 30% National Micronutrient Survey 4 % of children aged under 5 years with diarrhoea who are treated with zinc supplements Children aged 0-59 months 40.8% (BDHS 2011) 47% 56% BDHS 5 Percentage of households consuming Iodized (> 5 ppm) salts Households 80.3% (NMS 2011-12) 92% 100% National Micronutrient Survey 6 Percentage of households consuming adequately Iodized (> 15 ppm) salts Households 57.6% 75% 90% National Micronutrient Survey 7 Number of households consuming Vitamin A-fortified edible oil Households 0% 75% 90% National Micronutrient Survey NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 74 References Allen LH, Penland JG, Boy E, DeBaessa Y, and Rogers LM. Cognitive and neuromotor performance of Guatemalan schoolers with deficient, marginal and normal plasma vitamin B12. FASEB Journal. 1999; 13: A544. Allen LH. Impact of vitamin B-12 deficiency during lactation on maternal and infant health. Advances in Experimental Medicine and Biology. 2002; 503: 57-67. Arsenault JE, Yakes EA, Islam MM, Hossain MB, Ahmed T, Hotz C, Lewis B, Rahman AS, Jamil KM, and Brown KH. Very Low Adequacy of Micronutrient Intakes by Young Children and Women in Rural Bangladesh is Primarily Explained by Low Food Intake and Limited Diversity. Journal of Nutrition. 2013; doi: 10.3945/jn.112.169524. Bangladesh Bureau of Statistics. Report of the Household Income and Expenditure Survey (HIES) 2010. Planning Division, Ministry of Planning, Government of the People’s Republic of Bangladesh, 2010. Baqui AH, Black RE, El Arifeen S, Yunus M, Chakraborty J, Ahmed S, and Vaughan JP. Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children: community randomised trial. BMJ. 2002; 325 (7372): 1059-62. Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhoea in children in developing countries: pooled analysis of randomized controlled trials. American Journal of Clinical Nutrition. 2000; 72 (6): 1516–22. Bielsalski HK. Hidden Hunger, 13th ed. Berlin Heidelberg: Springer-Verlag, 2013; pp. 25-50. BjørkeMonsen AL, Ueland PM, Vollset SE, Guttormsen AB, Markestad, T, Solheim E, and Refsum H. Determinants of cobalamin status in newborns. Pediatrics. 2001; 108: 624–630. Brooks WA, Yunus M, Santosham M, Wahed MA, Nahar K, Yeasmin, S, and Black RE.Zinc for severe pneumonia in very young children: double-blind placebo-controlled trial. Lancet. 2004; 363 (9422): 1683–1688. Bushamuka VN, de Pee S, Talukder A, Keiss L, Panagides D, Taher A, Bloem MW. Impact of a homestead gardening program on household food security and empowerment of women in Bangladesh. Food Nutr Bull. 2005; 26: 17-25. Chaffee BW and King JC. Effect of zinc supplementation on pregnancy and infant outcomes: a systematic review. Paediatric and Perinatal Epidemiology. 2012; 26 (Suppl. 1), 118-137. Cole CR and Lifshifz F. Zinc nutrition and growth retardation. Paediatrics Endocrinology Review. 2008; 5 (4): 889-96. Darnton-Hill I. Overview: Rationale and elements of a successful food fortification program. Food and Nutrition Bulletin. 1998; 19 (2): 92-100. Darnton-Hill I, Webb P, Harvey PWJ, Hunt JM, Dalmiya N, Chopra M, Ball MJ, Bloem MW and de Benoist B. Micronutrient deficiencies and gender: social and economic costs. Am J Clin Nutr. 2005, 819 Suppl: 1198S-1205S. Dewey KG, Brown KH. 2002. Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull, in press at the time. Dhaka University, ICCIDD and UNICEF. Report of the national iodine deficiency survey of Bangladesh, 1993. Dhaka: Institute of Nutrition and Food Science, Dhaka University, 1993. Dhaka University, IPHN, BSCIC, UNICEF and ICCIDD. Report of the national iodine deficiency survey of Bangladesh, 1999. Dhaka: Institute of Nutrition and Food Science, Dhaka University, 1999. DGHS (Directorate General of Health Services). EPI coverage evaluation survey 2006. Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh; 2006. References 75 DGHS (Directorate General of Health Services). EPI coverage evaluation survey 2012. Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh; 2012. Dreyfuss ML, Stoltzfus RJ, Shrestha JB, Pradhan EK, LeClerq SC, Khatry SK, Shrestha SR, Katz J, and Albonico M. Hookworm, malaria and vitamin A deficiency contribute to anaemia and iron deficiency among pregnant women in the plains of Nepal. Journal of Nutrition. 2000; 130 (10): 2527– 2536. Eneroth H, El Arifeen S, Persson LA, Lönnerdal B, Hossain MB, Stephensen CB, and Ekström EC. Maternal multiple micronutrient supplementation has limited impact on micronutrient status of Bangladeshi infants compared with standard iron folic acid supplementation. Journal of Nutrition. 2010.140 (3): 618-24. Ezzati M, Lopez AD, Rodgers A and Murray CJL. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization, 2004. Fishman SM, Christian P, and West KP Jr. The role of vitamins in the prevention and control of anaemia. Public Health Nutrition. 2000; 3 (2): 125–150. (FPMU) Food Planning and Monitoring Unit. Bangladesh National Food Policy – Plan of Action (2008-2015). Dhaka: Food Planning and Monitoring Unit, Ministry of Food and Disaster Management, Government of the People’s Republic of Bangladesh, 2006. FPMU/Food Division. Bangladesh Country Investment Plan: A road map towards investment in agriculture, food security and nutrition. Ministry of Food and Disaster Management, Government of the People’s Republic of Bangladesh, 2011. Gregory J, Lowe S, Bates CJ, Prentice A, Jackson LV, Smithers G. National Diet and Nutrition Survey of People Aged 4-18 Years. Vol. 1. Report of the Diet and Nutrition Survey. London: The Stationery Office; 2000 Gröber U, Spitz J, Reichrath J, Kisters K, and Holick MF. Vitamin D Update 2013: From rickets prophylaxis to general preventive healthcare. Dermatoendocrinol. 2013; 5 (3): 331–347. Haas J and Brownlie T 4th. Iron deficiency and reduced work capacity: a critical review of the research to determine a causal relationship Journal of Nutrition. 2001; 131 (2S-2): 676S-688S. Hallberg L. Bioavailability of dietary iron in man. Annual Review of Nutrition. 1981; 1: 123–47 Henderson L, Gregory J, Swan G. National diet and nutrition survey: adults aged 19-64 years. Vol. 1: types and quantities of foods consumed. London: The Stationery Office; 2002. Hetzel BS. Iodine deficiency disorders (IDD) and their eradication. Lancet. 1983; 2 (8359): 1126-29. Hollies BW and Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. American Journal of Clinical Nutrition. 2004; 80 (Suppl): 1752S-1758S. Horton S and Ross J. The economics of iron deficiency. Food Policy. 2003; 28 (1), 51–75. Huffman SL, Baker J, Shumann J, and Zehner ER. The case for promoting multiple vitamin/ mineral supplements for women of reproductive age in developing countries. Washington, DC: The LINKAGES Project, Academy for Educational Development, 1998. ICDDR, B (International Centre for Diarrhoeal Disease Research), GAIN (Global Alliance for Improved Nutrition), and UNICEF (United Nations Children’s Fund).The National Micronutrient Survey 2011-12. UNICEF, June 2014. ICDDR, B. National Rickets Survey, Bangladesh 2008. ICDDR., B Health and Science Bulletin. 2009; 7 (1): 7-11. Imdad A and Butta ZA. Effects of calcium supplementation during pregnancy on maternal, fetal and birth outcomes. Paediatric and Perinatal Epidemiology. 2012; 26 (Suppl. 1), 138-152. Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, and Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database of Systematic Reviews.2010; (12): CD008524. NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 76 International Zinc Nutrition Consultative Group Technical Document #1; Food and Nutrition Bulletin. 