Complementary food supplements to achieve micronutrient adequacy for infants and young children

Formulation and acceptability of local nutrient-dense foods for young children: A formative study for the Child Health, Agriculture and Integrated Nutrition (CHAIN) Trial in rural Zimbabwe

Stunting affects almost one-quarter of children globally, leading to reduced human capacity and increased long-term risk of chronic disease. Despite intensive infant and young child feeding (IYCF) interventions, many children do not meet their requirements for essential nutrients. This study aimed to assess the feasibility of implementing an IYCF intervention utilizing nutrient-dense powders from egg, biofortified sugar beans and Moringa oleifera leaf in rural Zimbabwe. A mixed-methods formative study was conducted comprising the following: (i) a recipe formulation trial, (ii) trials of improved practices to assess acceptability of the intervention, and (iii) a participatory message formulation process to develop counselling modules for the IYCF-plus intervention. Twenty-seven mother-baby pairs were recruited between November 2019 and April 2020. Key domains affecting IYCF practices that emerged were time, emotional and physical space, cultural and religious beliefs, indigenous knowledge systems and gender dynamics. Household observations and sensory evaluation indicated high acceptability of the new ingredients. Recipe formulation and participatory message formulation by participants instilled community ownership and served to demystify existing misconceptions about the new food products. Families noted the potential for intervention sustainability because the foods could be grown locally. Supplementing complementary foods with nutrient-dense local food ingredients as powders has the potential to sustainably address nutrient-gaps in the diets of young children living in rural lower- and middle-income countries. Comprehensive IYCF counselling utilizing a gender-lens approach, family support and indigenous knowledge systems or resources are key elements to support positive behaviour change in complementary feeding interventions.

Enhanced effect of seasonal malaria chemoprevention when coupled with nutrients supplementation for preventing malaria in children under 5 years old in Burkina Faso: a randomized open label trial

BACKGROUND

In rural African settings, most of the children under the coverage of Seasonal Malaria Chemoprevention (SMC) are also undernourished at the time of SMC delivery, justifying the need for packaging malarial and nutritional interventions. This study aimed at assessing the impact of SMC by coupling the intervention with nutrients supplementation for preventing malaria in children less than 5 years old in Burkina Faso.

METHODS

A randomized trial was carried out between July 2020 and June 2021 in the health district of Nanoro, Burkina Faso. Children (n = 1059) under SMC coverage were randomly assigned to one of the three study arms SMC + Vitamin A (SMC-A, n = 353) or SMC + Vitamin A + Zinc (SMC-AZc, n = 353) or SMC + Vitamin A + PlumpyDoz(tm) (SMC-APd, n = 353)-a medium quantity-lipid-based nutrient supplement (MQ-LNS). Children were followed up for one year that included an active follow-up period of 6 months with scheduled monthly home visits followed by 6 months passive follow-up. At each visit, capillary blood sample was collected for malaria diagnosis by rapid diagnosis test (RDT).

RESULTS

Adding nutritional supplements to SMC had an effect on the incidence of malaria. A reduction of 23% (adjusted IRR = 0.77 (95%CI 0.61-0.97) in the odds of having uncomplicated malaria in SMC-APd arm but not with SMC-AZc arm adjusted IRR = 0.82 (95%CI 0.65-1.04) compare to control arm was observed. A reduction of 52%, adjusted IRR = 0.48 (95%CI 0.23-0.98) in the odds of having severe malaria was observed in SMC-APd arm compared to control arm. Besides the effect on malaria, this combined strategy had an effect on all-cause morbidity. More specifically, a reduction of morbidity odds of 24%, adjusted IRR = 0.76 (95%CI 0.60-0.94) in SMC-APd arm compared to control arm was observed. Unlike clinical episodes, no effect of nutrient supplementation on cross sectional asymptomatic infections was observed.

CONCLUSION

Adding nutritional supplements to SMC significantly increases the impact of this intervention for preventing children from malaria and other childhood infections.

TRIAL REGISTRATION

NCT04238845.

A complementary food supplement from local food ingredients to enhance iron intake among children aged 6-59 months in Benin

Nutritious complementary feeding is often not affordable in Benin, and iron deficiency exists. This research aimed at formulating an affordable and sensory acceptable complementary food supplement using local food ingredients to increase iron intake among children aged 6-59 months in Benin. The complementary food supplement was formulated to ensure that 10 g would cover 25% of the estimated average requirements for iron for children aged 6 to 12 months. Adansonia digitata fruit pulp, Moringa oleifera leaf powder, and Cochlospermum tinctorium root powder were used to compose the complementary food supplement, which was mixed with maize and sorghum ogi porridges before being presented to the mothers and children for the acceptability test. The mineral contents of Adansonia digitata fruit pulp in mg/100 g dw were 9.9 ± 0.1 for iron and 0.9 ± 0.1 for zinc. The iron and zinc contents of Moringa oleifera leaf powder and Cochlospermum tinctorium root powder in mg/100 g dw were 34.1 ± 2.2 and 26.8 ± 2.7 and 9 ± 0.0 and 0.9 ± 0.0, respectively. The complementary food supplement contained, in mg/100 g dw, 17.4 ± 1.1 of iron and 1.2 ± 0.1 of zinc. The maize and sorghum ogi porridges enriched with the complementary food supplement at substitution rates of 15% and 16% (in dry weight), respectively, were acceptable to 85% of children for sorghum ogi porridge and 87% for maize ogi porridge. The present study demonstrated the potential of local food ingredients in the formulation of an iron-rich and acceptable complementary food supplement for children aged 6-59 months in Benin.

Vision of Research on Human Linear Growth

The human body grows in length from conception to the maximal adult height over two decades. The shortest male population averages ∼150 cm and the tallest ∼183 cm. Nonetheless the dimensions of head and trunk are highly comparable, with the vast difference in the leg length. Stunting is a personal condition in which an individual has a standing height-for-age (HAZ) of less than two standard deviations of the standard curve median. It is associated with increased mortality, morbidity, and functional deficits. The process of losing relative stature is known as linear growth retardation, first attributed to chronic protein deficiency, then to an assortment of micronutrient deficiencies, and most recently to inflammation from unhygienic environmental conditions. Public health intervention trials responding to each of these possibilities have failed to produce true reversal responses measured in the 10s of centimeters. As to biological insights, there is no convenient way to separate weight from length growth with sonographic monitoring, but a third of infants can be born stunted. Normative growth (standard curves) competes with epigenetic adaptation (programming) as the beacon for in utero growth. Major investments into field trials allow us to discard multiple micronutrients and water/sanitation/hygiene interventions as measures to reverse established stunting. The preponderance of evidence is against catch-up growth during puberty. Future publications will be in the conceptual domain, resolving metrics, while the full range of stimuli and exposures impeding growth will be elucidated. Advances in measurement techniques in anthropometry and immunology and endocrinology will be mobilized to the literature.

