Anemia in Latin America and the Caribbean, 2009. Situation analysis, trends, and implications for public health programming / Anemia en América Latina y el Caribe, 2009. Análisis de la situación, tendencias, e implicancias para la programación en salud pública

[Executive summary] This report presents aggregated results on the prevalence of anemia and iron deficiency in countries of Latin America and Caribbean during the period 1981–2009. It provides the most recent data available on the prevalence of anemia at the national, subregional, and regional levels; trends; and estimated numbers of affected children and affected women of childbearing age. It summarizes the current situation of policies and programs to prevent and treat anemia and iron deficiency, and discusses their strengths and weaknesses. A joint initiative of the Micronutrient Initiative (MI) of Canada and the Pan American Health Organization (PAHO), the information in this report will be useful for governments, public health authorities, national policy makers, and other stakeholders interested in preventing anemia and iron deficiency.

Proposed vitamin a fortification levels.

Fortified complementary foods could be effective in preventing and controlling vitamin A and other common nutritional deficiencies in young children. Milk from well-nourished women is an excellent source of vitamin A. However, in Latin America many children are weaned prematurely and must receive the entire requirement of vitamin A from food. This paper proposes vitamin A fortification levels for foods targeted for children aged 6-23 mo to meet the existing intake gap among both breast-fed and weaned infants and young children. Estimates assume a nonsignificant contribution of common complementary foods and average levels of human milk intake by breast-fed infants and children. The estimated vitamin A gap for breast-fed infants aged 6-11 mo amounts to 63-92 microg RE [16-23% of recommended daily intake (RDI)] and for breast-fed children reaches 125 microg RE (31% of RDI). Weaned infants and children would have to fully meet the RDI (400 microg RE) from complementary foods. A fortified complementary food with 500 mg RE/100 g of dry product provided daily in a single ration of 40 g would meet 50% of the gap for weaned infants aged 6-11 mo and would raise the total intake above RDI for breast-fed infants aged 6-8 mo (125%) and 9-11 mo (127%). The same fortified food given in a daily ration of 60 mg would meet most of the gap (75%) for weaned children aged 12-23 mo and would increase total intake of breast-fed children aged 12-23 mo well above the RDI (144%), with no risk of exceeding established upper tolerable intake levels.

Food fortification to reduce vitamin A deficiency: International Vitamin A Consultative Group recommendations.

In developed countries, food fortification has proven an effective and low-cost way to increase the micronutrient supply and reduce the consequences of micronutrient deficiencies. It has been rarely used in the developing world, but general conclusions can be drawn. The biological efficacy, but not the effectiveness, of fortifying oil and hydrogenated oil products as well as cereal flours and meals with vitamin A has been shown. Sugar has been fortified with vitamin A in Central American countries for years, and biological efficacy and program effectiveness are well established. Efficacy of fortifying monosodium glutamate with vitamin A was demonstrated but a program has not been established. Fortification with vitamin A in the developing world should satisfy certain elements for success. a) A potential food matrix (a food regularly consumed, produced by a few centralized factories, without sensorial changes compared with the nonfortified equivalent, and nutrient remains bioavailable and in a sufficient amount) is required. b) Fortified foods should provide at least 15% of the recommended daily intakes for the target group (e.g., individuals consuming the lowest amount of the fortified food). c) Voluntary fortification of processed foods should be regulated to prevent excessive consumption of vitamin A. d) Neighboring countries should harmonize technical standards, facilitate compliance and minimize conflicts over global trade laws. e) A practical monitoring system should be instituted. f) Social marketing activities should be permanent and aimed at industry, government and consumers. g) Food fortification should be combined with other strategies (e.g., supplementation) to reach those not adequately covered by fortification alone. Infants and small children, whose dietary habits differ from those of adults, require special attention. Fortification of food commodities is a very attractive and economic way to prevent and control vitamin A deficiency. Effective food fortification might make supplementation of postpartum women and older children unnecessary.

Iron supplementation: overcoming technical and practical barriers.

