Preventing Hidden Hunger in Children Using Micronutrient Supplementation

  • Conrad R. Cole
    Correspondence
    Reprint requests: Conrad R. Cole, MD, MPH, MSc, Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229.
    Affiliations
    Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Published:August 06, 2012DOI:https://doi.org/10.1016/j.jpeds.2012.06.053
      NHANES (National Health and Nutrition Examination Survey)
      See related article, p 837
      Micronutrient malnutrition is often referred to as “hidden hunger,” and is quite prevalent in under-developed and developing countries. Hidden hunger is a nutritional deficiency that occurs in the presence of an otherwise nutritionally or calorically appropriate diet.
      • Burchi F.
      • Fanzo J.
      • Frison E.
      The role of food and nutrition system approaches in tackling hidden hunger.
      It does not refer to the overt and obvious hunger of poor people who are unable to afford enough to eat, but to a more insidious type of hunger caused by eating food that is cheap and filling but deficient in essential vitamins and micronutrients. This problem is widespread, in particular in Third World/ resource poor countries, where families may fill themselves with inexpensive energy dense foods, as they cannot afford the nutritional diversity (fruits, vegetables, fish, and meat) needed to provide a balanced diet.
      However, the prevalence of specific micronutrient deficiencies in certain high risk groups is also becoming significant in developed countries including the United States.
      • Polhamus B.
      • Dalenius K.
      • Mackintosh H.
      • Smith B.
      • Grummer-Strawn L.
      Pediatric Nutrition Surveillance 2009 Report.
      • Ganji V.
      • Zhang X.
      • Shaikh N.
      • Tangpricha V.
      Serum 25-hydroxyvitamin D concentrations are associated with prevalence of metabolic syndrome and various cardiometabolic risk factors in US children and adolescents based on assay-adjusted serum 25-hydroxyvitamin D data from NHANES 2001-2006.
      • Evatt M.L.
      • DeLong M.R.
      • Kumari M.
      • Auinger P.
      • McDermott M.P.
      • Tangpricha V.
      High prevalence of hypovitaminosis D status in patients with early Parkinson disease.
      • Cole C.R.
      • Grant F.K.
      • Swaby-Ellis E.D.
      • Smith J.L.
      • Jacques A.
      • Northrop-Clewes C.A.
      • et al.
      Zinc and iron deficiency and their interrelations in low-income African American and Hispanic children in Atlanta.
      This becomes more relevant during periods of economic depression when the cost rather than quality usually determines intake. Micronutrient deficiencies are also affected by life style changes including lack of exposure to sunlight in the case of vitamin D.
      Hidden hunger has been identified as a major public health issue as individuals with borderline micronutrient deficiencies do not develop classic signs and symptoms of overt deficiencies. However, if not identified and managed appropriately, affected individuals will suffer from long-term consequences, such as stunted growth and varying degrees of neurocognitive deficit. In the era of improved health consciousness, the use of dietary supplements has become widespread among adults and children.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • Dwyer J.T.
      • Engel J.S.
      • Thomas P.R.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      As a result, it is necessary to evaluate the effectiveness of these supplements in meeting the estimated average requirement of these nutrients and minerals.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • Dwyer J.T.
      • Engel J.S.
      • Thomas P.R.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      • Shakur Y.A.
      • Tarasuk V.
      • Corey P.
      • O'Connor D.L.
      A comparison of micronutrient inadequacy and risk of high micronutrient intakes among vitamin and mineral supplement users and nonusers in Canada.
      It is also important to assess whether the widespread use of these dietary supplements increases the potential for toxicities in certain populations.
      In this issue of The Journal, Bailey et al
      • Bailey R.L.
      • Fulgoni III, V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      attempt to shed more light on this subject. They examined whether the use of supplements in children was adequate to fill gaps in nutritionally inadequate diets or contributed to excessive micronutrient intake from a diet that already contained adequate or excessive micronutrients. The data analyzed was collected as part of the cross sectional National Health and Nutrition Examination Survey (NHANES) 2003-2006. Although a significant proportion of children reported being on supplements (one-fifth [21%] of those <2 years of age, almost one-half [42% of those 2-8 years of age, and one-third [29% and 26%] of those 9-13 years of age and 14-18 years of age, respectively), there were varying degrees of micronutrient intake. Interestingly, the children on supplements had better baseline intake of micronutrients from their food sources compared with those who were not on supplements. This can be presumed to be because these families are more informed and conscious about nutritional requirements for their children as dietary supplement use in adults has been shown to be associated with educational level attained.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • Dwyer J.T.
