Community and International Nutrition

Micronutrient Deficiencies in Early Pregnancy Are Common, Concurrent,

and Vary by Season among Rural Nepali Pregnant Women1
Tianan Jiang, Parul Christian,2 Subarna K. Khatry,* Lee Wu, and Keith P. West, Jr.
Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD 21205, and *Nepal Nutrition Intervention Project-Sarlahi (NNIPS), Nepal Netra Jyoti
Sangh, Tripureswor, Kathmandu, Nepal

ABSTRACT Pregnant women in developing countries are vulnerable to multiple micronutrient deficiencies. We
investigated their prevalence and seasonal variation as part of a baseline assessment in a population-based,
maternal micronutrient supplementation trial conducted in the rural Southeastern plains of Nepal. Serum concen-
trations of 11 micronutrients were assessed in 1165 pregnant women in the 1st trimester before supplementation.
Using defined cutoff values, the prevalence of deficiencies of vitamins A, E, and D were 7, 25, and 14%,
respectively. Nearly 33% of the women were deficient in riboflavin, and 40 and 28% had serum vitamin B-6 and
B-12 deficiencies, respectively. Only 12% of the women were folate deficient, but 61% were zinc deficient. The
prevalence of low serum iron concentration was 40%, and 33% were anemic (hemoglobin ⬍ 110 g/L). Multiple
micronutrient deficiencies were common among pregnant women. Over 10% of the pregnant women were both
anemic and deficient in B-complex vitamins, whereas 22% of women were both anemic and zinc deficient. Only
4% of women had no deficiency, whereas ⬃20% of the women had 2, 3, or 4 deficiencies. Almost 18% of women
had ⱖ5 deficiencies. Micronutrient status varied by season; it was generally best during the winter months, except
for serum vitamin D concentration, which peaked during the hot summer and monsoon months. Women in rural
South Asia are likely to begin a pregnancy with multiple micronutrient deficiencies that may vary with seasonality
in micronutrient-rich food availability. J. Nutr. 135: 1106 –1112, 2005.

KEY WORDS: ● micronutrients ● deficiency ● season ● pregnancy ● Nepal

Micronutrient deficiency in women of reproductive age is
recognized as a major public health problem in many devel-
oping countries (1– 4). Pregnant women are particularly vul-
nerable to nutritional deficiencies because of the increased
metabolic demands imposed by pregnancy involving a growing
placenta, fetus, and maternal tissues, coupled with associated
dietary risks (5,6). In turn, maternal undernutrition may pre-
dispose a mother to poor health, including infection, pre-
eclampsia/eclampsia, and adverse pregnancy outcomes such as
premature birth and intrauterine growth retardation (1,2).
Micronutrient deficiencies tend to coexist in impoverished
settings in part because of uniformly low consumption of foods
rich in multiple micronutrients.
Maternal iron deficiency and consequent anemia comprise
1
This work was carried out by the Center for Human Nutrition, the Depart-
ment of International Health of the Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD, in collaboration with the National Society for the Preven-
tion of Blindness, Kathmandu, Nepal, under the Micronutrients for Health Coop-
erative Agreement No. HRN-A-00-97-00015-00 and the Global Research Activity
Cooperative Agreement No. GHS-A-00-03-00019-00 between the Johns Hopkins
University and the Office of Health, Infectious Diseases and Nutrition, United
States Agency for International Development, Washington, DC, and grants from
the Bill and Melinda Gates Foundation, Seattle, WA; UNICEF, Kathmandu, Nepal;
and, the Sight and Life Research Institute, Baltimore, MD.
2
To whom correspondence should be addressed.
E-mail: pchristi@jhsph.edu.
a major problem in developing countries, affecting ⬎50% of
women during pregnancy (1–3). Other micronutrient defi-
ciencies are likely to be widely prevalent, especially those of
iodine, zinc, vitamin A, and the vitamin B-complex (1–3,7).
However, little information is available on the extent and
severity of multiple micronutrient deficiencies during preg-
nancy in community-based studies (8,9). Most data on vitamin
status are from select populations, hospital-based settings, or
are from cross-sectional studies in which nutrient status was
assessed at varying single time points during gestation. Because
marginal micronutrient deficiency in the 1st trimester could
lead to more severe deficiency later on due to stresses imposed
by pregnancy and parturition (10), nutritional status in early
pregnancy may be an important predictor of nutritional risk in
late pregnancy (8). In addition, seasonality appears to mark-
edly influence the prevalence of deficiency (7,11,12), which
may sometimes result in unexpected patterns and interpreta-
tion of micronutrient deficiencies.
In previous studies, we documented a high prevalence of
vitamin A and iron deficiency anemia among Nepali pregnant
women (13–15) at various stages of pregnancy. In the present
study, we investigated the prevalence of deficiency for vita-
mins A, E, D, riboflavin, B-6, B-12, folate, zinc, iron, and
copper during early pregnancy (⬍12 wk) in a rural population
of Nepalese pregnant women using published serological cutoff