Iron supplementation is probably the best available option to effectively address iron deficiency in pregnant women and young children because it can be targeted specifically to these high-risk groups. However, technical and practical barriers exist: limited information on the effectiveness of supplementation interventions, side effects that affect compliance, and supply/distribution constraints. An innovative approach to addressing these constraints is the use of sprinkles of powdered, microencapsulated ferrous fumarate that can be added directly to any semi-liquid food without changing their taste or consistency. This technique has been tested in initial trials in Ghana and found to be as effective as iron drops. Another approach to improve the effectiveness of iron interventions is through information, education and communication (IEC) programs. These interventions can help modify consumer behavior in some cases, but in some countries, geographic location, variations in language and population size can make the cost of IEC programs very high. IEC strategies in Indonesia aimed at increasing demand for iron supplements by systematic dissemination of specific messages, improving the quality and variety of tablets, increasing the availability and access to supplements by engaging the commercial sector, enrolling traditional birth attendants and other community volunteers in selling supplements. Key issues to be addressed include clarifying optimal starting points and duration of supplementation interventions--based on individual status or population prevalence, defining hemoglobin and ferritin cutoffs at which treatment should be instigated and evaluating the effectiveness of intermittent supplementation with multiple micronutrients.

Undernutrition among Honduran children 12-71 months old / Desnutrición en niños hondureños de 12 a 71 meses de edad

In 1996, the Ministry of Health of Honduras conducted a national micronutrient survey that included anthropometric measurements to determine the nutrition status of children 12-71 months old. Among the 1.744 children who participated, 38 percent of them were stunted, including 14 percent who were severely stunted; 24 percent were underweight, of which 4 percent were severely underweight; and 1 percent were wasted, of which 0,1 percent were severely wasted. The country can be divided into three groupings based on the level of stunting and underweight: 1) lowest prevalence: Tegucigalpa, San Pedro Sula, and medium cities; 2) medium prevalence: other urban areas, the rural north, and the rural south; and 3) highest prevalence: the rural west. Using logistic regression analysis, the important determinants of stunting were found to be: mother/caretaker's and father's schooling, source of water, the dominion (geographic location and strata) in which the child lived, and the "possession score" for ownership of such items as a radio, television, refrigerator, stereo system, and electric iron. The predictors for underweight were micronutrient status, diarrhea, maternal/caretaker's schooling, type of toilet, and possession score. Historical data indicate that the national prevalence of chronic undernutrition has changed little over the last 10 years despite the number of national food and nutrition plans implemented and the significant improvements in health services. It is possible that these positive interventions have been offset by the slow progress in economic development. Future nutrition interventions should take into account household-level perceived needs and priorities in order to set realistic nutrition targets

Para determinar el estado nutricional de los niños de 12 a 71 meses de edad, el Ministerio de Salud de Honduras realizó en 1996 una encuesta nacional sobre micronutrientes en la que se incluyeron mediciones antropométricas. De los 1 744 niños que participaron, 38% presentaban retraso del crecimiento, grave en 14%; 24% bajo peso, grave en 4%, y 1% emaciación, grave en 0,1%. El país se puede dividir en tres zonas en función del nivel de retraso del crecimiento y bajo peso: 1) la de baja prevalencia, formada por Tegucigalpa, San Pedro Sula y ciudades medianas; 2) la de prevalencia intermedia, formada por otras zonas urbanas y las zonas rurales del norte y del sur, y 3) la de alta prevalencia, integrada por las zonas rurales del oeste. Mediante un análisis de regresión logística se identificaron los siguientes factores como determinantes importantes del retraso del crecimiento: el nivel de escolaridad de las madres/cuidadoras y de los padres, las fuentes de agua, la localización geográfica de la residencia del niño y la "puntuación de posesiones", referida a la posesión de aparatos como radios, televisores, refrigeradores, equipos de música o planchas eléctricas. A su vez, los factores que predijeron el bajo peso fueron el estado de los micronutrientes, la diarrea, el nivel de escolaridad de las madres/cuidadoras, el tipo de instalación sanitaria y la "puntuación de posesiones". Los datos históricos indican que la prevalencia nacional de desnutrición crónica ha cambiado poco en los últimos 10 años, pese a la importante mejoría de los servicios de salud y a la puesta en marcha de varios planes nacionales de alimentación y nutrición. Es posible que estas intervenciones positivas hayan sido contrarrestadas por los lentos progresos del desarrollo económico. Las futuras intervenciones nutricionales deberían tomar en consideración las necesidades y prioridades percibidas a nivel doméstico, con el fin de fijar objetivos nutricionales realistas.

