Comparison of Micronutrient Intervention Strategies in Ghana and Benin to Cover Micronutrient Needs: Simulation of Bene-Fits and Risks in Women of Reproductive Age

Overlapping micronutrient interventions might increase the risk of excessive micronutrient intake, with potentially adverse health effects. To evaluate how strategies currently implemented in Benin and Ghana contribute to micronutrient intake in women of reproductive age (WRA), and to assess the risk for excess intakes, scenarios of basic rural and urban diets were built, and different on-going interventions were added. We estimated micronutrient intakes for all different scenarios. Four types of intervention were included in the scenarios: fortification, biofortification, supplementation and use of locally available nutrient-rich foods. Basic diets contributed poorly to daily micronutrient intake in WRA. Fortification of oil and salt were essential to reach daily requirements for vitamin A and iodine, while fortified flour contributed less. Biofortified products could make an important contribution to the coverage of vitamin A needs, while they were not sufficient to cover the needs of WRA. Iron and folic acid supplementation was a major contributor in the intake of iron and folate, but only in pregnant and lactating women. Risk of excess were found for three micronutrients (vitamin A, folic acid and niacin) in specific contexts, with excess only coming from voluntary fortified food, supplementation and the simultaneous overlap of several interventions. Better regulation and control of fortification and targeting of supplementation could avoid excess intakes.     

Characterization of the consistency of gruels consumed by infants in developing countries: assessment of the Bostwick consistometer and comparison with viscosity measurements and sensory perception

Standardized techniques are still needed to characterize the consistency of gruels for infants in developing countries. The aim of this study was to evaluate the interest of the use of the Bostwick consistometer. Bostwick flow was measured on gruels prepared with different flours, at low or high energy density (i.e. without or with amylase). The range of Bostwick flow, from 0 to 240 mm/30 sec, adequately described a wide range of gruel consistencies from completely liquid to almost solid. However, the temperature of the gruel must be carefully controlled during measurements as Bostwick flow is highly temperature dependent, especially in the case of gruels with high energy density. The relationship between Bostwick flow and apparent viscosity proved to depend on the type of gruel: at an apparent viscosity of 1 Pa.sec, gruels prepared from maize, rice, millet or multicomponent flours had different Bostwick flow values of, respectively, 20, 35, 75 and 55 mm/30 sec. Sensory analysis was then performed with a panel of mothers of infants and young children in Ouagadougou (Burkina Faso). Gruels of similar apparent viscosity and different Bostwick flow distances or of inversely similar Bostwick flow distances and different apparent viscosities were prepared by adding carob seed flour, and differentiation and ranking tests were then carried out. Both types of test revealed that mothers differentiated similar gruels having different Bostwick flow distances more easily than gruels having different apparent viscosities. It can thus be concluded that Bostwick flow, which is an empirical multi-criteria parameter, conveys the sensory perception of gruel consistency better than apparent viscosity.     

Driving Policy Change to Improve Micronutrient Status in Women of Reproductive Age and Children in Southeast Asia: The SMILING Project

Objective The SMILING (Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia) project aimed at creating awareness and improving policies around micronutrient deficiencies in five Southeast Asian countries (Vietnam, Laos, Thailand, Cambodia and Indonesia). Results The project showed large gaps in recent data on micronutrient status in most of the five countries. By updating existing, or creating national food composition tables, the SMILING project enabled analyses of food consumption in women of reproductive age and young children. Linear programming showed a high risk for multiple micronutrient deficiencies in these groups, and especially in pregnant women. Most programs to improve micronutrient status target iodine, iron and vitamin A deficiency. However, the high prevalence of zinc, vitamin D, thiamine and folate deficiency in the region warrant interventions too. For certain micronutrients (zinc, iron, calcium), dietary changes alone appeared not enough to fulfill requirements. Food fortification was identified to be a sustainable, long-term solution to improve micronutrient intake. Multiple criteria mapping by stakeholders in each country resulted in a list of country-specific priority interventions. Surprisingly, food fortification was ranked low, due to concerns on quality control and organoleptic changes of the fortified food. More advocacy is needed for new, innovative interventions such as delayed cord clamping. Conclusions for practice The SMILING project recommends regular surveys to monitor micronutrient status of population, to measure impact of interventions and to guide nutrition policies.

     

Micronutrient status of populations and preventive nutrition interventions in South East Asia

Objectives Since the 1990s, programs for the control of micronutrient deficiencies became a public health priority for many governments, including the countries partnering the project “Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia” (SMILING): Cambodia, Indonesia, Laos-PDR, Thailand and Vietnam. The aim of this study was to map which micronutrient deficiencies have been addressed and which interventions were in place in the SMILING countries. Methods The mapping covered the period up to 2012. Updated information from relevant surveys after 2012 is included in this paper after the completion of the SMILING project. The mapping of micronutrient status was limited to either national or at least large-scale surveys. Information on nutrition interventions obtained through a systematic mapping of national programs combined with a snowball collection from various sources. Results Among the five SMILING countries, Thailand differed historically by an early implementation of a nationwide community-based nutrition program, contributing to reductions in undernutrition and micronutrient deficiencies. For Cambodia, Indonesia, Laos PDR, and Vietnam, some national programs addressing micronutrients have been implemented following adjusted international recommendations. National surveys on micronutrient status were scattered and inconsistent across the countries in design and frequency. Conclusion for practice In conclusion, some micronutrient deficiencies were addressed in national interventions but the evidence of effects was generally lacking because of limited nationally representative data collected. Improvement of intervention programs to efficiently reduce or eliminate micronutrient deficiencies requires more systematic monitoring and evaluation of effects of interventions in order to identify best practices.