0022-3166/05 $8.00 © 2005 American Society for Nutritional Sciences.

Manuscript received 2 November 2004. Initial review completed 26 December 2004. Revision accepted 14 February 2005.

1106
 MICRONUTRIENT DEFICIENCY IN EARLY PREGNANCY
values. The coexistence of multiple deficiencies and seasonal
variations in micronutrient status were also examined.
SUBJECTS AND METHODS
Study design and population. The present study utilized baseline
data collected from a double-masked, cluster-randomized, controlled
trial conducted in the Southeastern plains District of Sarlahi, Nepal,
from December 1998 to April 2001 (15,16). The main objectives of
the trial were to ascertain the effect of daily maternal supplementa-
tion with folic acid, folic acid ⫹ iron, folic acid ⫹ iron ⫹ zinc, and
a multiple micronutrient formulation, all with vitamin A, compared
with an active placebo (containing vitamin A alone), on reducing
low birth weight, fetal loss, and infant mortality and morbidity. The
study was approved by the ethical review committees of the Ministry
of Health in Nepal and the Johns Hopkins Bloomberg School of
Public Health in Baltimore, MD.
To identify pregnancies in early gestation, all eligible women of
reproductive age (married women, 15– 45 y of age who were not
menopausal, sterilized, or not already breast-feeding an infant ⬍ 12
mo of age) in the study area were visited every 5 wk and monitored
for pregnancy. Pregnancy was ascertained with a urine test (human
chorionic gonadotrophin antigen test; Clue, Orchid Biomedical Sys-
tems) among women who had reportedly not menstruated in the past
30 d. Women who tested positive were enrolled after obtaining
consent. At enrollment, newly identified pregnant women were ad-
ministrated a baseline interview to obtain data on 1-wk frequencies of
symptoms of morbidity, intake of food, alcohol, and tobacco use, and
information on household socioeconomic status. Anthropometric
measurements included weight, height and mid-upper arm circumfer-
ence (MUAC)3 measurements.
Of 30 village development communities, comprising approxi-
mately one third of the total in the study area, 9 were selected to
represent different geographic and ethnic communities; all had rea-
sonable access to the main roads and relative proximity to the project
laboratory. Women from these communities were invited to partici-
pate in a substudy involving venous blood collection for subsequent
serum analysis of micronutrient status twice during pregnancy, before
supplementation and in the third trimester. The samples were drawn
via venipuncture and collected into 7-mL trace metal-free vacuum
test tubes (Vacutainer, Becton Dickinson). The vacutainers contain-
ing blood were kept on ice and brought to the clinic where they were
centrifuged at 750 ⫻ g for 20 min to separate the serum. Serum
aliquots were placed into trace element–free cryotubes (Nalgene
Company, Sybron International), stored in liquid nitrogen tanks, and
shipped to the Johns Hopkins Bloomberg School of Public Health in
Baltimore, MD, where they were stored at ⫺80°C before analyses.
Laboratory analysis. Hemoglobin (Hb) assessment was done on
the spot using a homeglobinometer (HemoCue). Serum ferritin con-
centration was analyzed with ELISA procedures using a commercial
fluoroimmunometric assay (DELFIA® Ferritin, Perkin Elmer Wallac).
The interassay CV for ferritin was ⬃5%, using pooled serum samples.
Serum iron, zinc, and copper concentrations were analyzed by atomic
absorption spectrometry (AAnalyst 600, Perkin Elmer). Serum folate
was measured by a microbiological assay in 96-well microplates using
a chloramphenicol-resistant strain of Lactobacillus rhamnosus
(NCIMB 10463) (17). Serum vitamin B-12 was determined by a
microbiological assay in 96-well microplates using a colistin-sulfate-
resistant strain of Lactobacillus lactis (NCIMB 12519) (18,19). Both
microorganisms were cryopreserved and the cultures were stable for
many months. The interassay CVs for folate and vitamin B-12 were
7.6 and 8.4%, respectively. Serum 25-hydroxyvitamin D concentra-
tion was used to evaluate the vitamin D status, determined by an
immunoassay method with kits from the Nichols Institute. The inter-
and intra-assay CVs were 16.4 and 5.6%, respectively.
Serum retinol, ␤-carotene, and ␣-tocopherol were determined
simultaneously by a reverse-phase HPLC (Beckman, System Gold)