Undernutrition among Honduran children 12-71 months old

In 1996, the Ministry of Health of Honduras conducted a national micronutrient survey that included anthropometric measurements to determine the nutrition status of children 12-71 months old. Among the 1 744 children who participated, 38 percent of them were stunted, including 14 percent who were severely stunted; 24 percent were underweight, of which 4 percent were severely underweight; and 1 percent were wasted, of which 0.1 percent were severely wasted. The country can be divided into three groupings based on the level of stunting and underweight: 1) lowest prevalence: Tegucigalpa, San Pedro Sula, and medium cities; 2) medium prevalence: other urban areas, the rural north, and the rural south; and 3) highest prevalence: the rural west. Using logistic regression analysis, the important determinants of stunting were found to be: mother/caretaker's and father's schooling, source of water, the dominion (geographic location and strata) in which the child lived, and the "possession score" for ownership of such items as a radio, television, refrigerator, stereo system, and electric iron. The predictors for underweight were micronutrient status, diarrhea, maternal/caretaker's schooling, type of toilet, and possession score. Historical data include that the national prevalence of chronic undernutrition has changed little over the last 10 years despite the number of national food and nutrition plans implemented and the significant improvements in health services. It is possible that these positive interventions have been offset by the slow progress in economic development. Future nutrition interventions should take into account household-level perceived needs and priorities in order to set realistic nutrition targets (AU) (AU)

Vitamin A deficiency and anemia among children 12-71 months old in Honduras

Vitamin A deficiency (VAD) and iron deficiency anemia (IDA) have been recognised as public health problems in Honduras for over 30 years. This paper, based on the 1996 National Micronutrient Survey on 1 678 children 12-71 months of age, presents the results for vitamin A status and anemia prevalence, as well as the level of vitamin A in sugar at the household level. The results showed that 14 percent of the children were subclinically vitamin A deficient (plasma retinol < 20 ug/dL) and 32 percent were at risk of VAD (plasma retinol 20-30 ug/dL). These data indicate that VAD is a moderate public health problem in Honduras. Logistic regression analysis showed that children 12-23 months old living in areas other than the rural south of the country were at greatest risk of subclinical VAD. Infection, indicated by an elevated alpha-1-acid-glycoprotein level, increased the risk of subclinical VAD more than three-fold. Children from households that obtained water from a river, stream, or lake were at twice the risk of subclinical VAD compared to other children. That same double risk was found for children from a household with an outside toilet. VAD can be controlled by fortifying sugar. Retinol levels in sugar at the household level were about 50 percent of those mandated by Honduran law. There appears to be a significant leakage of unfortified sugar into the market. This is particularly true in the rural north, where 33 percent of samples contained no retinol. Overall 30 percent of children were anemic (Hb < 11g/dL). Logistic regression analysis showed that children whose fathers lived with them but who had not attended at least grade 4 of primary school were at 33 percent greater risk of being anemic. Infection and being underweight increased the risk of being anemic by 51 percent and 21 percent respectively. Many of the anemic children had not been given iron supplements, suggesting health care providers may not be aware that anemia is widespread among young children and/or know how to diagnose it (AU)

Vitamin A deficiency and anemia among children 12-71 months old in Honduras / Deficiencia de vitamina A y anemia en niños de 12 a 71 meses de edad en Honduras

Vitamin A deficiency (VAD) and iron deficiency anemia (IDA) have been recognized as public health problems in Honduras for over 30 years. This paper, based on the 1996 National Micronutrient Survey on 1.678 children 12-71 months of age, presents the results for vitamin A status and anemia prevalence, as well as the level of vitamin A in sugar at the household level. The results showed that 14 per cent of the children were subclinically vitamin A deficient (plasma retinol < 20 ug/dL) and 32 per cent were at risk of VAD (plasma retinol 20-30 ug/dL). These data indicate that VAD is a moderate public health problem in Honduras. Logistic regression analysis showed that children 12-23 monts old living in areas other than the rural south of the country were at greatest risk of subclinical VAD. Infection, indicated by an elevated alpha-1-acid-glycoprotein level, increased the risk of subclinical VAD more than three-fold. Children from households that obtained water from a river, stream, or lake were at twice the risk of subclinical VAD compared with other children. That same doubled risk was found for children from a household with an outside toilet. VAD can be controlled by fortifying sugar. Retinol levels in sugar at the household level were about 50 per cent of those mandated by Honduran law. There appears to be significant leakage of unfortified sugar into the market. This is particularly true in the rural north, where 33 per cent of samples contained no retinol. Overall, 30 per cent of children were anemic (Hb < 11 g/dL). Logistic regression analysis showed that children whose fathers lived with them but who had not attended at least grade 4 of primary school were at 33 per cent greater risk of being anemic. Infection and being underweight increased the risk of being anemic by 51 per cent and 21 per cent, respectively. Many of the anemic children had not been given iron supplements, suggesting health care providers may not be aware that anemia is widespread among young children and/or know how to diagnose it

