Realistic Food-Based Approaches Alone May Not Ensure Dietary Adequacy for Women and Young Children in South-East Asia

Objectives Micronutrient deficiencies, in southeast Asia (SE Asia), remain a public health challenge. We evaluated whether promoting the consumption of locally available nutritious foods, which is a low-risk micronutrient intervention, alone can ensure dietary adequacy, for women of reproductive age and 6–23 m old children. Methods Representative dietary data from Cambodia, Indonesia, Lao PDR, Thailand and Vietnam were analysed using linear programming analysis to identify nutrients that are likely low in personal food environments (problem nutrients), and to formulate food-based recommendations (FBRs) for three to six target populations per country. Results The number of problem nutrients ranged from zero for 12–23 m olds in Indonesia, Thailand and Vietnam to six for pregnant women in Cambodia. The FBRs selected for each target population, if adopted, would ensure a low percentage of the population was at risk of inadequate intakes for five to ten micronutrients, depending on the country and target population. Of the 11 micronutrients modelled, requirements for iron, calcium and folate were most difficult to meet (≥ 10 of the 24 target populations), using FBRs alone. The number of individual FBRs selected per set, for each target population, ranged from three to eight; and often included meat, fish or eggs, liver/organ meats, vegetables and fruits. Conclusions for practice Intervention strategies need to increase access to nutritious foods, including products fortified with micronutrients, in SE Asia, when aiming to ensure dietary adequacy for most individuals in the population.

     

Iron absorption by human subjects from different iron fortification compounds added to Thai fish sauce

OBJECTIVES: (a) To measure iron absorption by human subjects from citric acid stabilized fish sauce fortified with ferrous sulfate, ferric ammonium citrate or ferrous lactate and (b) to identify the effect of added citric acid (3 g/l) on iron absorption from ferrous sulfate fortified fish sauce. DESIGN: Iron absorption from the intrinsically labeled compounds was determined via erythrocyte incorporation of isotopic labels ((57)Fe and (58)Fe) using a randomized crossover design. In three separate absorption studies, 10 adult women each consumed a basic test meal of rice and vegetable soup seasoned with isotopically labeled, iron fortified fish sauce. RESULTS: Iron absorption was significantly lower from ferrous lactate and from ferric ammonium citrate fortified fish sauce than from ferrous sulfate fortified fish sauce. Fractional iron absorption (geometric mean; -1s.d., +1s.d.) was 8.7(3.6; 21.4)% for ferrous lactate compared to 13.0(5.4; 31.4)% from ferrous sulfate, P = 0.003 (study 1) and 6.0(2.5; 14.3)% from ferric ammonium citrate relative to 11.7(4.4; 30.7)% from ferrous sulfate, P < 0.001, in study 2. Citric acid added at a molar ratio of approximately 2.5 to iron had no effect on iron absorption from ferrous sulfate (study 3). Iron absorption in the presence of citric acid was 14.1(6.4; 30.8)% compared to 12.0(5.8; 24.7)% in its absence (P = 0.26). CONCLUSIONS: Iron absorption was 50-100% higher from ferrous sulphate fortified fish sauce than from fish sauce fortified with ferric ammonium citrate or ferrous lactate. In the presence of citric acid as a chelator, ferrous sulfate would appear to be a useful fortificant for fish sauce. SPONSORSHIP: International Atomic Energy Agency (IAEA), Vienna, Austria.     

Combined iron and zinc supplementation in infants improved iron and zinc status, but interactions reduced efficacy in a multicountry trial in southeast Asia

