Department of Physiology, St. John's Medical College, St. John's National Academy of Health Sciences, Bengaluru, India.
Division of Nutrition, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, India.
Am J Clin Nutr. 2021 Oct 4;114(4):1261-1266. doi: 10.1093/ajcn/nqab245.
When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.
当公众健康计划中的单一营养素被认为对目标健康结果影响不佳时，政策反应可能是通过在现有计划之上增加额外的强制性计划来提供更多的营养素。然而，我们强烈建议谨慎行事，因为营养素（如药物）在适量摄入时是有益的，但过量摄入时可能有害。在人口中营养素不足的风险的不正确测量，或者评估营养素缺乏程度的不正确生物标志物截止值，可能会导致不必要的动机来对多个干预计划进行反应性分层。当与资源匮乏的经济体中的其他重要计划进行权衡时，额外分层计划的财务和社会成本并不是微不足道的，并且当公共卫生自主权、公平性和耻辱感的伦理困境没有得到解决时，情况更是如此。印度的一个例子就是人们认为贫血症的流行对正在进行的药物铁补充计划的反应停滞不前。对此的反应是提出一项政策建议，通过强制性在补充喂养计划（如综合儿童发展服务和学校午餐计划）中提供的大米中添加铁，进一步增加铁的摄入量。这是在正在进行的药物铁补充以及其他自愿铁强化（如盐和加工食品）的基础上增加的。然而，在提供更多之前，重要的是要考虑为什么现有的计划显然不起作用，同时还要考虑过度摄入和相关危害的可能性。这在全球范围内都是相关的，特别是对于那些考虑采取多种干预措施来解决微量营养素缺乏的国家。在没有深思熟虑地考虑社会、生物和伦理框架的情况下，通过分层多种营养素干预措施而不是正确地提供更多，可能会适得其反。那么，治疗方法可能会变成疾病本身。