En Honduras, la deficiencia de vitamina A (DVA) y la anemia ferropénica (AF) han sido problemas de salud pública reconocidos desde hace más de 30 años. Este trabajo, que se basa en la Encuesta Nacional de Micronutrientes de 1996 aplicada a 1 678 niños de 12 a 71 meses de edad, presenta los resultados relacionados con la situación de la vitamina A y la prevalencia de anemia, así como con las concentraciones de vitamina A en el azúcar de consumo domiciliario. Según los resultados, 14% de los niños tenían deficiencia subclínica de vitamina A (retinol plasmático < 20 g/dL) y 32% estaban en riesgo de DVA (retinol en plasma 20­30 g/dL). Estos datos indican que en Honduras la DVA es un problema de salud pública de importancia moderada. Un análisis de regresión logística demostró que los niños de 12­23 meses de edad que no vivían en la zona rural del sur del país corrían el mayor riesgo de DVA subclínica. El tener una infección, reflejada en una elevación de las concentraciones de alfa-1-glucoproteína ácida, aumentó más de tres veces el riesgo de DVA subclínica. Los niños de hogares con agua extraída de ríos, arroyos o lagos mostraron un riesgo doble de DVA subclínica, en comparación con otros niños. Ese mismo riesgo doble se encontró en niños de hogares con el baño situado en el exterior. La VDA puede controlarse mediante la fortificación del azúcar. Las concentraciones de retinol en el azúcar de consumo domiciliario fueron de alrededor de 50% de las dictadas por la ley en Honduras. Hay una filtración importante de azúcar sin fortificar en el mercado, particularmente en la zona rural del norte, donde 33% de las muestras no tenían retinol. En general, 30% de los niños mostraron anemia (Hb < 11 g/dL). Un análisis de regresión logística reveló que los niños cuyos padres vivían con ellos pero no habían cursado por lo menos el cuarto año de primaria corrían un riesgo 33% mayor de tener anemia. La presencia de una infección y el tener insuficiencia de peso aumentaron el riesgo de anemia en 51 y 21%, respectivamente, lo cual indica que los proveedores de atención de salud no siempre saben que la anemia es un problema muy diseminado en niños pequeños ni tampoco saben diagnosticarla

Nutrition of Honduran mothers/caretakers

In 1966, the Honduran Ministry of Health conducted a national micronutrient survey of children 12-71 months old, which also included an assessment of the nutrition status of their mothers/caretakers. THe 1 126 mothers/caretakers who participated in the survey tended to be short and plump. About 15 percent of them were at obstetric risk by virtue of their short stature and/or low body weight. About 9 percent had chronic energy deficiency (CED), but 27 percent were at least 20 percent overweight. CED was associated with socioeconomic indicators of poverty. Risk factors for being at higher than grade 4, 5, or 6 of primary school, coming from a wealthier household, and living in San Pedro Sula or medium-sized cities. Among the women surveyed, 26 percent of nonpregnant and 32 percent of pregnant mothers/caretakers were anemic. The likely principal cause of anemia was the low intake of bioavailable iron from food and, in some cases, excessive iron loss associated with intestinal parasities, especially hookworm. Only 50 percent of the mothers/caretakers participating in this study had received iron during their last pregnancy, and just 13 percent had received postpartum vitamin A. The results highlighted the need to develop and implement an effective program to control iron deficiency anemia in women of reproductive age, including by fortifying such widely consumed foods as processed wheat and maize flour and by routinely administering iron supplements to high-risk groups. Postpartum vitamin A supplementation should be encouraged to protect both the mother and newborn infant against vitamin A deficiency (AU)

Nutrition of Honduran mothers/caretakers / La nutrición de madres y guardianas en Honduras