2004; 25 (suppl 2). IPHN and HKI (Institute of Public Health Nutrition and Helen Keller International). Bangladesh nutritional blindness study, 1982-83; Dhaka: Helen Keller International, 1985. IPHN and HKI (Institute of Public Health Nutrition and Helen Keller International). Nutritional Surveillance Project 2005; Dhaka: Helen Keller International, 2005. IPHN and HKI (Institute of Public Health Nutrition and Helen Keller International). Vitamin A status throughout the life cycle in rural Bangladesh: National Vitamin A Survey 1997-98. Dhaka: Helen Keller International, 1999. IPHN and HKI (Institute of Public Health Nutrition and Helen Keller International). Anaemia is a serious public health problem in pre-school children and pregnant women in rural Bangladesh. Nutrition Surveillance Project Bulletin. No.10. Helen Keller International, 2002. IPHN and HKI (Institute of Public Health Nutrition and Helen Keller International). The burden of anaemia in rural Bangladesh: An urgent need for action. Nutrition Surveillance Project Bulletin. No.16. Helen Keller International; 2006. IPHN (Institute of Public Health Nutrition). National Guidelines: Prevention and Treatment of Iron Deficiency Anaemia. Dhaka: IPHN 2001. IPHN (Institute of Public Health Nutrition). National strategy for anaemia prevention and control in Bangladesh. Dhaka: IPHN, 2007. IPHN (Institute of Public Health Nutrition). National Strategy for Infants and Young Child Feeding in Bangladesh. IPHN, Directorate General of Health Services, Ministry of Health and family welfare, Government of the People’s Republic of Bangladesh, 2007. IPHN, BSCIC, UNICEF and ICCIDD (Institute of Public Health Nutrition, Bangladesh Small and Cottage Industries Corporation, United Nations Children’s Fund and International Council for the Control of Iodine Deficiency Disorders). Evaluation of universal salt iodization (USI) in Bangladesh, 1999. Institute of Public Health Nutrition, 1999. Jahan K. and Hossain M. Nature and extent of malnutrition in Bangladesh. Bangladesh National Nutrition Survey, 1995-96, Institute of Nutrition and Food Science, University of Dhaka, July, Part1. 1998; 116: 134. Jansson LT, Kling S, and Dallman PH. Anemia in children with acute infection seen in a primary care pediatric outpatient clinic. Paediatrics Infectious Diseases. 1986; 5 (4): 424–427. Jones G, Steketee R W, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362 (Vol 362): 65–71 JPGSPH and HKI (James P Grant School of Public Health and Helen Keller International). State of food security and nutrition in Bangladesh 2011. JPGSPH, Helen Keller International, and Government of the People’s Republic of Bangladesh, 2012. Khan KU. Homestead gardening in Bangladesh: enhancing the nutritional and economic status of the rural population. Khulna, Bangladesh: Khulna University, 2011. Lawn JE, Cousens S, Zupan J: 4 million neonatal deaths: When? Where? Why? Lancet 2005, 365 (9462):891–900. Leklem JE. Vitamin B-6. In: Ziegler EE, Filer LJ Jr, editors. Present Knowledge in Nutrition. 7th ed. Washington, DC; 1997. International Life Sciences Institute Press: 174–183. Lindström E, Hossain MB, Lönnerdal B, Raqib R, El Arifeen S, and Ekström EC. Prevalence of anaemia and micronutrient deficiencies in early pregnancy in rural Bangladesh, the MINI Mat trial. Acta Obstetriciaet Gynecologica Scandinavica. 2011; 90 (1): 47–56. Linpisarn S, Tienboon P, Promtet N, Putsyaninunt P, Santawanpat S, and Fushs GJ. Iron deficiency and anaemia in children with a high prevalence of haemoglobinopathies: implications for screening. International Journal of Epidemiology. 1996; 25 (6): 1262–1266. References 77 Mejia LA. Role of vitamin A in iron deficiency anaemia. In: Fomon SF, Zlotkin S, editors. Nutritional Anaemias. Nestle Nutrition Workshop Series. Vevey: Nestle Ltd. New York: Raven Press. 1992; 30: 93–101. Merrill RD, Labrique AB, Shamim AA, Schulze KJ, Christian PK, Merrill RK and West KP Jr. Elevated and variable groundwater iron in rural north western Bangladesh. Journal of Water and Health. 