More than iron and folate: Multi-micronutrient supplementation recommended in Asia for preconception and during pregnancy

Iron and folate are the most common micronutrient supplements recommended to women planning a pregnancy, during pregnancy and postpartum, to reduce outcomes such as maternal anaemia, low birth weight, pre-term birth and neural tube defects.

Analysing seven countries, namely Singapore, Indonesia, Thailand, Vietnam, Philippines, Hong Kong, and Taiwan, researchers said other micronutrients such as vitamin B12, or those which help enhance nutrient absorption can be taken together to reduce risks of deficiencies as well as infections.

“Current supplementation strategies often focus on just one or two micronutrients such as iron–folate supplements, which could limit their effectiveness in view of multiple nutrient deficiencies and associated adverse outcomes​,” they wrote.

First author, Mary Chong Foong Fong from the National University of Singapore told NutraIngredients-Asia: “Other important micronutrients that are often found lacking in current diets include calcium, vitamin D and omega-3 fatty acids​.”

The data was extracted from national surveys, sub-national cohort studies, systematic reviews and the World Health Organization (WHO) databases.

Findings were published in the Womens’ Health​ journal.

Pre-pregnancy​

The International Federation of Gynecology and Obstetrics (FIGO) recommends additional daily iron, folate and vitamin B12 supplementation in women planning for a pregnancy, during pregnancy, and the first three months postpartum.

Analysing the pre-pregnancy group, researchers highlighted a lack of data in micronutrient intake and status.

Iron intake was lowest in the Philippines, Taiwan, Thailand and highest in Singapore, Indonesia and Vietnam. Data on iron status (plasma levels) was only found for Vietnam which reported more 10% iron deficiency in this group.

Data on folate intake in this group was only available from Thailand, which found mean intake less than half the minimum recommended by FIGO. Folate status for Taiwan, Vietnam and Indonesia revealed most were not deficient but about 20% were folate-insufficient.

Data on vitamin B12 intake was also limited, with only Vietnam reporting less than half the recommended intake by FIGO, although mean plasma levels showed no deficiency.

These findings suggest that iron, folate and vitamin B12 intake was low or borderline sufficient among women in these regions, despite local intake recommendations in all seven regions being largely consistent with those of FIGO.

During pregnancy​

The scarcity of micronutrient data is more prominent in pregnant women than in women of reproductive age.

Data on iron intake for pregnant women were only available for Vietnam, Thailand, and Indonesia. Intake was reported to be below the recommended levels by FIGO for pregnant women. Only Singapore and the Philippines presented data for iron status which found median levels slightly above the WHO cut-off level for deficiency.

Data on folate intake and status was also scare and only available from Vietnam and Singapore. Intake was within the range recommended by FIGO, and median plasma folate levels were above the WHO cut-off level for deficiency.

For vitamin B12, intake and status data were also limited. Vietnam’s data on intake was above the FIGO recommendation and Singapore’s data for median plasma levels was above the cut-off for deficiency.

Researchers said the lack of data on folate and vitamin B12 makes it challenging to come to any conclusive findings, although it can be inferred with existing trends found in women of reproductive age.

They highlighted that gaps in national data on micronutrient intake and status could hinder the effective management of other micronutrient deficiencies.

Researchers recommend that studies with standardised methodology can help identify deficiency in women throughout the reproductive years, and can guide policy makers and governments in developing programs and interventions.

Existing programs​

The study revealed the existence of micronutrient intake recommendation, food fortifications, and supplementation programmess, however only few countries implemented such programmess, and there is limited data. 

For example, in Indonesia, the Philippines, and Thailand, fortification of staple foods, such as flour or rice with specific micronutrients (iron, folate, or B vitamins), is mandatory, and iodisation of salt is mandatory in most South East Asian regions.

“However, the success of implementing these strategies does not appear to have been formally evaluated. The coverage of large-scale or commercial food fortification for target populations also needs to be considered, especially for low-income families or those in rural areas with limited access to markets​.”

In terms of supplementation strategies, some countries like Indonesia, Philippines, Thailand, and Vietnam have implemented supplementation programs often focusing on iron and folate.

Supplementation strategies for other micronutrients, such as vitamin B12 are rare despite FIGO’s recommendation. Within the seven countries, only Vietnam (women all stages) and Hong Kong (pregnant women, vegetarian) recommend vitamin B12 supplementation.

The direct impact of supplementation-related programs is largely unknown.

Supplement use appears low to moderate from 2% in non-pregnant women in Indonesia, to 33% among pregnant women in Indonesia and 73% in Singapore, and 25% of lactating mothers in Vietnam.

This is a potential issue, since early nutrition deficits are likely to persist into later life.

“Consideration should be given to supplementing with multiple micronutrients in addition to iron and folate particularly early in pregnancy, to further reduce risk of key birth outcomes​.”

In previous studies, multiple micronutrient supplements have been shown to provide greater benefits than iron–folate supplements for some birth outcomes, with no increased risk of harm to the mother or child.

Chong recommends consumption of fruits, vegetables and wholegrains “as they provide a whole range of micronutrients (e.g. vitamins, minerals) and phytochemicals (e.g. carotenoids, flavonoids) to meet the body’s requirements and for optimising health​.”

She advised against excessive vitamin A for these groups of women.

In addition, digestion issues may contribute to micronutrient deficiencies which not also increases adverse birth outcomes, but also increases susceptibility to infections.

For instance, in Vietnam, a population-based intervention combining weekly iron/folic acid supplementation with regular deworming has shown sustained effectiveness in reducing both iron deficiency anemia and soil-transmitted helminth infections.

Source: Women's Health

https://doi.org/10.1177/1745506520973110​

 “A landscape of micronutrient status in women through the reproductive years: Insights from seven regions in Asia”​

Authors: Mary Foong-Fong Chong, et al​.