3
Abbreviations used: Hb, hemoglobin; MUAC, mid-upper arm circumference;
NIST, the National Institute of Standards and Technology.
1107
attached to an autosampler (717 Plus AS, Waters) using a procedure
described by Yamini et al. (20) with modifications. The internal
standard used was all-trans-ethyl-␤-apo-8⬘-carotenoate (Fluka
Chem). The column (Allsphere ODS-2, 3 ␮m, 150 ⫻ 4.6 mm,
Alltech Associate) was eluted isocratically with a mobile phase
consisting of 84% acetonitrile, 14% tetrahydrofuran, 6% methanol
(added 0.2% ammonium acetate), and 0.1% triethylamine. Quality
control was maintained by repeated analyses of standard reference
material (SRM, 968c, the National Institute of Standards and Tech-
nology, NIST, Gaithersburg, MD) and pooled reference standards.
The precision and accuracy of the method were also assessed through
participation in the Micronutrients Measurement Quality Assurance
Program of Round Robin Proficiency Testing from the NIST, in
which 12 “unknown” samples are analyzed and submitted yearly for
the entire study period.
Serum riboflavin concentration was determined as a surrogate for
riboflavin using reverse-phase HPLC (model 1100, Agilent Technol-
ogies) with a fluorescence detector (Model FP-1520, Jasco). Before
HPLC, 50 ␮L of serum was deproteinized using trichloroacetic acid,
and the supernatant was heated for 15 min. HPLC was performed
using C18-coated silica column (Alltech) with a mobile phase con-
sisted of 65% (v:v) 5 mmol/L ammonium acetate and 35% (v:v)
methanol. Fluorescence excitation and emission wavelengths were
460 and 525 nm, respectively. The minimum detectable concentra-
tion was 0.35 nmol riboflavin/L. Intra- and interassay CVs were 1.5
and 4.8%, respectively, using pooled human serums. The serum
concentration of pyridoxal 5⬘-phosphate, the active form of vitamin
B-6, was measured using HPLC. The serum (100 ␮L) was deprotein-
ized by the addition of perchloric acid. Precolumn derivatization was
performed with potassium cyanide. The fluorescent cyanide deriva-
tives were detected by fluorometry (Model FP-1520, Jasco) with
wavelengths for excitation at 318 nm and for emission at 418 nm.
The analytical HPLC column was an Alltech 3 ␮m ODS (C18), with
a guard column packed with 40 ␮m C18 material (Alltech). The
mobile phase was 50 mmol/L potassium phosphate buffer (pH 3.2)
containing 50 mmol/L sodium perchlorate and mmol/L heptane sul-
fonic acid. The minimum detectable concentration was 2 nmol/L.
Published cutoff values for defining deficient concentrations of mi-
cronutrients were used.
Statistical analysis. Descriptive statistical tests were applied to
maternal biological, demographic and socioeconomic, and biochem-
ical variables. Maternal age, gestational age at sample collection, BMI
(calculated as kg/m2), and biochemical variables were treated as
continuous variables, and diet and seasons were treated as categorical
variables.
The proportion of women with deficient status was calculated for
single and multiple micronutrients. We defined the 4 seasons as
follows: Spring (March–May), Summer (June–August), Fall (Septem-
ber–November), and Winter (December–February). Univariate anal-
yses were done to examine the association between season and
micronutrient status. We performed step-wise multiple linear regres-
sion analyses to assess seasonal variation in micronutrient concentra-
tion using Spring as the reference season. Maternal age, gestational
age, BMI, parity, tobacco and alcohol use, socioeconomic status, and
ethnicity were adjusted in the model. The prevalence of micronutri-
ent deficiency was determined for each season, and significant differ-
ences among the prevalence were assessed using ␹2 analyses. The
results were expressed as means ⫾ SD, and a P-value of ⬍0.05 was
considered significant. Statistical analyses were performed using SAS
software version 8.2 (SAS Institute).
RESULTS
Over a period of 2 y, 1316 (26.3%) of a total of 4996
pregnant women were eligible for enrollment into the substudy
of the trial. Of these, 1165 (88.5%) agreed to a venous blood
draw at baseline, and a few more agreed to a finger prick (n
⫽ 67) allowing us to do Hb assessments on a total of 1232
(93.6%) women. Sample size varied across the micronutrient
determinations (n ⫽ 1158 –1165) because of inadequate quan-
tities of serum in some cases.
1108 JIANG ET AL.