2010; 8 (4): 818–825. Merrill RD, Shamim, Ahmed A; Hasmot A, Labrique, Alain B, Schulze, Kerry; Christian, Parul and West, Keith P. High prevalence of anaemia with lack of iron deficiency among women in rural Bangladesh: a role for thalassemia and iron in groundwater. Asia Pacific Journal of Clinical Nutrition. 2012; 21 (3); 416 424. MOHFW (Ministry of Health and Family Welfare). Bangladesh National Nutrition Policy 2015. Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, 2013. Mitra and Associates and Macro International. Bangladesh Demographic and Health Survey. National Institute of Population Research and Training (NIPORT); 1993. Mitra and Associates and Macro International. Bangladesh Demographic and Health Survey. National Institute of Population Research and Training (NIPORT); 1999. Mitra and Associates and Macro International. Bangladesh Demographic and Health Survey. National Institute of Population Research and Training (NIPORT); 2007. Mitra and Associates and Macro International. Bangladesh Demographic and Health Survey. National Institute of Population Research and Training (NIPORT); 2011. Ones G, Steketee RW, Black RE, Bhutta ZA, Morris SS: How many child deaths can we prevent this year? Lancet 2003, 362 (9377): 65 –71. PANO and WHO (Pan American Health Organization and World Health Organization). Guiding principles for complementary feeding of the breastfed child, PAHO, 2003. Powers HJ, Bates CJ, and Duerden JM. Effects of riboflavin deficiency in rats on some aspect of iron metabolism. International Journal for Vitamin and Nutrition Research. 1983; 53 (4): 371–376. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, Editors. Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Chapter 5. Dietary reference intakes for adequacy: Calcium and Vitamin D. Institute of Medicine, National Academy of Sciences (USA); 2011. Sattar S, Ahmed T, Rasul CH, Saha D, Salam MA and Hossain MI. Efficacy of a high-dose in addition to daily low-dose vitamin A in children suffering from severe acute malnutrition with other illnesses. PLoS ONE. 2012; 7 (3): e33112. doi: 10.1371/journal.pone.0033112. Sazawal S, Black RE, Ramsan M, et al. Effect of zinc supplementation on mortality in children aged 1–48 months: a community-based randomised placebo-controlled trial. Lancet. 2007; 369 (9565): 927– 934. Sommer A and West KP Jr. Vitamin A deficiency: health, survival and vision. New York: Oxford University Press; 1996. UNICEF (United Nations Children’s Fund). UNICEF Data: Monitoring the situation of children and women; http://data.unicef.org/nutrition/iodine. UNICEF and MI (United Nations Children’s Fund and Micronutrient Initiative). Vitamin and mineral deficiency: a global progress report. Ottawa, Canada: Micronutrient Initiatives, 2004. Villamor E and Fazwi WW. Vitamin A supplementation: implications for morbidity and mortality in children. Journal of Infectious Diseases. 2000; 182 (Suppl 1): S122-S133. Walker CF and Black RE. Zinc and the risk for infectious disease. Annual Review of Nutrition. 2004; 24: 255–275. WHO& FAO (World Health Organization and Food and Agricultural Organization of the United Nations). Guideline for food fortification with micronutrients. 2006, 57. NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 78 WHO and UNICEF (World Health Organization and United Nations Children’s Fund). Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization, 2003. WHO, UNICEF and ICCIDD (World Health Organization, United Nations Children’s Fund and International Council for the Control of Iodine Deficiency Disorders). Assessment of iodine deficiency disorders and monitoring their elimination. A guide for programme managers. 3rd edition. Geneva: World Health Organization, 2007. WHO, UNICEF and UNU (World Health Organization, United Nations Children’s Fund and United Nations University). Iron deficiency anaemia: assessment, prevention, and control. A guide for programme managers. Geneva: World Health Organization, 2001. WHO (World Health Organization). Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO Global Database on Vitamin A Deficiency. Geneva: World Health Organization, 2009. WHO (World Health Organization). Guideline: Calcium supplementation in pregnant women. Geneva: World Health Organization, 2013. WHO (World Health Organization). Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization, 2012. WHO (World Health Organization). Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. Geneva: World Health Organization, 2011. WHO (World Health Organization). Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva: World Health Organization, 2011. WHO (World Health Organization). Guideline: Vitamin D supplementation in pregnant women. Geneva: World Health Organization, 2012. WHO (World Health Organization): Guideline: Vitamin A supplementation in postpartum women. Geneva: World Health Organization, 2011. WHO (World Health Organization). Iodine status worldwide: WHO Global Database on Iodine Deficiency. Geneva: World Health Organization, 2011. WHO (World Health Organization). Vitamin and Mineral Requirements in Human Nutrition, 2nd edition. Geneva: World Health Organization, 2004. WHO (World Health Organization). Weekly iron–folic acid supplementation (WIFS) in women of reproductive age: its role in promoting optimal maternal and child health. Position statement. Geneva: World Health Organization, 2009. WHO (World Health Organization). Worldwide prevalence of anaemia 1993-2005: WHO Global Database on Anaemia. Geneva: World Health Organization, 2008. WHO/NUT/98.1, 1998. Complementary feeding of young children in developing countries; a review of current scientific knowledge. World Health Organization, Geneva. WHO/UNICEF/UNU 2001. Iron Deficiency Anaemia: Assessment, Prevention, and Control-A Guide for Programme Manager Yusuf HK, Khatun F and Rahman AKMM. National survey on iodine deficiency disorders and universal salt iodization survey of Bangladesh 2004-5. Dhaka: Institute of Public Health Nutrition; 2007. p. 158. Annexes 79 Annexes Annex 1: Strategy Development Process This document has been developed following a consultative process that started after dissemination of the National Micronutrient Survey 2011-12. The Institute of Public Health Nutrition initially formed a technical committee to identify a process of consultation to formulate a national micronutrient deficiency control strategy. In order to ensure that the NSPCMD accurately reflects the views of its stakeholders, an extensive consultation process was under taken from October 2013 to April 2014. The consultation process included participants from relevant ministries, academia, research institutions, international and national organizations and UN organizations. The consultation process involved group discussion meetings with various stakeholders and then a series of workshops for each of concerned micronutrients. The workshop outputs and recommendations were compiled along with extensive literature support and distributed among all relevant stakeholders’ for comments and feedback. The Ministry of Health and Family Welfare constituted an “Expert Working Group”, incorporating members from different ministries, agencies, institutions, etc. (Annex2) to provide technical leadership for the development of the National Strategy on Prevention and Control of Micronutrient Deficiencies. The Expert Working Group was also responsible for identifying critical issues to be addressed and build synergy between existing legislation, policies, protocols and guidelines. The following table provides major events in the process of developing the Strategy. Table: Milestones in the NSPCMD Development process Time Period Event September 9, 2013 IPHN formed a Technical Committee First Technical Committee Meeting October 8, 2013 Second Technical Committee Meeting November 2013 to March 2014 Five Sub-group Consultation