Deficiencies of iron and zinc are prevalent worldwide. Interactions between these micronutrients therefore have important consequences, also for supplementation. To investigate effects on hemoglobin and zinc concentrations and interactions of iron and zinc supplementation in infants, data from 4 parallel, randomized, placebo-controlled, double-blind trials in Indonesia, Thailand, and Vietnam were pooled. Infants (n=2468), aged 4-6 mo, were supplemented daily with iron (10 mg) and/or zinc (10 mg) for 6 mo. At 3 sites, infants were given vitamin A capsules (VAC) at recruitment. Combined supplementation reduced prevalences of anemia by 21% (P<0.01) and zinc deficiency by 10% (P<0.05) but was less effective (P<0.05) than supplementation with either iron (28% reduction in anemia) or zinc alone (18% reduction in zinc deficiency). Iron reduced the effect of zinc supplementation (interaction P<0.01), but had no separate effect on zinc status, whereas zinc supplementation had a negative effect on hemoglobin concentrations (-2.5 g/L, P<0.001), independent of iron supplementation (Pinteraction=0.25). The effect of iron supplementation on hemoglobin concentrations was almost twice as large in boys than in girls (effect size 12.0 vs. 6.8 g/L, respectively). In infants not receiving iron, VAC administration tended to be associated with lower (3.2%, P=0.07) hemoglobin concentrations. Combined supplementation of iron and zinc was safe and effective in reducing the high prevalences of anemia and iron and zinc deficiencies. Zinc supplementation may negatively affect iron status but iron supplementation does not seem to affect zinc status. Furthermore, VAC administration in the absence of iron supplementation may increase the incidence of anemia.     

Executive summary--Biomarkers of Nutrition for Development: Building a Consensus

The ability to develop evidence-based clinical guidance and effective programs and policies to achieve global health promotion and disease prevention goals depends on the availability of valid and reliable data. With specific regard to the role of food and nutrition in achieving those goals, relevant data are developed with the use of biomarkers that reflect nutrient exposure, status, and functional effect. A need exists to promote the discovery, development, and use of biomarkers across a range of applications. In addition, a process is needed to harmonize the global health community's decision making about what biomarkers are best suited for a given use under specific conditions and settings. To address these needs, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, organized a conference entitled "Biomarkers of Nutrition for Development: Building a Consensus," which was hosted by the International Atomic Energy Agency. Partners included key multilateral, US agencies and public and private organizations. The assembly endorsed the utility of this initiative and the need for the BOND (Biomarkers of Nutrition for Development) project to continue. A consensus was reached on the requirement to develop a process to inform the community about the relative strengths or weaknesses and specific applications of various biomarkers under defined conditions. The articles in this supplement summarize the deliberations of the 4 working groups: research, clinical, policy, and programmatic. Also described are content presentations on the harmonization processes, the evidence base for biomarkers for 5 case-study micronutrients, and new frontiers in science and technology.     

Moving towards evidence-based policy and program planning in multiple micronutrient interventions for children: symposium summary

This article provides a summary of the symposium "Multiple Micronutrient Interventions during Early Childhood: Moving toward Evidence-Based Policy and Program Planning." The symposium reviewed the strength of evidence of multiple micronutrient interventions on child health, growth, and development, case examples demonstrating how information from program evaluations and the local context can be used to improve program design and performance, and the process by which evidence evolves, resulting in guidelines for policy-makers and program managers. The presentations highlighted the importance of an interactive platform at the country level where the scientific community and country stakeholders exchange ideas, develop a priority implementation research agenda, and clarify key issues to generate and modify policy and programs based on the best evidence available and the ability to deliver results in real time.     

Performance of the CRAFTi portable fluorometer comparing with the HPLC method for determining serum retinol

Objective

To determine the performance of a portable fluorometer for measuring serum retinol (SR) concentration.

Design and methods

Serum samples were obtained from 75 factory worker women and 143 school children. SR concentration was quantified using a portable fluorometer (‘CRAFTi’) and HPLC analysis.

Results

SR by HPLC (1.23 ± 0.43 μmol/L) and CRAFTi (1.16 ± 0.46 μmol/L) was significantly correlated. Sensitivity and specificity were 85.3% and 78.0% (cutoff of 1.05 μmol/L). Kappa statistics showed moderate agreement.

Conclusions

CRAFTi portable fluorometer is a promising field-friendly tool for screening vitamin A deficiency.     

Zinc supplementation improved length growth only in anemic infants in a multi-country trial of iron and zinc supplementation in South-East Asia

Data from 4 randomized, placebo-controlled, double-blind trials in Indonesia, Thailand, and Vietnam, the South-East Asian Multicountry Trial on Iron and Zinc supplementation in Infants (SEAMTIZI), were pooled to investigate the effects of iron and zinc supplementation infant growth. Infants (n = 2451) aged 4-6 mo old were supplemented with iron (10 mg/d) and/or zinc (10 mg/d) for 6 mo. Overall, neither iron nor zinc supplementation prevented the progressive growth faltering during infancy, which is common in many developing countries. However, infants who received zinc were less likely to be stunted at the end of the supplementation period (odds ratio 0.80; 95% CI 0.64-1.0). Boys had a 30% higher risk of being stunted at the end of the study than girls (P < 0.01). Baseline factors modified the effect of supplementation, with infants anemic at baseline (hemoglobin < 105 g/L) benefiting from zinc supplementation, with an estimated increase in height-for-age Z-score (HAZ) score of 0.17 (P < 0.01), but with no effect of zinc supplementation on growth in infants not anemic at baseline. Iron supplementation negatively affected linear growth in infants with a birth weight of >3500 g (estimated effect size, -0. 14 HAZ score; P < 0.01), but with no significant effect in infants with a lower birth weight. This study shows that blanket supplementation of infants with iron or zinc will not be beneficial to all recipients and may have adverse effects in some. Hence, interventions such as iron and zinc supplementation for infants should be restricted to subgroups in which there is a clear benefit and baseline factors should be considered and characterized before implementing new policies.     

Dietary intake of spices and herbs in habitual northeast thai diets

Spices and herbs are rich in polyphenols and widely used in habitual diets in the tropical regions. To elucidate their effects on human health, intake of the portion of spices and herbs from habitual diets should be determined. Consumption patterns were determined from 24-hour records or recalls of 181 men and 370 women in Khonkaen and Ubon Ratchathani provinces, representing upper and lower northeast Thailand. There was a slight variation in dishes, but twelve spices/herbs were commonly used in the two areas. The amounts of spices/ herbs in the four most common dishes (Somtum, Jaew, Pon and Kang-Nor-Mai) were estimated by weighing ingredients before and after cooking. The average amount of spices/herbs consumed was 4.9, 26.1, 14 and 11 g/meal, contributing 36.6, 43.1, 20.6 and 29.8 mg polyphenols/meal for Somtum, Jaew, Pon and Kang- Nor-Mai, respectively. Chili was common in all recipes, with an average amount of 8.3-27.5 mg polyphenols/meal. In conclusion, habitual northeast Thai diets contain several spices/herbs and a substantial amount of polyphenols was commonly consumed.     

Use of nutritional biomarkers in program evaluation in the context of developing countries

The Lancet series on maternal and child undernutrition emphasized the need for accurate and reliable biomarkers that reflect nutrient status and measure the impact of interventions. An initiative called Biomarkers of Nutrition for Development (BOND) by the Eunice Kennedy Shriver National Institute of Child Health and Human Development aims to provide guidance for the selection and interpretation of biomarkers that meet a range of interests, including research, clinical policy, and program development. This article summarizes the activities of the program working group of the BOND initiative. The working group specified biomarkers according to program objectives such as assessing the nutritional situation or status of target populations/areas; monitoring progress of intervention; and evaluating program impact. In addition, the biomarkers developed were required to be feasible in the field settings. Based on these considerations, population-based biomarkers for programs are proposed for case examples of vitamin A, folate, vitamin B-12, iron, and zinc. Biomarkers of underlying infection/inflammation, anthropometric measures of growth, and dietary intake are recommended to be included. A program manager guide and future research to develop biomarkers for program context are recommended.     

Decreased parasite load and improved cognitive outcomes caused by deworming and consumption of multi-micronutrient fortified biscuits in rural Vietnamese schoolchildren

Micronutrient deficiencies are associated with impaired growth and cognitive function. A school-based fortification program might benefit schoolchildren but a high prevalence of parasite infestation might affect effectiveness. A randomized, double-blind, placebo-controlled 2 × 2 factorial trial was conducted to assess the efficacy of multi-micronutrient fortified biscuits with or without de-worming on growth, cognitive function, and parasite load in Vietnamese schoolchildren. Schoolchildren (n = 510), 6-8 years of age were randomly allocated to receive albendazole or placebo at baseline and four months of multi-micronutrient fortified biscuits (FB) or non-fortified biscuits. Children receiving FB for four months scored higher on two cognitive tests: Raven's Colored Progressive Matrices and the Digit Span Forward test. Children receiving albendazole plus FB had the lowest parasite load after four months. In children receiving FB, mid-upper arm circumference was slightly improved (+0.082 cm) but there were no differences in other indexes of anthropometry. Combining multi-micronutrient fortified biscuits with de-worming is an effective strategy.