In 1996, the Honduran Ministry of Health conducted a national micronutrient survey of children 12-71 months old, which also included an assessment of the nutrition status of their mothers/caretakers. The 1.126 mothers/caretakers who participated in the survey tended to be short and plump. About 15 per cent of them were at obstetric risk by virtue of their short stature and/or low body weight. About 9 per cent had chronic energy deficiency (CED), but 27 per cent were at least 20 per cent overweight. CED was associated with socioeconomic indicators of poverty. Risk factors for being at least 20 per cent overweight included being over 30 years old, not breast-feeding, having attended no higher than grade 4, 5, or 6 of primary school, coming from a wealthier household, and living in San Pedro Sula or medium-sized cities. Among the women surveyed, 26 per cent of nonpregnant and 32 per cent of pregnant mothers/caretakers were anemic. The likely principal cause of anemia was the low intake of bioavailable iron from food and, in some cases, excessive iron loss associated with intestinal parasites, especially hookworm. Only 50 per cent of the mothers/caretakers participating in this study had received iron during their las pregnancy, and just 13 per cent had received post-partum vitamin A. The results highlight the need to develop and implement an effective program to control iron deficiency anemia in women of reproductive age, including by fortifying such widely consumed foods as processed wheat and maize flour and by routinely administering iron supplements to high-risk groups. Postpartum vitamin A supplementation should be encouraged to protect both the mother and newborn infant against vitamin A deficiency

En 1996, el Ministerio de Salud de Honduras realizó una encuesta nacional sobre los micronutrientes en niños de 12 a 71 meses de edad, en la cual también se evaluó el estado nutricional de las madres o guardianas. Las 1 126 madres o guardianas que participaron en la encuesta mostraron la tendencia a ser de estatura baja y a tener un exceso de peso. Alrededor de 15% eran de riesgo obstétrico elevado debido a su baja estatura, su poco peso corporal, o ambas cosas. Cerca de 9% tenían deficiencia energética crónica (DEC), pero 27% tenían un sobrepeso mínimo de 20%. La DEC se asoció con indicadores socioeconómicos de pobreza. Entre los factores de riesgo de tener un sobrepeso mínimo de 20% figuraron tener más de 30 años de edad, no haber amamantado, no haber cursado más allá de cuarto, quinto o sexto año de primaria, venir de un hogar más próspero, y vivir en San Pedro Sula o en una ciudad de tamaño mediano. De las mujeres encuestadas, 26% de las madres y guardianas no embarazadas y 32% de las embarazadas tenían anemia. La causa más probable de la afección fue la poca ingestión de hierro biodisponible en los alimentos y, en algunos casos, la pérdida excesiva de hierro ocasionada por la parasitosis intestinal, especialmente la anquilistomiasis. Solamente 50% de las madres o guardianas que participaron en el estudio habían recibido hierro durante el embarazo previo, y apenas 13% habían recibido vitamina A después del parto. Los resultados subrayan la necesidad de crear y poner en marcha un programa eficaz para controlar la anemia por deficiencia de hierro en mujeres de edad reproductiva aplicando determinadas medidas, entre ellas la fortificación de alimentos de consumo general, como las harinas procesadas a base de trigo y maíz, y la administración periódica de suplementos de hierro a grupos de alto riesgo. La suplementación con vitamina A después del parto debe fomentarse con el fin de proteger a la madre y al recién nacido de la deficiencia de esta vitamina.

Vitamin A deficiency in Latin America and the Caribbean: an overview / La deficiencia de vitamina A en América Latina y el Caribe: un resumen

Vitamin A deficiency (VAD) has been known to exist in Latin America and the Caribbean since the mid-1960s; however, except for pioneering work by the Institute of Nutrition of Central America and Panama/Pan American Health Organization on sugar fortification in Central America, there was little interest in controlling it because of the low frequency of clinical findings. More recently, implications of the effect of subclinical VAD on child health and survival has generated increased interest in assessing the problem and a greater commitment to controlling it. The information available by mid-1997 on the magnitude of VAD in countries of the Region was extensively reviewed. Internationally accepted methods and cutoff points for prevalence estimations were used to compile information from relevant dietary, biochemical, and clinical studies carried out between 1985 and 1997 in samples of at least 100 individuals. VAD in the Region of Latin America and the Caribbean is mostly subclinical. The national prevalence of subclinical VAD (serum retinol < 20 mg/dl) in children under 5 years of age ranges between 6% in Panama and 36% in El Salvador. The problem is severe in five countries, moderate in six, and mild in four. There are no recent data from Chile, Haiti, Paraguay, Uruguay, Venezuela, and the English-speaking Caribbean. The population affected amounts to about 14.5 million children under 5 years of age (25% of that age group). Schoolchildren and adult women may also have significant VAD. Actions currently implemented to control VAD include (a) universal or targeted supplementation, with sustained high coverage rates through national immunization days in some countries; (b) sugar fortification, which is well established in El Salvador, Guatemala, and Honduras (a significant effect has been documented in Guatemala and Honduras) and is under negotiation in Bolivia, Colombia, Costa Rica (to be resumed), Ecuador, Nicaragua, and Peru; and...