      • Engel J.S.
      • Thomas P.R.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      Inadequate intake of certain micronutrients from the diet was common in specific age groups with the use of supplements adding micronutrients that would have otherwise being inadequate. However, the use of supplements also increased the probability of excessive intake of certain nutrients (iron, copper, selenium, folic acid, and vitamins A and C). These findings are similar to that previously reported in adults using the same NHANES 2003-2006 data.
      • Bailey R.L.
      • Fulgoni III, V.L.
      • Keast D.R.
      • Dwyer J.T.
      Dietary supplement use is associated with higher intakes of minerals from food sources.
      Minority children (non-Hispanic black and non-black Hispanic), who are the most at risk for micronutrient deficiencies are less likely to be on supplements.
      • Polhamus B.
      • Dalenius K.
      • Mackintosh H.
      • Smith B.
      • Grummer-Strawn L.
      Pediatric Nutrition Surveillance 2009 Report.
      • Cole C.R.
      • Grant F.K.
      • Swaby-Ellis E.D.
      • Smith J.L.
      • Jacques A.
      • Northrop-Clewes C.A.
      • et al.
      Zinc and iron deficiency and their interrelations in low-income African American and Hispanic children in Atlanta.
      • Bailey R.L.
      • Fulgoni III, V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      This study in children adds an important dimension to understanding the complexities of providing appropriate amounts of micronutrients to healthy individuals on a regular diet.
      Interventions required to reduce hidden hunger include nutrition education, fortification, and supplementation. Globally, dietary diversification has being the backbone for improving the micronutrient status of populations.
      • Bailey R.L.
      • Fulgoni III, V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      Programs directed toward eliminating or significantly decreasing micronutrient deficiencies have been broad based so that the interventions can be accepted by communities, health care providers, and policy makers. Fortification programs in the United States and Europe have been very successful in reducing the prevalence of specific micronutrients (eg, folate, iron, vitamin D, iodine).
      • Polhamus B.
      • Dalenius K.
      • Mackintosh H.
      • Smith B.
      • Grummer-Strawn L.
      Pediatric Nutrition Surveillance 2009 Report.
      • Pfeiffer C.M.
      • Hughes J.P.
      • Lacher D.A.
      • Bailey R.L.
      • Berry R.J.
      • Zhang M.
      • et al.
      Estimation of trends in serum and RBC folate in the U.S. population from pre- to postfortification using assay-adjusted data from the NHANES 1988-2010.
      However, there are subgroups in the population that continue to have significantly low intake of essential micronutrients. There is need to evaluate the diets of these groups through dietary data collected nationally from programs such as NHANES and the Canadian community health survey. Targeted educational and social programs can be developed to address the key nutrition knowledge gaps and cultural needs of these communities. A key limitation of the article by Bailey et al is the lack of data on the foods consumed to potentially identify specific food groups/foods or dietary habits that contributed to the deficits in intake.
      • Bailey R.L.
      • Fulgoni III, V.L.
      • Keast D.R.
      • Lentino C.V.
      • Dwyer J.
      Do dietary supplements improve micronutrient sufficiency in children and adolescents?.
      It might also be necessary to evaluate the fortification strategy of foods and to potentially include new products (foods/micronutrients) or increase the current amounts of specific micronutrients. When intakes are inadequate, food fortification may be the appropriate choice for some nutrients, while in other situations, when requirements are markedly higher for some population subgroups than for the general population, supplements may be the most appropriate intervention.
      • L'Abbe M.R.
      • Cockell K.A.
      • Lee N.S.
      Micronutrient supplementation: when is best and why?.
      Dietary supplement use continues to have an impact in reducing the prevalence of micronutrient deficiencies. Evaluating the composition of these supplements and providing guidance to manufacturers, policy makers, and distributors might lead to further reduction in the prevalence of micronutrient deficiencies. This report is provocative and raises a call to determine the optimal doses of micronutrients that should be in supplements for preventing long-term consequences of deficiencies while avoiding toxicities. Studies in children are needed to identify the appropriate amounts of micronutrients needed as the majority of their recommended dietary allowances are based on assumptions from adult values. These studies will help to establish the role of supplements in the prevention and treatment of hidden hunger.

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