Vitamin D fortification of foods in India: present and past scenario

India is a densely populated country known for its traditional, cultural and lingual diversity. In India Deficiency of vitamin D is seen in both the genders and among all the age groups. Micronutrient deficiencies are steadily adding to the increasing burden of health related co-morbidities with low dietary calcium and magnesium intake in Indian population. Despite lots of sunshine, vitamin D insufficiency is widespread in India according to the age and regions (50-90%). In order to increase vitamin D intake with normal diet, the food industry will have to find a more effective strategy to improve general health conditions. The breadth of widely used foods, including milk, cheese, margarine, dairy products, and various breakfast drinks, can improve the condition of vitamin D deficiency in Asian countries such as India. The requirements for calculating the necessary micronutrients and vitamin D fortification of foods and drinks, successful strategies should be developed and emphasized. There is need to improve the effectiveness of various fruit drinks through fortification of vitamin D, which can reduce vitamin D deficiency in the general population as well as in different age groups.

Implications of phytate in plant-based foods for iron and zinc bioavailability, setting dietary requirements, and formulating programs and policies

Plant-based diets in low-income countries (LICs) have a high content of phytic acid (myo-inositol hexaphosphate [InsP6]) and associated magnesium, potassium, and calcium salts. Together, InsP6 acid and its salts are termed "phytate" and are potent inhibitors of iron and zinc absorption. Traditional food processing can reduce the InsP6 content through loss of water-soluble phytate or through phytase hydrolysis to lower myo-inositol phosphate forms that no longer inhibit iron and zinc absorption. Hence, some processing practices can reduce the need for high-dose iron fortificants in plant-based diets and alleviate safety concerns. Dietary phytate-to-iron and phytate-to-zinc molar ratios are used to estimate iron and zinc bioavailability and to identify dietary iron and zinc requirements according to diet type. The European Food Safety Authority has set adult dietary zinc requirements for 4 levels of phytate intake, highlighting the urgent need for phytate food composition data. Such data will improve the ability to estimate the prevalence of inadequate zinc intakes in vulnerable groups in LICs, which will facilitate implementation of targeted policies to alleviate zinc deficiency.

Identifying Dietary Strategies to Improve Nutrient Adequacy among Ethiopian Infants and Young Children Using Linear Modelling

Nutrient adequacy of young children's diet and best possible strategies to improve nutrient adequacy were assessed. Data from the Ethiopian National Food Consumption Survey were analysed using Optifood (software for linear programming) to identify nutrient gaps in diets for children (6-8, 9-11 and 12-23 months), and to formulate feasible Food-Based Dietary Recommendations (FBDRs) in four regions which differ in culture and food practices. Alternative interventions including a local complementary food, micronutrient powders (MNPs), Small quantity Lipid-based Nutrient Supplement (Sq-LNS) and combinations of these were modelled in combination with the formulated FBDRs to compare their relative contributions. Risk of inadequate and excess nutrient intakes was simulated using the Estimated Average Requirement cut-point method and the full probability approach. Optimized local diets did not provide adequate zinc in all regions and age groups, iron for infants <12 months of age in all regions, and calcium, niacin, thiamine, folate, vitamin B12 and B6 in some regions and age-groups. The set of regional FBDRs, considerably different for four regions, increased nutrient adequacy but some nutrients remained sub-optimal. Combination of regional FBDRs with daily MNP supplementation for 6-12 months of age and every other day for 12-23 months of age, closed the identified nutrient gaps without leading to a substantial increase in the risk of excess intakes.

Feasibility and acceptability of food-based complementary feeding recommendations using Trials of Improved Practices among poor families in rural Eastern and Western Uganda

Inadequate complementary feeding practices are a major contributor to stunting among children in Uganda. The WHO recommends the promotion of local food-based complementary feeding recommendations (FBCFRs) to address nutrient gaps during complementary feeding. This study tested the feasibility and acceptability of FBCFRs, using trials of improved practices (TIPs). Qualitative and quantitative methods were used in a cross-sectional survey over three household visits. At first household visit, information on socio-demographic factors and food frequency was collected and FBCFRs introduced. The second household visit assessed the use and barriers related to the FBCFRs, while the third household visit assessed the continued use of the FBCFRs. Focus group discussions and key informant interviews provided the insights into community norms on the FBCFRs. Most FBCFRs were feasible and acceptable. However, caretakers found it difficult to implement a full set of FBCFRs together with the recommended frequencies. Caretakers were more likely to try and continue using FBCFRs that had familiar methods of preparation and commonly used ingredients. Seasonality and cost were major barriers to use. Through TIPs, mothers demonstrated that they are open to try new ways of improving their children's nutrition.

Optimization of red teff flour, malted soybean flour, and papaya fruit powder blending ratios for better nutritional quality and sensory acceptability of porridge

This study was carried out to optimize the compositions of red teff flour with malted soybean flour and papaya fruit powders for better nutritional quality and sensory acceptability of porridge. Total eleven formulations of the composite flours were determined using D-optimal mixture design with the help of Minitab Version 16 Statistical Software. The three ingredients were considered in the ranges of 55%-70%, 20%-30%, 5%-15% for red teff flour, malted soybean flour, and Papaya fruit powder, respectively. The prepared porridge samples from formulations were analyzed for nutritional composition, antinutritional factors, and sensory acceptability. Results of the study showed the significant difference (p < .05) in ash, fat, fiber, protein, carbohydrate, energy, iron, calcium, zinc, β-carotene, phytates, tannin, appearance, taste, mouthfeel, and overall acceptability as the composition of ingredients were changed. The overall optimum point was found in a range of red teff flour (60%-70%), malted soybean flour (20%-27.5%), and papaya fruit powder (10%-12.5%). In conclusion, the present approach can help in improve infants dietary quality of complementary foods by developing nutritionally enhanced red teff-based porridge used for intervention of malnutrition.

The Evolving Applications of Spreads as a Foodlet for Improving the Diets of Infants and Young Children

Action is needed to reduce the burden of micronutrient malnutrition in developing countries, and because low-income populations are vulnerable to deficiencies of multiple micronutrients, we need to move beyond approaches that comprise only single nutrients. The normal and evolutionary manner in which to consume nutrients is in the context of foods, both snacks and meals. Spreads are high-viscosity-fat products prepared by mixing dried powdered ingredients with a vegetable fat chosen for its viscosity. Spreads are not traditionally used for feeding infants or young children and were initially proposed as a way to treat children recovering from severe malnutrition. In preparation for the International Research Group on Infant Supplementation (IRIS) III intervention, a sequel to the IRIS I study (which was the focus of a workshop in Lima, Peru, from May 30–June 1, 2001), the feasibility of preparing a FOODlet for feeding infants and young children was explored. Within the spectrum of intervention tools for micronutrient supplementation, tablets are a pharmaceutical form, fortified spreads are a food, and sprinkles are an intermediate approach. The issues still to be discussed and resolved with regard to creating such a spread include its specific micronutrient formulation, the capacity of young children to consume the required amounts (from either the FOODlet alone or the FOODlet mixed with other foods), the iron content and overall antioxidant protection of the spread matrix and its vitamins, potential allergenicity of proteins, and the economic implications of using such a FOODlet in low-income societies.

Vitamin A status and body pool size of infants before and after consuming fortified home-based complementary foods

Background

Home fortification using sachets of micronutrient powder (e.g. “Sprinkles”) is a food-based approach offering an alternative to high dose vitamin A (VA) supplements for infants. The primary objective was to investigate the impact of VA-home fortification on infant VA pool size. The secondary objective was to compare VA status of infants assessed by the modified relative dose response (MRDR) test before and the ¹³C-retinol isotope dilution (¹³C-RID) test in the same infants after vitamin A supplementation.

Methods

A randomized-controlled trial was conducted in 7–9 month old infants in Ghana. Eligible children were randomly allocated to receive a daily sachet of “Sprinkles” with or without VA for 5 months added to complementary foods. The MRDR test indirectly determined VA liver reserves at baseline and the ¹³C-RID determined VA body pool at follow-up in the same cohort of children.

Results

At baseline, the MRDR values (95 % CI) for infants were comparable in the intervention and control groups: normal at 0·032 (SD 0·018) (0·025–0·038) and 0·031 (SD 0·018) (0·024–0·038), respectively. After intervention, total body stores (TBS) and liver retinol concentrations did not differ between intervention and control groups; TBS were 436 (SD 303) and 434 (SD 186) μmol, respectively, and estimated liver concentrations were 0·82 (SD 0·53) and 0·79 (SD 0·36) μmol/g liver, indicating adequate reserves in all children.

Conclusions

Both the MRDR and ³C-RID tests confirmed that the infants had adequate VA status before and after home fortification of their complementary foods. These tests offered more information than serum retinol concentrations alone, which predicted VA deficiency using current suggested cutoffs not corrected for inflammation status.

Selecting desirable micronutrient fortificants for plant-based complementary foods for infants and young children in low-income countries

The World Health Organization (WHO) recommends that both breast-fed and non-breast-fed children are fed micronutrient fortified complementary foods designed to meet their high nutrient requirements from aged 6 to 23 months of age. This paper summarises the steps recommended by WHO/FAO to identify the country-specific micronutrient shortfalls in complementary diets and establish desirable levels of bioavailable fortificants for centrally processed plant-based complementary foods for infant and young child feeding. The goal of the WHO/FAO guidelines is to achieve a desirably low prevalence of inadequate micronutrient intakes in the target group whilst simultaneously ensuring minimal risk of excessive intakes.

Key strategies to further reduce stunting in Southeast Asia: lessons from the ASEAN countries workshop

BACKGROUND

To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified.

OBJECTIVE

Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia.

METHODS

Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries.

RESULTS

Between 1990-2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation.

CONCLUSIONS

In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.

Impact of vitamin A with zinc supplementation on malaria morbidity in Ghana

BACKGROUND

Malaria is a leading cause of morbidity and mortality among young children and is estimated to cause at least 1 million deaths each year especially among pregnant women and young children under the age of five years. Vitamin A supplementation is known to reduce morbidity and mortality in young children. Zinc is required for growth and immunity and we sought to replicate the study by Zeba et al. which showed 30% lower cases of clinical malaria in children on a combination of zinc and a large dose of vitamin A compared with children on vitamin A alone based on the hypothesis that combined vitamin A and zinc reduced symptomatic malaria compared to vitamin A alone.

OBJECTIVES

The primary objective was to determine the effect of vitamin A alone vs. vitamin A and zinc supplements on the incidence of clinical malaria and other anthropometric indices. It also sought to assess the effects on the incidence of anaemia, diarrhoea and pneumonia.

METHODS

The study was community-based and 200 children between the ages of 6-24 months were randomised to receive either vitamin A (100,000 IU for infants less than 12 months & 200,000 IU for children greater than 12 months and 10 mg daily zinc in the intervention group or vitamin A and zinc placebo for 6 months in the control group.

RESULTS

The number of children who were diagnosed with uncomplicated malaria in the intervention group was 27% significantly lower compared with the children in the control group (p = 0.03). There were, however, no effects on severe malaria, pneumonia, anaemia and diarrhea.

CONCLUSIONS

Our study confirms a significant role of vitamin A and zinc in reducing malaria morbidity.

Specially formulated foods for treating children with moderate acute malnutrition in low- and middle-income countries

BACKGROUND

Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low- and middle-income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid-based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition.

OBJECTIVES

To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low- and middle-income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective.

SEARCH METHODS

In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition-related organisations and researchers in this field.    

SELECTION CRITERIA

We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses using the random-effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods.

MAIN RESULTS

Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care - the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight-for-height (MD 0.20 z-score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid-based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses - there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid-based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non-recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight-for-height, and mid-upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid-based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses - no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid-based nutrient supplements versus specific types of blended foods - a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods - in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet - no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content.

AUTHORS' CONCLUSIONS

In conclusion, there is moderate to high quality evidence that both lipid-based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid-based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short-term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.

Nutrient density in complementary feeding of infants and toddlers

The paradigm of the first 1000 days of life, the period from conception to the second birthday, has been advanced as a critical window of opportunity to save a life and a child's future. Infancy and toddler life, through the first 24 months after birth, is a unique period during which human milk is recommended as either the exclusive source of nutrition (6 months) or a variable component thereof. After the maternal delivery of milk is accounted for, the remainder of the energy and nutrients needs come from complementary foods. There is an intrinsic gap left by the maternal milk supply in volume and micronutrient content in relation to expanding infant and toddler needs. The nutrient density approach provides us with a mathematical framework to manage the closing of the nutrient gap. The intrinsic nutrient content of the unprocessed foods appropriate for young children is limited. The most problematic nutrients are calcium, iron and zinc. Some manner to enhance the nutrient density of the complementary foods is an incontestable necessity. The nutrient density consideration, which identifies for us the nature of the problem, offers a tool for the titrating of the fortification to an adequate--but safe--addition.

State of the art of Ready-to-Use Therapeutic Food: a tool for nutraceuticals addition to foodstuff

Therapeutic foodstuff are a challenge for the use of food and functional food ingredients in the therapy of different pathologies. Ready-to-Use Therapeutic Food (RUTF) are a mixture of nutrients designed and primarily addressed to the therapy of the severe acute malnutrition. The main ingredients of the formulation are powdered milk, peanuts butter, vegetal oil, sugar, and a mix of vitamins, salts, and minerals. The potential of this food are the low percentage of free water and the high energy and nutritional density. The high cost of the powdered milk, and the food safety problems connected to the onset of toxigenic moulds on the peanuts butter, slowed down considerably the widespread and homogenous diffusion of this product. This paper presents the state of the art of RUTF, reviews the different proposed recipes, suggests some possible new formulations as an alternative of novel recipes for this promising food.

Mixture of ferric sodium ethylenediaminetetraacetate (NaFeEDTA) and ferrous sulfate: an effective iron fortificant for complementary foods for young Chinese children

BACKGROUND

Ferric sodium ethylenediaminetetraacetate (NaFeEDTA) enhances iron absorption in the presence of phytate. However, the amount of NaFeEDTA that would have to be added to a complementary food to provide the necessary intake of iron for an infant or young child if NaFeEDTA were the sole iron fortificant exceeds the Acceptable Daily Intake (ADI) of EDTA for this age group. EDTA increases iron absorption at a molar ratio EDTA:iron of less than 1:1.

OBJECTIVE

To determine whether iron absorption is enhanced with a mixture offerrous sulfate (FeSO₄) and NaFeEDTA.

METHODS

Two studies with a crossover design were conducted in separate groups of 14 and 15 children aged 24 to 31 months. A complementary food consisting of millet porridge with cabbage, tofu, and pork-filled wheat flour dumplings was fortified with 2 mg iron as either FeSO₄ or NaFeEDTA (study 1) or 4 mg iron as FeSO₄ or a mixture of 2 mg each of FeSO₄ and NaFeEDTA (study 2). Iron absorption was determined based on erythrocyte incorporation of stable iron isotopes.

RESULTS

In study 1, the geometric mean (± SD) iron absorption was 8.0% (3.1, 20.8) and 9.2% (3.1, 27.0) from food fortified with FeSO₄ and NaFeEDTA, respectively. In study 2, iron absorption was significantly higher from food fortified with 4 mg iron as 1:1 mixture of FeSO₄/NaFeEDTA than from food fortified with FeSO₄; the geometric mean iron absorption was 6.4% (3.0, 13.5) and 4.1% (1.9, 8.9), respectively.

CONCLUSIONS

The enhancing effect of EDTA on iron absorption is less strong in composite meals containing enhancers; nevertheless, the equal mixture of FeSO₄ and NaFeEDTA significantly enhanced iron absorption and can be a strategy to ensure adequate iron absorption from phytate-containing complementary foods.

Oral Administration of Ferrous Sulfate, but not of Iron Polymaltose or Sodium Iron Ethylenediaminetetraacetic Acid (NaFeEDTA), Results in a Substantial Increase of Non-Transferrin-Bound Iron in Healthy Iron-Adequate Men

Background

Oral iron supplementation with ferrous sulfate (FeSO4) at dosage levels suggested by the international guidelines poses a safety hazard to young children with malaria. Exposure to loosely bound iron in the circulation has been advanced as a potential factor.

Objective

To evaluate the kinetics of circulating concentrations of plasma iron and non-transferrin-bound iron (NTBI) in response to oral iron administration in healthy adults.

Methods

Plasma samples were collected at 90-minute intervals over a period of 270 minutes from 10 healthy Guatemalan men after oral administration of water or 100 mg of iron from each of three iron compounds: FeSO4, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), and iron polymaltose. The four tests were administered in an individually randomized sequence. Serum iron concentration was measured spectrophotometrically by the ferrozine method, and NTBI concentration was measured by a fluorometric competitive binding assay. The kinetic response and the maximal and cumulative changes in circulating concentrations of the biomarkers of interest were compared.

Results

Serum iron and NTBI responses to oral administration of FeSO4 were significantly greater than responses to plain water or the other two iron compounds. NTBI concentrations after NaFeEDTA or iron polymaltose ingestion were not different from those determined after water intake.

Conclusions

Administration of two iron compounds of proven bioavailability, but with complex absorption characteristics, is associated with a negligible NTBI response, potentially mitigating the safety concerns associated with iron supplementation in malarial areas.

Program responses to acute and chronic malnutrition: divergences and convergences

Program approaches for addressing acute malnutrition and those for addressing chronic malnutrition have grown in different directions. Their specialization has led to productive advances in the efficacy of specific interventions but has also created divergences in implementation. Greater convergence and integration between the 2 sets of approaches would help programs respond to the diversity of conditions faced in the field and enable a more comprehensive continuum of care from prevention to treatment. After reviewing the causes of the differences in approach, this paper examines programmatic and scientific challenges to greater convergence and suggests steps to promote effective integration of acute and chronic malnutrition services. Steps include strengthening community linkages between program platforms, assessing the degree and type of integration needed in various situations, identifying cost efficiencies, and developing joint tools where possible.

Randomised comparison of the effects of Sprinkles and Foodlets with the currently recommended supplement (Drops) on micronutrient status and growth in Iranian children

BACKGROUND/OBJECTIVES

Multiple micronutrient supplementation with Sprinkles powder and crushable Foodlets tablets may be effective means of controlling micronutrient deficiencies in infants. Their efficacy has not been tested in countries like Iran where wheat as the staple food may affect nutrient bioavailability. This study aimed to compare the efficacy of Sprinkles, Foodlets and the current supplement (Drops) for improving micronutrient status and growth among Iranian infants.

SUBJECTS/METHODS

Infants of 6-18 months of age, living in an urban district of Iran were randomised to receive daily Sprinkles (n=120), Foodlets (n=121) or Drops (n=121) for 4 months. Haemoglobin (Hb), serum ferritin, serum retinol, serum zinc, 25(OH) D concentration and anthropometry were assessed at baseline and at 4 months.

RESULTS

Iron status improved with all treatments. Drops showed significantly greater changes in Hb and serum ferritin, though changes in anaemia prevalence were not different across groups. Infants having Foodlets and Sprinkles had significantly greater reductions in proportion of children with zinc deficiency compared with Drops. No significant differences in treatment effects were observed for mean serum 25(OH) D and retinol, or for growth of infants across groups.

CONCLUSION

The study was the first efficacy trial with Sprinkles and Foodlets in the Middle East where wheat or rice is the principal complementary foods. Differences across treatment groups were largely consistent with supplement micronutrient composition for iron and zinc, with no benefit in this population for serum retinol, 25(OH) D, growth or anthropometric status. The trial identified trade-offs in combining multiple micronutrients in a single delivery mechanism.

Acceptability of zinc-fortified, lipid-based nutrient supplements (LNS) prepared for young children in Burkina Faso

Micronutrient deficiencies are a public health concern among young children in low-income countries, and novel strategies are needed to improve the nutritional status of children at risk. One promising approach is the use of lipid-based nutrient supplements (LNS), which can be added to complementary food at the time of consumption. The optimal amount of zinc to include in LNS is uncertain, and concerns have been expressed about possible adverse effects of zinc on sensory characteristics of LNS. We conducted a series of acceptability studies of LNS containing either 0 or 10 mg of zinc per daily 20 g LNS dose among Burkinabe children 9-15 months old and their mothers. These acceptability studies included observations of children's consumption, maternal and child sensory reaction to the products using a 5-unit hedonic scale, a triangle test for detection of differences and a review of maternal reports of their child-feeding experiences during a 2-week home-feeding trial. The LNS products were well appreciated by the mothers and children during the sensory trials and the 2-week home-feeding trial. The addition of 10 mg zinc to LNS did not affect the consumed proportion of the offered porridge-LNS-mixture (P = 0.43). Results of the triangle test with mothers confirmed that there was no detectable difference between products containing 0 or 10 mg zinc per 20 g LNS dose. Most importantly, interviews and focus groups following the 2-week home-feeding trial indicated good acceptability of the products by mothers and their children.

Effect of an improved local ingredient-based complementary food fortified or not with iron and selected multiple micronutrients on Hb concentration

OBJECTIVE

To assess the effect of an improved local ingredient-based gruel fortified or not with selected multiple micronutrients (MM) on Hb concentration of young children.

DESIGN

In a nutrition centre that we opened in their villages, children received either MM supplement (containing iron, zinc, vitamin A, vitamin C and iodine) with the improved gruel (MMGG) or the improved gruel only (GG), twice daily, 6 d/week, for 6 months. We assessed baseline and endpoint Hb concentration and anthropometric indices.

SETTING

Kongoussi, a rural and poor district of Burkina Faso.

SUBJECTS

In a community-based trial, we randomly assigned 131 children aged 6-23 months with Hb concentrations in the range of 80-109 g/l into two groups.

RESULTS

The groups did not differ significantly at baseline. Mean baseline Hb concentration was 89·2 (sd 6·5) g/l and 90·3 (sd 8·4) g/l in the GG and the MMGG, respectively (P = 0·42). It increased to 104·1 (sd 11·4) g/l in the GG (P < 0·001) and 107·6 (sd 14·7) g/l in the MMGG (P < 0·001). The between-group difference of 3·5 (95 % CI -1·0, 8·1) g/l in mean (sd) endpoint Hb concentration was not significant (P = 0·13). The endpoint anthropometric indices were not different between the groups.

CONCLUSIONS

This MM supplement had no additional effect on Hb concentration. Thorough studies are needed to evaluate the actual efficacy of the gruel before its introduction into household routine.

The impact of common micronutrient deficiencies on iodine and thyroid metabolism: the evidence from human studies

Deficiencies of micronutrients are highly prevalent in low-income countries. Inadequate intake of iodine impairs thyroid function and results in a spectrum of disorders. Other common deficiencies of micronutrients such as iron, selenium, vitamin A, and possibly zinc may interact with iodine nutrition and thyroid function. Randomised controlled intervention trials in iodine- and iron-deficient populations have shown that providing iron along with iodine results in greater improvements in thyroid function and volume than providing iodine alone. Vitamin A supplementation given alone or in combination with iodised salt can have a beneficial impact on thyroid function and thyroid size. Despite numerous studies of the effect of selenium on iodine and thyroid metabolism in animals, most published randomised controlled intervention trials in human populations failed to confirm an impact of selenium supplementation on thyroid metabolism. Little evidence is available on interactions between iodine and zinc metabolism.

Current and Potential Role of Specially Formulated Foods and Food Supplements for Preventing Malnutrition among 6- to 23-Month-Old Children and for Treating Moderate Malnutrition among 6- to 59-Month-Old Children

Reducing child malnutrition requires nutritious food, breastfeeding, improved hygiene, health services, and (prenatal) care. Poverty and food insecurity seriously constrain the accessibility of nutritious diets that have high protein quality, adequate micronutrient content and bioavailability, macrominerals and essential fatty acids, low antinutrient content, and high nutrient density. Diets based largely on plant sources with few animal-source and fortified foods do not meet these requirements and need to be improved by processing (dehulling, germinating, fermenting), fortification, and adding animal-source foods, e.g., milk, or other specific nutrients. Options include using specially formulated foods (fortified blended foods, commercial infant cereals, or ready-to-use foods [RUFs; pastes, compressed bars, or biscuits]) or complementary food supplements (micronutrient powders or powdered complementary food supplements containing micronutrients, protein, amino acids, and/or enzymes or lipid-based nutrient supplements (120 to 250 kcal/day), typically containing milk powder, high-quality vegetable oil, peanut paste, sugar, and micronutrients. Most supplementary feeding programs for moderately malnourished children supply fortified blended foods, such as corn–soy blend, with oil and sugar, which have shortcomings, including too many antinutrients, no milk (important for growth), suboptimal micronutrient content, high bulk, and high viscosity. Thus, for feeding young or malnourished children, fortified blended foods need to be improved or replaced. Based on success with ready-to-use therapeutic foods (RUTFs) for treating severe acute malnutrition, modifying these recipes is also considered. Commodities for reducing child malnutrition should be chosen on the basis of nutritional needs, program circumstances, availability of commodities, and likelihood of impact. Data are urgently required to compare the impact of new or modified commodities with that of current fortified blended foods and of RUTF developed for treating severe acute malnutrition.

Effects of nutrient fortified complementary food supplements on anemia of infants and young children in poor rural of Gansu

OBJECTIVE

To assess the effectiveness of complementary food supplements with protein and multi-micronutrients on hemoglobin and anemia in infants and young children.

METHODS

In 5 poor counties of Gansu, 984 children aged 6-12 months were enrolled and divided into two groups. In addition to the usual home-made complementary food, all the children were fed one sachet of either Formula I or Formula II supplements each day. Protein and micronutrients were provided in Formula I, while the same energy intake was secured in Formula II as in Formula I. A massive dose of vitamin A was supplemented to all the children every 6 months. Hemoglobin test was done at the same time.

RESULTS

Prevalence of anemia was about 35% in both Formula I and Formula II group at baseline, and there were no differences in hemoglobin concentration between the two groups. During the 6-month and 12-month supplementation, hemoglobin of children in Formula I group was higher than that in Formula II group (P < 0.05), and hemoglobin increase in Formula I group was significantly higher than that in Formula II group (P < 0.001). After 6- and 12-month supplementation, the prevalence of anemia in Formula I group dropped to 19.1% and 8.2% respectively, and it was 28.0% and 12.4% in Formula 2 group. The prevalence of anemia in Formula I group was significantly lower than that in Formula II group (P < 0.05). After adjusting age and hemoglobin level at baseline, the hemoglobin increase at age of 24 months in formula 1 group was higher (10.7 g/L vs 7.9 g/L, P < 0.0001).

CONCLUSION

Micronutrient fortified complementary food supplements, with large-dose vitamin A, is effective for children aged 6-12 months in terms of iron deficiency prevention.

Impact of Zinc Fortification on Zinc Nutrition

Food fortification is increasingly recognized as an effective approach to improve a population's micronutrient status. The present report provides a critical review of the scientific evidence currently available on the impact of zinc fortification on zinc nutrition.

The available studies clearly show that zinc fortification can increase dietary zinc intake and total daily zinc absorption. Most absorption studies also indicate that adding zinc to food does not adversely affect the absorption of other minerals, such as iron. Despite the positive effect of zinc fortification on total zinc absorption, only a few studies have found positive impacts of zinc fortification on serum zinc concentrations or functional indicators of zinc status. The reasons for these inconsistent results are uncertain but may relate to the choice of food vehicles, the age group and zinc status of the study populations, or particular aspects of the study design. Thus, additional research is needed to determine the impact of zinc fortification, with or without other micronutrients, in populations at risk for zinc deficiency.

Because of the benefits of increasing intake in populations at high risk for zinc deficiency, the documented increase in total zinc absorption that occurs following zinc fortification, the absence of any adverse effects, and the relatively low cost of adding zinc, public health planners should consider including zinc in mass and targeted fortification programs in such populations. Because of the limited available information on program impact, it will be important to evaluate the outcomes of such programs.

Preventive Zinc Supplementation among Infants, Preschoolers, and Older Prepubertal Children

Zinc supplementation trials carried out among children have produced variable results, depending on the specific outcomes considered and the initial characteristics of the children who were enrolled. We completed a series of meta-analyses to examine the impact of preventive zinc supplementation on morbidity; mortality; physical growth; biochemical indicators of zinc, iron, and copper status; and indicators of behavioral development, along with possible modifying effects of the intervention results. Zinc supplementation reduced the incidence of diarrhea by ∼20%, but the impact was limited to studies that enrolled children with a mean initial age greater than 12 months. Among the subset of studies that enrolled children with mean initial age greater than 12 months, the relative risk of diarrhea was reduced by 27%. Zinc supplementation reduced the incidence of acute lower respiratory tract infections by ∼15%. Zinc supplementation yielded inconsistent impacts on malaria incidence, and too few trials are currently available to allow definitive conclusions to be drawn. Zinc supplementation had a marginal 6% impact on overall child mortality, but there was an 18% reduction in deaths among zinc-supplemented children older than 12 months of age. Zinc supplementation increased linear growth and weight gain by a small, but highly significant, amount. The interventions yielded a consistent, moderately large increase in mean serum zinc concentrations, and they had no significant adverse effects on indicators of iron and copper status. There were no significant effects on children's behavioral development, although the number of available studies is relatively small. The available evidence supports the need for intervention programs to enhance zinc status to reduce child morbidity and mortality and to enhance child growth. Possible strategies for delivering preventive zinc supplements are discussed.

Critical review of strategies to prevent and control iron deficiency in children

Iron deficiency is prevalent in infants and young children in developing countries and is associated with adverse developmental outcomes. The routine provision of additional iron by food fortification or the use of iron supplements is generally recommended. The wisdom of this approach in regions where the transmission of Plasmodium falciparum malaria is perennial and intense is now being questioned, because a large trial in Pemba, Tanzania, demonstrated an increased risk of serious morbidity among children under the age of 3 years who were given routine daily iron and folic acid supplements. However, the results of a concurrent substudy suggest that the untoward effects occurred in children who were not iron deficient, and that iron deficiency itself is associated with an increased risk of severe morbidity that can be reduced by iron and folic acid supplementation. There is an urgent need for additional research to confirm these observations, to establish the role, if any, of the concurrent folic acid supplementation, to evaluate the risk of alternative methods for delivering iron that, on theoretical grounds, could be safer, and to establish the programmatic feasibility of targeting iron fortificants or supplements to iron-deficient children. It is evident that a single strategy for ensuring adequate iron nutrition in young children in different parts of the world is no longer likely to be satisfactory. Moreover, integration with other health-related strategies, particularly malaria control programs, will be essential.

An energy-dense complementary food is associated with a modest increase in weight gain when compared with a fortified porridge in Malawian children aged 6-18 months

Poor complementary feeding practices are associated with stunting and growth faltering throughout the developing world. The objective was to compare the effect of using peanut-/soy-based fortified spread (FS) and corn porridge fortified with fish powder (FP) as complementary foods on growth in rural Malawian children. A total of 240 children were enrolled at the age of 6 mo and randomized to receive FS or FP. Both complementary foods provided 836 kJ/d from 6 to 9 mo of age and 1254 kJ/d from 9 to 18 mo of age. Children were followed monthly for anthropometry and fortnightly for the symptoms of fever, cough, or diarrhea until they were 18 mo old. Zn and Se status were assessed at 6 and 12 mo. The primary outcomes were the rates of weight and length gain from 6-12 mo and from 12-18 mo. Children who received FS gained 110 g more (95% CI 220 to 10) from 6-12 mo of age than children receiving FP. Weight gain did not differ between children receiving FS and FP between 12 and 18 mo of age, nor did statural growth from 6 to 12 mo or 12 to 18 mo. A total of 23% of all children were Zn deficient at 6 mo of age and this increased to 37% at 12 mo of age. Neither FS nor FP was associated with significantly improved Zn status. FS was associated with better weight gain from 6-12 mo of age and may be useful in conjunction with additional interventions to improve infant growth in the developing world.

Efficacy and safety of twice-weekly administration of three RDAs of iron and folic acid with and without complement of 14 essential micronutrients at one or two RDAs: a placebo-controlled intervention trial in anemic Cambodian infants 6 to 24 months of age

OBJECTIVE

To determine the differential efficacy and safety of twice-weekly administration of 3 RDAs of iron and folic acid, with and without a complement of 2 RDAs of 11, and 1 RDA of 3 additional essential micronutrients as compared to a placebo control (PlbCON) given as foodLETs.

SUBJECTS/METHODS

A total of 250 children aged 6-24 months were enrolled after recruitment by village health workers; 19 of them dropped out during the trial. Children were assigned to one of three treatment arms and followed for 20.5 weeks; 41 supervised twice-weekly dosings of 30 mg of iron plus folic acid, either with or without accompanying micronutrients or placebo were given as foodLETs, a tool for ready-to-eat fortification in infant food. Initial and final measurements of anthropometry and blood biomarkers for hematological, iron stores and inflammatory status, as well as for abnormal hemoglobin (Hb), were obtained. Symptoms of listlessness, vomiting, watery stools and acute respiratory infections were monitored weekly.

RESULTS

Iron-containing supplements increased Hb concentrations significantly (P<0.0001) and virtually eradicated any IDA, as compared to no change in hematological status in the PlbCON group (P=0.011). Iron stores, as reflected by ferritin, increased significantly with iron-containing treatments (P<0.0001). Responses were as effective in individuals with HbE as in those with exclusively HbA phenotypes. Watery stools (P=0.002) and listlessness (P=0.001) were significantly more frequent in those receiving iron and folic acid alone than in the PlbCON group. In contrast, acute respiratory infections (P=0.014) and listlessness (P=0.001) were significantly less frequent in those receiving the multiple micronutrient formulation than in the PlbCON group.

CONCLUSIONS

Supplementation of micronutrients along with iron and folic acid mitigates the excess morbidity of iron-folate alone, without reducing its efficacy in correcting anemia and building iron stores. FoodLETs are a suitable vehicle to provide micronutrient supplementation to infants.

Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control

BACKGROUND/OBJECTIVES

Despite repeated public commitments and availability of various forms of iron supplements, rates of anaemia in developing countries remain high. A major reason for this lack of success has been poor adherence. The objective of this study was to compare the effectiveness of daily and flexible administration of micronutrient Sprinkles on adherence, acceptability and haematological status among young children in rural Bangladesh.

SUBJECTS/METHODS

A sample of 362 children (haemoglobin (Hb)>or=70 g l(-1)) aged 6-24 months were cluster-randomized to receive 60 sachets of Sprinkles either (i) daily over 2 months; (ii) flexibly over 3 months; or (iii) flexibly over 4 months. With a flexible regimen, mothers/caregivers decided how frequently to use Sprinkles without exceeding one sachet per day. Adherence was assessed monthly by counting the number of sachets used and acceptability was evaluated through focus group discussions. Haemoglobin was measured at baseline, at the end of each intervention period and 6 months post-intervention.

RESULTS

Mean percent adherence was significantly higher in the flexible-4-month group (98%) compared to the flexible-3-month (93%) and daily-2-month (88%) groups (P<0.01). Most mothers found flexible administration to be more acceptable than daily due to perceived benefits of use. Hb at the end of intervention was significantly higher in the flexible-4-month group compared to the daily group (P=0.03). Anaemia prevalence decreased by 65% in the flexible-4-month group compared to 54% in the flexible-3-month and 51% in the daily-2-month groups. Percent of cured children who maintained a non-anaemic status 6 months post-intervention was significantly higher in the flexible-4-month (82%) and flexible-3-month (80%) groups than the daily-2-month (53%) group (P<0.05).

CONCLUSIONS

The adherence, acceptability and haematological response to flexible administration over 4 months were found preferable to daily.

Nutritional iron deficiency

Iron deficiency is one of the leading risk factors for disability and death worldwide, affecting an estimated 2 billion people. Nutritional iron deficiency arises when physiological requirements cannot be met by iron absorption from diet. Dietary iron bioavailability is low in populations consuming monotonous plant-based diets. The high prevalence of iron deficiency in the developing world has substantial health and economic costs, including poor pregnancy outcome, impaired school performance, and decreased productivity. Recent studies have reported how the body regulates iron absorption and metabolism in response to changing iron status by upregulation or downregulation of key intestinal and hepatic proteins. Targeted iron supplementation, iron fortification of foods, or both, can control iron deficiency in populations. Although technical challenges limit the amount of bioavailable iron compounds that can be used in food fortification, studies show that iron fortification can be an effective strategy against nutritional iron deficiency. Specific laboratory measures of iron status should be used to assess the need for fortification and to monitor these interventions. Selective plant breeding and genetic engineering are promising new approaches to improve dietary iron nutritional quality.

Contribution of a novel high-density micronutrient condiment (HDMC) to nutrient adequacy of home-prepared Guatemalan dishes

BACKGROUND

The diet of low-income Guatemalan populations is mostly plant-based, deficient in some vitamins and minerals, and rich in antinutritional compounds that reduce the bioavailability of several micronutrients. Objective. To describe the manner in which low-income Guatemalan women in rural and urban settings would prepare dishes for main meals using a high-density multimicronutrient condiment (HDMC) and to compare the nutrient density and contribution to the recommended dietary allowance (RDA) of the dishes with and without added HDMC.

METHODS

A sample of 30 women, 15 each from rural and urban households, were enrolled. The women were given 20 g of the HDMC and asked to prepare a dish at home, serve it to their families at a time of their own choosing, record the recipe and the amount of condiment added, and report these facts to an interviewer on the following day. The nutrient content of each dish was calculated from food-composition table values for raw, whole ingredients and the package label values for the HDMC.

RESULTS

For all dishes combined, the HDMC provided on average 78% of the total vitamins. The proportion of the total vitamins provided by the HDMC varied greatly among different dishes. Typically a single serving of a dish without added HDMC provided less than half of the RDA (vitamin B12 and folate) for children and adult women. The midday meal is the most important meal of the day and should provide at least half of the RDA of all essential nutrients. With the HDMC added, the dishes on average provided 2 to 10 times the RDA for nutrients such as vitamins B6 and C and niacin in the reference children, and just satisfied the RDA intake for corresponding nutrients in adult women.

CONCLUSIONS

The proportion of the RDAs of micronutrients provided by this novel, micronutrient-rich condiment varies over a wide range, depending on idiosyncrasies of recipe ingredients, amounts of condiment added, individuals served, and age- and physiology-dependent requirements. HDMCs could provide an efficient way to deliver essential micronutrients to vulnerable populations.

Growth and change in blood haemoglobin concentration among underweight Malawian infants receiving fortified spreads for 12 weeks: a preliminary trial

OBJECTIVE

Fortified spreads (FSs) have proven effective in the rehabilitation of severely malnourished children. We examined acceptability, growth and change in blood haemoglobin (Hb) concentration among moderately underweight ambulatory infants given FS.

METHODS

This was a randomised, controlled, parallel-group, investigator-blind clinical trial in rural Malawi. Six- to 17-month-old underweight infants (weight for age < -2), whose weight was greater than 5.5 kg and weight-for-height z score greater than -3 received for 12 weeks at home 1 of 8 food supplementation schemes: nothing, 5, 25, 50, or 75 g/day milk-based FS or 25, 50, or 75 g/day soy-based FS. Outcome measures included change in weight, length and blood Hb concentration.

RESULTS

A total of 126 infants started and 125 completed the intervention. All infants accepted the spread well, and no intolerance was recorded. Average weight and length gains were higher among infants receiving daily 25 to 75 g FS than among those receiving only 0 to 5 g FS. Mean Hb concentration remained unchanged among unsupplemented controls but increased by 10 to 17 g/L among infants receiving any FS. All average gains were largest among infants receiving 50 g of FS daily: mean difference (95% confidence interval) in the 12-week gain between infants in 50 g milk-based FS group and the unsupplemented group was 290 g (range, -130 to 700 g), 0.9 cm (range, -0.3 to 2.2 cm), and 17 g/L (range, 0 to 34 g/L) for weight, length and blood Hb concentration, respectively. In soy- vs milk-based FS groups, average outcomes were comparable.

CONCLUSIONS

Supplementation with 25 to 75 g/day of highly fortified spread is feasible and may promote growth and alleviate anaemia among moderately malnourished infants. Further trials should test this hypothesis.

Design of optimal food-based complementary feeding recommendations and identification of key "problem nutrients" using goal programming

The WHO is urging countries to promote improved complementary feeding practices to ensure optimal health, growth, and development of young children. To help achieve this, a rigorous 4-phase approach for designing optimal population- specific food-based complementary feeding recommendations (CFRs) was developed and is illustrated here. In phase I, an optimized diet is selected, using goal programming (Model #1), which aims to provide a desired nutrient content with respect to habitual diet patterns and cost. Based on its food patterns, a set of draft CFRs is designed. In phase II, their success for ensuring a nutritionally adequate diet is assessed via linear programming (Model type #2) by sequentially minimizing and maximizing the level of each nutrient (i.e., worst and best-case scenarios) while respecting the CFRs. For nutrients that are <70% of desired levels, the best food sources are identified via linear programming in phase III (Model #3). Different combinations of these foods are incorporated into the original draft of the CFRs to produce alternative CFRs, which are then compared on the basis of their cost, flexibility, and "worst-case scenario" nutrient levels (Model type #2) to select, in phase IV, a final set of CFRs. A hypothetical example is used to illustrate this approach. Outcomes include a set of optimal, population-specific CFRs and practical information regarding key "problem nutrients" in the local diet. Such information is valuable for nutrition promotion, as well as nutrition program planning and advocacy, to help achieve global initiatives for improving the complementary feeding practices of young children living in disadvantaged environments.

Zinc: the missing link in combating micronutrient malnutrition in developing countries

The first cases of human Zn deficiency were described in the 1960s in the Middle East. Nevertheless, it was not until 2002 that Zn deficiency was included as a major risk factor in the global burden of disease, and only in 2004 did WHO/UNICEF include Zn supplements in the treatment of acute diarrhoea. Despite this recognition Zn is still not included in the UN micronutrient priority list, an omission that will continue to hinder efforts to reduce child and maternal mortality, combat HIV/AIDS, malaria and other diseases and achieve the UN Millennium Development Goals for improved nutrition in developing countries. Reasons for this omission include a lack of awareness of the importance of Zn in human nutrition, paucity of Zn and phytate food composition values and difficulties in identifying Zn deficiency. Major factors associated with the aetiology of Zn deficiency include dietary inadequacies, disease states inducing excessive losses or impairing utilization and physiological states increasing Zn requirements. To categorize countries according to likely risk of Zn deficiency the International Zinc Nutrition Consultative Group has developed indirect indicators based on the adequacy of Zn in the national food supplies and/or prevalence of childhood growth stunting. For countries identified as at risk confirmation is required through direct measurements of dietary Zn intake and/or serum Zn in a representative sample. Finally, in at risk countries either national or targeted Zn interventions such as supplementation, fortification, dietary diversification or modification, or biofortification should be implemented, where appropriate, by incorporating them into pre-existing micronutrient intervention programmes.

New approaches for designing and evaluating food fortification programs

Historically, food fortification programs were often undertaken with little attention to issues such as micronutrient bioavailability, optimal levels of addition, or efficacy or to monitoring impact on nutritional status, health, and human function. Several developments in recent years have enabled substantial progress to be made in the design and evaluation of fortification programs. The methodology for estimating the prevalence of inadequate nutrient intakes in a population and tolerable upper intake levels has been established and can be used as the basis for estimating desirable amounts of nutrient addition. More attention is being paid to assessing the bioavailability of nutrients (especially minerals) using stable and radioactive isotopes, and bioavailability of iron compounds can be estimated from changes in total body iron calculated from the ratio of transferrin receptors to serum ferritin. Procedures for quality control of the fortification process have been established. New approaches to monitoring the impact of fortification over time include assessment of liver retinol stores using retinol isotope dilution. In summary, the design and evaluation of food fortification programs now requires a series of formative research procedures on the part of nutritionists, which were not often expected or conducted in the past.