The prevalence of vitamin A deficiency (serum retinol [SR] < 20 microg/dl) in children from one to five years of age in the Philippines rose from 35.8% to 38% between 1993 and 1998, despite a twice-yearly universal vitamin A capsule distribution program. The Philippines 1998 National Nutrition Survey, with one-time SR measurements from 11,620 children from one to four years of age, collected over an eight-month period from one month to more than six months after distribution of vitamin A capsules, was an opportunity to examine the impact of the program on the children's vitamin A status, using post hoc analysis. Overall, a detectable impact of vitamin A capsules on SR was limited to groups with the highest prevalence of vitamin A deficiency and lasted up to four months after dose administration. In highly urban cities in Visayas, where very high prevalences of deficient SR (SR < 10 microg/dl) were found, the prevalence of deficient SR was reduced from 27% to 9% one to two months after distribution of vitamin A capsules, and to 16% at three to four months. In Mindanao, a statistically significant reduction from 38% to 32% was seen in the prevalence of deficient to low SR (SR < 20 microg/dl) one to four months after distribution of vitamin A capsules. There was no overall reduction in the prevalence of vitamin A deficiency or deficient and low SR (SR < 20 microg/dl) in Luzon, but a significant interaction with stunting was observed in Luzon non-highly urbanized cities. Two aspects are of concern. First, the magnitude of the effect of high-dose vitamin A capsules on SR, and hence on the extent of reduction in deficiency, is limited. Second, the effect does not persist for six months, which is the interval between doses. Thus there is no decrease in the prevalence of deficiency over time. With more frequent dosing (especially to those most deficient in SR), a progressive reduction in vitamin A deficiency could, however, be expected; this hypothesis could be tested. The policy implication arising from these results is that a shift in resources is warranted. In areas of low prevalence of vitamin A deficiency, distribution of vitamin A capsules should be targeted to stunted children. In areas of high prevalence, vitamin A capsules should be distributed to children one to five years old at least three times a year.

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Rice, the staple in all regions in the Philippines, is an excellent vehicle for fortification. The Food and Nutrition Research Institute developed the technology for the fortification of rice with iron, using ferrous sulphate as the fortificant. A prototype machine was manufactured for the production of iron-fortified premix with a capacity of 200 kg per batch. A study on iron bioavailability showed a significant increase in the amount of iron absorbed with iron-fortified rice. A clinical trial conducted with 173 schoolchildren for six months showed a greater increase in haemoglobin in subjects who received ironfortified rice than in those who did not. The problems and constraints that arise with rice fortification include the added cost of fortification (estimated at 2.5% of the cost of rice), which would probably be passed on to the consumer, and the presence of numerous rice mills throughout the country, which may pose difficulties in enforcement. Nevertheless, when carried out in large rice mills, fortification of rice with iron could reach a significant portion of the population.