Workshops on Vitamin A, Iodine Nutrition, Iron and Anaemia, Zinc/B12 Deficiency and Vitamin D/Calcium February 16, 2014 Development of First Draft NSPCMD and disseminated among stakeholders for review February 16-19, 2014 Bilateral discussion with experts of different stakeholders on First Draft March 13, 2014 MOHFW Formulate Expert Working Group April 15, 2014 Incorporate comments and developed Second Draft April 18, 2014 Expert Working Group meeting to review Second Draft April 24, 2014 Broader workshop for intensive review of the proposed Strategy May 2014 Incorporation of comments and Final Draft developed September 2014 Expert Working Group meeting, decision to incorporate further recommendations March 2015 Expert Working Group meeting, finalization of the strategy May 2015 Approval by MOHFW NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 80 Annex 2: Expert Working Group: List of Members Chair Roxana Quader, Additional Secretary (PH & WH), MOHFW Members (In no particular order) Ministry of Health and Family Welfare Niru Shamsur Nahar, Joint Chief (Planning) Subash Chandra Sarker, Joint Secretary (Public Health) Iffat Ara Mahmood, Deputy Secretary (Public Health-2) Directorate General of Health Services (DGHS) Dr. Syed Abu Zafar Md. Musa, Director, Primary Health Care and Line Director (MNC &AH) Directorate General of Family Planning (DGFP) Dr. Mohammed Sharif, Director, MCH-Services Unit and Line Director (MC-RAH) Ministry of Industries Abu Taher Khan, Director (Technology) and Project Director, CIDD Project, Bangladesh Small and Cottage Industries Corporation (BSCIC) Md. Abdus Sabur Chowdhury, Deputy Secretary Ministry of Food Ruhul Amin Talukder, Director, FPMU Ministry of Children & Women Affairs Md. Alamgir Hussain, Deputy Chief Ministry of Agriculture Sams-e-Ara Binte Huda, Deputy Secretary Ministry of Fisheries & Livestock M. Saiful Hassan, Deputy Secretary Ministry of Education Sakeun Nahar Begum, Deputy Secretary Ministry of Information Md. Robiul Islam, Deputy Secretary Budget Institute of Public Health Nutrition (IPHN) Dr.Md. Shah Nawaz, Director-IPHN and Line Director-NNS, DGHS Dr. Md. Abdul Jalil, Deputy Director, IPHN &Programme Manager, NNS Dr. Moudud Hossain, Programme Manager, NNS Dr. Taherul Islam Khan, Programme Manager, NNS Dr. Nasreen Khan, Deputy Program Manager, NNS University of Dhaka Dr. Aleya Mowlah, Professor of Director, Institute of Nutrition and Food Science Dr. ABM Faruque, Professor, Department of Pharmacy, SSMC & Mitford Hospital Goal, Objectives and Background 81 Sir Salimullah Medical College and Hospital Prof. Dr. Ferdousi Begum, Professor, Department of Obstetrics and Gynaecology Ministry of Disaster Management Amena Begum, Deputy Secretary Directorate General of Drug Administration Md. Altaf Hossain UNICEF, Bangladesh Noreen Prendiville, Chief, Nutrition Section Dr. Ireen Akhter Chowdhury, Nutrition Officer (Micronutrient) Dr. Mohsin Ali, Nutrition Specialist Global Alliance for Improved Nutrition (GAIN) Basanta Kumar Kar, Country Manager International Centre for Nutrition and Food Security (icddr, b) Dr. Tahmeed Ahmed, Senior Scientist and Director, Centre for Nutrition and Food Security Micronutrient Initiatives Dr. S M Mustafizur Rahman, Country Director BRAC University Dr. Zeba Mahmud, Director Nutrition, BRAC Institute of Global Health (BIGH) Food and Agriculture Organization (FAO) Lalita Bhattacharjee, Nutritionist World Health Organization (WHO) Farzana Bilkes, National Professional Officer -Nutrition & Food Safety, WHO, Bangladesh Bangladesh Breastfeeding Foundation (BBF) Dr. S. K. Roy, Chairman Helen Keller International (HKI) Shirin Afroz, Programme Coordinator NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES BANGLADESH (2015-2024) 82 NATIONAL STRATEGY ON PREVENTION AND CONTROL OF MICRONUTRIENT DEFICIENCIES, BANGLADESH (2015-2024) December 2015 Design and Printing Supported by: