When setting targeting priorities for micronutrient interventions, the intervention options must first be defined (both those currently in place and those that are feasible but not currently used). Three specific interventions that are used for micronutrient malnutrition (beyond the usual primary health care methods) are the promotion of dietary diversity, fortification of staple foods (or foods consumed by the affected population) and supplementation. Usually, the long-term goal of a program is to shift from immediate care of severe deficiency through therapeutic supplementation to long-term, sustainable management of the population at risk usually through fortification and dietary modification. Before making elaborate program plans or changes, it is important to identify the populations of concern and the severity of the problem.

MN Deficiency Ranking Analysis

Ranking analysis is often used with targeting indicators to help choose target areas or groups. When using the indicators for micronutrient deficiencies, severity is defined using cut-offs like those shown in Section 1. When a population is at high risk, immediate prophylactic measures are needed (usually universal supplementation for iron and vitamin A and targeted supplementation with iodine). When a population has moderate deficiency, the interventions shift towards targeted supplementation, increased public health control measures (e.g. immunization, parasite control, water and sanitation improvement, control and treatment of illnesses resulting from parasites and infections), and food based approaches (e.g. nutrition education, food production). Usually at this point, preparation for food fortification (universal foods) is made if not begun. By the time a population is categorized as low risk, the interventions include only supplementation to the high-risk groups (or those identified in the clinics) and primarily to fortification of food and some public health measures such as immunization and promotion of personal sanitation and hygiene.

In order to use the approach of ranking analysis to identify those worst-off areas, it is often best to look at several indicators or risk factors. Since some micronutrient deficiency clinical indicators are not very sensitive for moderate and mild deficiency, it is often necessary to rely on more sensitive (yet, less specific) indicators for risk. For example, when considering vitamin A deficiency it might be important to rank using not only nightblindness, but also general malnutrition, inadequate consumption of vitamin A foods, etc.

Coverage

Once areas have been ranked, it is also be important to assess the coverage (both for regions and sub-populations) of current programs. Coverage shows the current targeting or lack of, and thus is a simple one-way analysis using the deficiency of interest as the outcome. You might want to use several indicators of coverage if the program has several components (e.g. capsule distribution, consumption of fortified foods, consumes food from home garden, etc.) to make a more effective recommendation for re-targeting strategies. The idea is to identify which areas actually have the highest risk and are receiving the least attention. This will involve both assigning a status of high and low to the level of deficiency and the level of coverage. A basic example is given here using anemia as the outcome and iron tablet distribution as the measure of coverage. The cut-off points were determined by running a histogram and selecting the mid-point for each iron tablets (50%) and anemia (60%):

Program Coverage for Anemia

The numbers in the cells represent districts, which can be used in several formulas to present population prevalence, population coverage, malnourished coverage, and program focusing as shown in PANDA Analysis.

Multiple Micronutrient Considerations

Although there is still of serious lack of data on multiple micronutrient intervention strategies, this should not be dismissed when planning intervention strategies. More often now, there will be data collected on more than one MN deficiency in a data set; therefore leading to analysis that will contribute to our understanding of MN deficiency interactions. As a part of decision making for targeting and program planning, remember that micronutrient deficiencies rarely occur in isolation. This should bring resource conservation to mind, since several interventions could potentially be rolled up into one, depending on the following factors:

1. Target group composition is the same (considering age, sex) or target group(s) access the same distribution site at the same time
2. Geographic area targeted is the same
3. Inhibitory micronutrient interaction is not a problem

In more general terms, a successful intervention requires having strategic program planning, political support, involvement of the community, communication in the community, an appropriate vehicle (food), sustainability, and a system for monitoring and evaluating. First, studies must support that the two or more micronutrients can successfully be combined to alleviate both or all of the deficiencies under consideration. Second, a careful assessment must be made for program compatibility with these micronutrients in terms of awareness building, monitoring of the programs, analysis of the causes, and resource availability. Almost always there will be some overlap in some or many of the areas of program coordination; and most often multiple micronutrient supplementation and fortification makes more sense both biologically and operationally.

Analyzing data to detect deficiency overlap and interactions, it is best to work with a study designed to look at the difference between the groups that receive one nutrient, both nutrients, and no nutrients of interest. It is likely the data you have has not been designed for analysis of nutrient interactions, but it will still be possible to look (more generally) at tabulations to show overlap of deficiencies compared between age, gender, and socio-demographic characteristics. This will both help contribute to the literature on micronutrient deficiency overlap, as well as improving the intervention strategy recommendations.

The goal for intervention is to adapt the strategy to reach the deficient individuals appropriate to the phase of deficiency. If there are a lot of severely affected individuals, then usually there will be either blanket (or in some cases) targeted supplementation to provide immediate alleviation to those who are affected. The feasibility of multiple supplementation as pills or tablets is not far different to that of single nutrient supplementation; one issue is that they would need to be taken regularly and frequently. One parallel is iron supplementation for women, which is not widely successful. While a constraint may be due to some side effects, there are many others, of distribution, counseling, and the simple difficulty of daily use of the tablets. Thus test marketing and promotion of multiple supplements may lead the way in some societies, perhaps especially more urbanized and developed -- and this should be pursued -- but other means of providing multiple supplements also need to be looked into.

After some progress in reducing MN deficiencies has been made, there is usually a transition from supplementation to fortification and education programs to increase the nutrient specific food consumption. Fortification involves a long stage of research and testing, as well as commitment from the food industry, but it offers a very sustainable source of the nutrient if the right vehicle is chosen.

Cost of Intervention- Feasible Targeting

We know from previous programs the approximate unit costs and costs per death averted for single micronutrient supplementation and fortification.  Table 1. indicates that the direct costs of delivering nutrients as supplements or as fortified foods are low.  Costs in life years gained either from reductions in mortality and/or living without illness and disability show similar effects of micronutrient interventions (Table 2). 

*The disability-adjusted life years, or DALY is an indicator of time lived with a disability or years lost due to premature death.   Estimates of years lost due to early death are based on a standard expectation of life at each age and the years lived with a disability are converted into an equivalent time loss through multiplication by a set of weights that reflect reduction in functional capacity.

The question of whether to include a wide range of nutrients when considering intervention strategies -- such as zinc, or the water-soluble vitamins (Bs and C) -- turns more on the possible cost-effectiveness in terms of health and nutritional outcome, than only on the extent, consequences, and presentation of the deficiency. The argument may be the reverse of the usual -- do we have reason not to include a micronutrient that may be limiting? For example, a cheap vitamin (say thiamin) might anyway be included even if the evidence for deficiency is sparse. Indeed, this is what happens with blended foods like Thriposha, commercial weaning foods, and breakfast cereals. Hence the undramatic deficiencies (like zinc, folate, and perhaps other water-soluble vitamins) may finally get attention through a policy of multiple fortification and supplementation.

What are the realities and constraints for multiple fortification and supplementation? Multiple fortification is common in commercial products, breakfast cereals being a good example. Double fortification with specific nutrients, notably iron and iodine in salt, has been investigated for some time; here there are a number of problems of interaction and acceptability, and success has not yet been achieved. As the scope of possible products to fortify expands this will all become easier technically, the issue will increasingly be to implement feasible solutions. Support for the necessary research, promotion, pilot testing, and eliciting the policy commitment for multiple fortification, in close cooperation with the food industry, represents an important opportunity to make a real difference.                  

Targeting- The Bottom Line

When targeting a program, consider that deficiency overlap is likely and therefore it is essential to not view each micronutrient deficiency as an independent problem, but instead as an accumulated outcome of malnutrition. Also, it helps to address the importance of combining efforts in an intervention. It is often possible not only to address the intertwining forms of malnutrition more effectively, but also to reduce distribution costs (when more than one micronutrient is given to the same targeted group) and to combine the intervention tool (e.g. a multi-fortified food or multi-nutrient supplement) at times. The most common problem detecting the need is the lack of data on multiple deficiencies and the lack of sub-clinical data, whereas the most common problem in addressing the problem through supplementation is finding the right dosage and frequency of delivery to the needy populations.   To see specifics on targeting for VAD, IDA, and IDD follow the links in red at the top.