TABLE 1
Mean, median, and percentile distributions of serum concentrations of vitamins, trace minerals,
and Hb indices among Nepalese pregnant women in the 1st trimester

n1 Mean SD 5% 25% Median 75% 95%

Retinol, ␮mol/L 1165 1.20 0.38 0.66 0.92 1.16 1.40 1.89
␤-Carotene, ␮mol/L 1165 0.24 0.21 0.06 0.12 0.18 0.28 0.57
␣-Tocopherol, ␮mol/L 1165 12.12 4.04 6.66 9.28 11.44 14.35 19.59
Vitamin D, nmol/L 1163 51.10 24.63 17.65 32.46 47.20 66.04 95.40
Riboflavin, nmol/L 1163 18.66 14.86 6.38 10.11 14.36 21.28 44.16
Vitamin B-6,2 nmol/L 1164 24.63 20.92 9.07 15.62 21.22 29.15 48.82
Vitamin B-12, pmol/L 1158 237.1 138.3 64.7 140.6 211.0 301.4 464.5
Folate, nmol/L 1164 17.71 23.20 5.39 9.32 14.12 20.15 38.90
Zinc, ␮mol/L 1165 8.26 2.01 5.40 6.85 8.09 9.36 11.49
Iron, ␮mol/L 1156 14.96 7.33 5.38 9.87 13.90 18.64 28.78
Copper, ␮mol/L 1165 23.52 6.91 14.64 18.31 23.52 27.77 36.08
Ferritin, ␮g/L 1163 19.42 19.49 3.11 6.91 13.31 25.21 58.75
Hb, g/L 1232 115.8 19.2 78.0 106.0 117.0 127.0 144.0

1 Total sample size varies due to missing values or insufficient serum for analysis.
2 Defined as pyridoxal-5⬘-phosphate.

Maternal age and gestational age at enrollment were 23.6
⫾ 6.0 y and 10.9 ⫾ 4.6 wk, respectively; 26% of the women
were nulliparous. The women were stunted with a height of
150.5 ⫾ 5.5 cm; 14% were below the cutoff value of 145 cm
(21). Subjects were also thin and wasted with a MUAC of 21.9
cm, and BMI of 19.3 kg/m2.
Serum micronutrient concentrations were normally distrib-
uted during early pregnancy except for riboflavin, vitamin
B-12, folate, and ferritin, which were slightly skewed to the
left (Table 1).
Using defined cutoff values (7,13,22–29), the prevalence of
deficiencies of vitamins A, E, and D were 7, 25, and 14%,
respectively. Nearly one third of the women were deficient in
riboflavin, and 40 and 28% had serum vitamin B-6 and B-12
deficiencies, respectively. Only 12% of the women were folate
deficient, but 61% were zinc deficient. The prevalence of low
serum iron concentration was 40%, whereas 33% were anemic
(hemoglobin ⬍ 110 g/L). Multiple micronutrient deficiencies
were common among pregnant women. Over 10% of the
pregnant women were both anemic and deficient in B-com-
plex vitamins, whereas 22% of women were both anemic and
zinc deficient. Because zinc deficiency was the most common
micronutrient deficiency, occurring in ⬃60% of women, it was
also the most frequent coexisting micronutrient deficiency
(Table 2). Only 4% of women had no deficiency, whereas
14.3, 21.5, 20.6, 21.9, and 17.7 had 1, 2, 3, 4, or 5 or more
deficiencies, respectively (data not shown). Women who were
deficient in certain nutrients were more likely to have other
micronutrient deficiencies (Table 3). For example, among the
women with vitamin A deficiency, a higher proportion was
deficient in vitamin E (70%), vitamin B-6 (52%), or riboflavin
(44%) or were anemic (49%) relative to the overall preva-
lence of these in the population. The prevalence of micronu-
trient deficiencies differed by season (Table 4). Overall, most

TABLE 2
The prevalence of concurrent deficiencies of 2 micronutrients among Nepalese pregnant women in the 1st trimester1

Vitamin Vitamin Vitamin Vitamin

D E Riboflavin B-6 B-12 Folate Zinc Iron2 Anemia3

Vitamin A 0.8 4.7 3.0 3.5 1.7 1.1 4.0 3.0 3.4
Low vitamin A status 4.6 15.6 14.0 15.6 9.3 5.2 23.2 14.4 14.4
Vitamin D 3.9 4.6 7.1 5.8 1.6 7.7 6.2 2.8
Vitamin E 8.7 10.4 5.4 4.0 15.6 8.3 8.2
Riboflavin 15.0 11.7 4.8 21.2 12.1 11.9
Vitamin B-64 11.8 5.5 26.0 17.2 13.8
Vitamin B-12 3.1 18.4 13.4 10.5
Folate 8.0 5.9 4.4
Zinc 25.1 22.0
Iron 18.4

1 Deficiency is defined as retinol ⬍ 0.70 ␮mol/L (13), ␣-tocopherol ⬍ 9.3 ␮mol/L (22), vitamin D ⬍ 25.0 nmol/L (23), riboflavin ⬍ 11.3 nmol/L (24),
vitamin B-6 ⬍ 19 nmol/L (25), vitamin B-12 ⬍ 150 pmol/L (26), folate ⬍ 6.7 nmol/L (27), and zinc ⬍ 8.6 ␮mol/L (28); low vitamin A status is defined
as ⬍1.05 ␮mol/L (13).
2 Iron deficiency is defined as ferritin ⬍ 10 ␮g/L (27).
3 Anemia is defined as Hb ⬍ 110 g/L (27,29).
4 Vitamin B-6 as pyridoxal-5⬘-phosphate.
 MICRONUTRIENT DEFICIENCY IN EARLY PREGNANCY 1109

TABLE 3
Prevalence of micronutrient deficiencies among Nepalese pregnant women in the 1st trimester by the presence of an index
micronutrient deficiency1

Conditional deficiency

Index Vitamin Vitamin Vitamin Vitamin Vitamin

nutrient n Deficiency A D E Riboflavin B-6 B-12 Folate Zinc Iron Anemia

% %

Vitamin A 79 6.8 — 11.4 69.6 44.3 51.9 25.6 16.5 59.5 44.3 49.4
Vitamin D 162 13.9 5.6 — 27.8 32.7 50.6 41.6 11.1 55.6 44.4 20.4
Vitamin E 294 25.3 18.7 15.3 — 34.4 41.2 21.1 15.7 61.9 32.7 32.7
Riboflavin 370 31.8 9.5 14.4 27.3 — 47.0 36.7 15.1 66.8 38.2 37.3
Vitamin B-6 469 40.3 8.7 17.5 25.8 37.1 — 29.1 13.7 64.4 42.7 34.1
Vitamin B-12 328 28.3 6.1 20.4 18.9 41.2 41.5 — 11.0 64.9 47.4 36.9
Folate 134 11.1 9.7 13.5 34.3 41.8 47.8 26.9 — 69.4 50.8 38.1
Zinc 712 61.1 6.6 12.7 25.6 34.7 42.5 30 13.1 — 41.1 36.0
Iron 463 39.8 7.6 15.6 20.7 30.5 33.6 33.6 14.7 63.1 — 46.2
Anemia 370 32.8 10.5 8.9 26.0 37.3 43.2 32.8 13.8 69.2 58.0 —

1 See Table 2 for deficiency criteria and definitions.

micronutrient deficiencies assessed tended to be less prevalent
during the winter season. Serum retinol concentrations were
significantly lower in the hot and humid monsoon season
(April–September), whereas ␤-carotene and vitamin B-6 con-
centrations were higher in summer and winter than in other
seasons (Fig. 1). As expected, vitamin D levels were lowest in
the winter months and highest in summer (June–August) and
fall (September–November). Serum zinc concentrations were
higher in fall and lower in summer. Multiple regression anal-
ysis also revealed that with the exception of vitamin D and
copper, women had better micronutrient status during the
winter months (December–February) than in the other sea-
sons (data not shown).
DISCUSSION
In the present study we documented that the prevalence of
multiple micronutrient deficiencies was common among
women in the 1st trimester of pregnancy in rural Nepal, likely
reflecting dietary inadequacy as they entered pregnancy. Be-
cause micronutrient status was assessed at a gestational age of
10.9 ⫾ 4.6 wk, the confounding effect of hemodilution that
peaks in the 3rd trimester (30,31) was likely to be minimal.
The present study has several advantages over previous
studies that examined micronutrient status during pregnancy.
Apart from having a large sample size, a wide range of micro-
nutrients was examined simultaneously in a community-based
study, allowing estimation of the extent of maternal micronu-
trient deficiencies in early pregnancy in this rural Nepali
setting. In addition, we report the extent to which multiple
deficiencies coexist, data that are scarce in rural developing
country settings. The results of the present study also have the
potential to provide valuable reference values for assessing
nutritional status. However, the assessment of vitamin and
mineral status during pregnancy is complicated because there
is a general lack of pregnancy-specific laboratory indices for
nutritional evaluation (6), and pregnancy itself may alter

TABLE 4
The prevalence of micronutrient deficiency by season among Nepalese pregnant women in the 1st trimester1,2

Spring Summer Fall Winter

(Hot and dry) (Hot and monsoon) (Post-monsoon) (Cold and dry) P-Value

Vitamin A 9.0 6.5 9.8 1.5 0.0004

␤-Carotene 17.6 11.5 25.1 6.6 ⬍0.0001
Vitamin E 32.4 19.8 24.6 19.9 0.0001
Vitamin D 16.4 4.3 7.1 24.4 ⬍0.0001
Riboflavin 33.8 33.2 35.5 24.7 0.037
Vitamin B-6 53.9 26.0 38.3 34.6 ⬍0.0001
Vitamin B-12 24.9 33.3 29.5 27.8 0.112
Folate 12.3 14.8 12.6 6.3 0.014
Zinc 59.3 71.9 55.7 56.6 0.0003
Iron 22.6 17.8 26.8 16.4 0.024
Ferritin 39.6 40.8 42.3 37.5 0.753
Anemia 30.2 40.0 44.9 22.8 ⬍0.0001

1 Seasons are defined as Spring, March–May; Summer, June–August; Fall, September–November; and Winter, December–February.
2 See Table 2 for deficiency criteria and definitions.
1110 JIANG ET AL.

FIGURE 1 Seasonal variation in mean serum micronutrient concentrations among Nepalese pregnant women in the 1st trimester over a 2-y
period from December 1998 until April 2001. As shown on the figure keys, concentrations of some nutrients were adjusted to scale: retinol level was
adjusted upward by a factor of 10, ␤-carotene by a factor of 100, and zinc by a factor of 2, whereas vitamin D concentration was adjusted downward
by a factor of 2 and vitamin B-12 by a factor of 10.