Se sabe que la deficiencia de vitamina A (DVA) ha existido en América Latina y el Caribe desde mediados de los años sesenta. No obstante, si se exceptúan algunas iniciativas tempranas del Instituto de Nutrición de Centro América y Panamá, había escaso interés en controlarla debido a la detección infrecuente de signos clínicos. En época más reciente, las consecuencias de la DVA para la salud y la supervivencia infantiles ha suscitado gran interés en evaluar el problema y despertado un mayor empeño por controlarlo. La información que estaba disponible a mediados de 1997 sobre la frecuencia de la DVA en países de la Región se revisó minuciosamente. Se aplicaron métodos y puntos de corte aceptados mundialmente para la estimación de la prevalencia a fin de recopilar infomación obtenida de estudios alimentarios, bioquímicos y clínicos efectuados entre 1985 y 1997 con muestras de 100 personas como mínimo. La DVA en la Región de América Latina y el Caribe es eminentemente subclínica. La prevalencia nacional de la forma subclínica de DVA (retinol sérico < 20 µg/dL) en niños menores de 5 años oscila de 6% en Panamá a 36% en El Salvador. El problema es grave en cinco países, moderado en seis y leve en cuatro. No hay datos recientes para Chile, Haití, Paraguay, Uruguay, Venezuela y el Caribe de habla inglesa. En total la población afectada se aproxima a 14,5 millones de niños menores de 5 años (25% de ese grupo de edad). Los escolares y las mujeres en edad adulta también pueden tener una frecuencia elevada de DVA. Las medidas que actualmente están en marcha para controlar la DVA incluyen, entre otras, a) la suplementación dirigida a toda la población o a grupos particulares, con elevadas tasas de cobertura logradas durante los días en que se efectúan las inmunizaciones de alcance nacional en algunos países; b) la fortificación del azúcar, que ya se ha instaurado en El Salvador, Guatemala y Honduras (se ha observado un efecto notable en Guatemala...

Vitamin A deficiency in Latin America and the Caribbean: An overview

Vitamin A deficiency (VAD) has been known to exist in Latin America and the Caribbean since the mid-1960s; however, except for pioneering work by the Institute of Nutrition of Central America and Panama/Pan American Health Organization on sugar fortification in Central America, there was little interest in controlling it because of the low frequency of clinical findings. More recently, implicatons of the effect of subclinical VAD on child health and survival has generated increased interest in assessing the problem and a greater commitment to controlling it. The information available by mid-1997 on the magnitude VAD in countries of the region was extensively reviewed. Internationally accepted methods and cutoff points for prevalence estimations were used to compile information from relevant dietary, biochemical, and clinical studies carried out between 1985 and 1997 in samples of at least 100 individuals. VAD in the region of Latin America and the Caribbean is mostly subclinical. The national prevalence of subclinical VAD (serum retinol <20 ug/d) in children under 5 years of age ranges between 6 percent in Panama and 36 percent in El Salvador. The problem is severe in five countries, moderate in six, and mild in four. There are no recent data from Chile, Haiti, Paraguay, Uruguay, Venezuela, and the English-speaking Caribbean. The population affected amounts to about 14.5 million children under 5 years of age (25 percent of that age group). Schoolchildren and adult women may also have significant VAD. Actions currently implemented to control VAD include (a) universal or targeted supplementation; with sustained high coverage rates through national immunization day in some countries; (b) sugar fortification, which is well established in El Salvador, Guatemala and Honduras ( a significant effect has been documented in Guatemala and Honduras and is under negotiation in Bolivia, Columbia, Costa Rica (to be resumed), Equador, Nicaragua and Peru; and (c) limited dietary diversification activities.(AU)