“normal” values (9) independently of the effects of hemodilu-
tion. Furthermore, because of the lack of standardization of the
assay and different cutoff values to define deficient status, the
prevalence of a nutrient deficiency may vary between studies.
Inadequacy of a single nutrient is most likely associated
with deficiencies of other micronutrients. Our population
study provides evidence that rural pregnant women in South
Asia are likely to suffer from multiple deficiencies. This was
evident from our estimate that simultaneous deficiencies for
ⱖ2 micronutrients affected 82% of women who entered the
trial early in pregnancy. The likelihood of certain micronutri-
ent deficiencies was higher in the presence of specific other
micronutrient deficiencies, suggesting potential metabolic in-
teractions. For example, among women with vitamin A defi-
ciency, nearly half or more also had vitamin E, riboflavin, and
vitamin B-6 deficiencies and were anemic, substantially above
their respective univariate rates in the population. Joint, ap-
parently noninteractive deficiencies were also evident, sug-
 MICRONUTRIENT DEFICIENCY IN EARLY PREGNANCY
gested by comparable index and conditional prevalences. For
example, B-complex vitamin (riboflavin, vitamins B-6 and
B-12) and iron deficiencies were comparable irrespective of
concurrent zinc deficiency, possibly derived in part from a
shared dietary deficit of good food sources such as meat, little
of which is consumed in this setting (data not shown) and
elsewhere in rural South Asia. Compounding the adverse
effects of infrequent intake of micronutrient-rich foods is also
a diet that is characteristically high in inhibitors of mineral
absorption. Phytates, for example, which are abundant in rice
and other grains, inhibit zinc absorption in particular (32); this
could help explain the higher prevalence of this nutrient
deficit.
Coexisting nutritional deficiencies could reduce the poten-
tial benefit of a single nutrient supplement in improving nu-
trition status and morbidity (33,34). The role of vitamin
deficiencies in the etiology of anemia was described (33–36).
Specifically, vitamin A, riboflavin, vitamin B-6, vitamin B-12,
and folate exert hematopoietic function (35–37), suggesting
that anemic women should possibly be supplemented not only
with iron but also with vitamin A (33) and other micronutri-
ents (36,37). However, less is known about metabolic inter-
actions of micronutrients. Zinc may interact with vitamin A to
potentiate the effect of vitamin A in restoring night vision
among night-blind pregnant women with low initial serum
zinc concentrations (38).
The diet of the majority of rural Nepalese is monotonous
and low in vegetables and animal sources (39); it is highly
dependent on a largely local market system and seasonal
availability. In Nepal, in the period before the monsoon sea-
son, the availability of fruit and vegetables drops dramatically,
causing an increase in their prices (39). The rainy monsoon
season causes pronounced seasonal shortages, whereas vegeta-
bles tend to be more abundant in the dry, mid-winter season.
Such variation in availability, and cost, of various foods can
affect the status of certain micronutrients. In the present study,
for example, biochemical concentrations of most, although
not all, assessed micronutrients were higher in the dry, mid-
winter months. Alternatively, late dry season concentration
peaks in serum ␤-carotene and vitamin B-6 presumably cor-
respond to the mango harvest and to increased banana avail-
ability at that time of year in the southeastern plains of Nepal.
Previously, we found maternal night blindness prevalence to
increase during the hot summer months before the monsoon
season, but then to decline during the short mango season in
June–July (40), mimicking the seasonal dynamic in xeroph-
thalmia that has long been reported among South Asian
children (41). A seasonal pattern in Hb was similar to that
reported by Bondevik et al. (12) in pregnant women in a
hospital setting in Nepal, in which the prevalence of anemia
was highest during and after the monsoon period. No seasonal
variation was observed in serum concentrations of vitamin
B-12 and ferritin, similar to reports by Ronnenberg et al. (7)
among Chinese women and Backstrand et al. (42) among
Mexican women. Vitamin D concentrations peaked in the
monsoon and hot summer months, presumably in response to
increased exposure to sunlight. Exposure to UV light during
the monsoon season may be high, despite cloud cover, because
of the planting and other agricultural work in which women
may be involved during this season (43). Knowing the high-
risk seasonal periods for maternal micronutrient deficiencies
can aid in developing and targeting interventions for their
control.
In summary, we report here the population prevalence of
low and deficient maternal status with respect to multiple
1111
micronutrients in the Southern plains of Nepal, based on
published serum concentration cutoff values. We found that
⬎80% of women exhibited evidence of ⱖ2 micronutrient
deficiencies, and that seasonality can markedly and differen-
tially influence maternal status, likely associated with season-
ality of micronutrient-rich foods as well as other potential
epidemiologic risk factors (e.g., infection). Because the find-
ings reflect maternal status in the 1st trimester of pregnancy,
they may be also taken to represent the burden of micronu-
trient deficiency in rural women of reproductive age in this
population, and provide regional guidance on approaches and
timing to the control of multiple micronutrient deficiencies
early in pregnancy and throughout the reproductive years in
rural South Asia.
ACKNOWLEDGMENTS
Apart from the authors, the following members of the Nepal study
team helped in the successful implementation of the study: Steven C.
LeClerq, Sharada Ram Shrestha and Jonne Katz; Field Managers
Tirtha Raj Shakya and Rabindra Shrestha; Field Supervisors Uma
Shankar Sah, Arun Bhetwal, Gokarna Subedi, and Dhrub Khadka;
and Laboratory Scientist Tracey Wagner for conducting laboratory
analyses. Special thanks to the team of phlebotomists for their hard
work in conducting home-based blood collection, which made this
analysis possible; Elizabeth K. Pradhan and Gwendolyn Clemens for
computer programming and data management; Ravi Ram, Seema Rai,
and Sunita Pant for data cleaning and supervision.
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