     

Improving Micronutrient Status of Vulnerable Groups in South-East Asia: The SMILING Experience

Introduction

The purpose of this commentary is to start a national conversation about the future of maternal and child health (MCH). In the coming decades, we will have unprecedented opportunities to improve MCH, but will also face unprecedented threats.

Methods

This paper examines emerging opportunities and threats to MCH, and discusses strategies for leading the future of MCH.

Results

Scientific advancements will continue to drive improvements in MCH, but to unleash its full potential for improving population health future MCH research must become more transdisciplinary, translational, and precise. Technological innovations could dramatically transform our work in MCH while big data could enhance predictive analytics and precision health; our challenge will be to assure equitable access. The greatest gains in MCH will continue to come from improving social conditions, which will require advancing MCH in all policies. Climate change, infectious outbreaks and antimicrobial resistance pose increasing threats to MCH, which can be averted by reducing global warming, implementing global early warning systems, and instituting responsible antimicrobial stewardship. The growing burden of chronic diseases in children and adults need to be addressed from an ecological and life course perspective. The water crisis in Flint shined a spotlight on the growing health threats from America’s decaying infrastructure.

Discussion

We can lead the future of MCH by starting a national conversation, improving MCH research, and preparing future MCH workforce, but the future of MCH will depend on our effectiveness in bringing about social and political change in the coming decades.

     

Multi-criteria Mapping of Stakeholders’ Viewpoints in Five Southeast Asian Countries on Strategies to Reduce Micronutrient Deficiencies Among Children and Women of Reproductive Age: Findings from the SMILING Project

Background

Despite scientific evidence on the potential impact or importance of specific interventions to improve micronutrient status of vulnerable groups, political commitment and extensive support from national stakeholders is paramount to support introduction and implementation of these interventions at national level. In order to develop efficient nutritional strategies to improve the micronutrient status of children < 5 years of age and women of reproductive age that will be supported by a wide range of stakeholders, a better understanding of viewpoints on the nutrition politics and strategies is necessary. Multi-criteria mapping (MCM) was successfully used to assess the stakeholder’s viewpoint in a wide variety of contexts since the late 1990s.

Objective

The objective of the present study was to assess the viewpoints of stakeholders on a wide range of potential nutritional interventions in the five Southeast Asian countries participating in the SMILING project.

Method

MCM methodology was used to appraise the stakeholder’s viewpoints in five countries.

Results

The results show that the overall stakeholders’ preference was for actions already implemented in their country rather than for new, innovative options, even for supplementation. Indirect interventions such like food fortification (except in Indonesia), delayed cord clamping or food-based approaches were generally less favored by the stakeholders. However, the majority of stakeholders agreed that new approaches should be considered and put in place in the future provided that evidence of their impact was demonstrated, that they received adequate technical support for their implementation and their monitoring, and that they will be accompanied by strong advocacy among decision-makers, civil society and beneficiaries.

Conclusions for practice

To conclude, for the introduction of new, innovative strategies to reduce micronutrient deficiencies in South-East Asia, convincing stakeholders appears to be the first hurdle to be taken.

     

Characterization of the consistency of gruels consumed by infants in developing countries: assessment of the Bostwick consistometer and comparison with viscosity measurements and sensory perception

Standardized techniques are still needed to characterize the consistency of gruels for infants in developing countries. The aim of this study was to evaluate the interest of the use of the Bostwick consistometer. Bostwick flow was measured on gruels prepared with different flours, at low or high energy density (i.e. without or with amylase). The range of Bostwick flow, from 0 to 240 mm/30 sec, adequately described a wide range of gruel consistencies from completely liquid to almost solid. However, the temperature of the gruel must be carefully controlled during measurements as Bostwick flow is highly temperature dependent, especially in the case of gruels with high energy density. The relationship between Bostwick flow and apparent viscosity proved to depend on the type of gruel: at an apparent viscosity of 1 Pa.sec, gruels prepared from maize, rice, millet or multicomponent flours had different Bostwick flow values of, respectively, 20, 35, 75 and 55 mm/30 sec. Sensory analysis was then performed with a panel of mothers of infants and young children in Ouagadougou (Burkina Faso). Gruels of similar apparent viscosity and different Bostwick flow distances or of inversely similar Bostwick flow distances and different apparent viscosities were prepared by adding carob seed flour, and differentiation and ranking tests were then carried out. Both types of test revealed that mothers differentiated similar gruels having different Bostwick flow distances more easily than gruels having different apparent viscosities. It can thus be concluded that Bostwick flow, which is an empirical multi-criteria parameter, conveys the sensory perception of gruel consistency better than apparent viscosity.     

Micronutrient intake of children in Ghana and Benin: Estimated contribution of diet and nutrition programs

We estimated how micronutrient needs of young children, aged 6–24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in three age groups (6–8, 9–12, and 13–24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin D and iodine depending on the micronutrient considered. The contribution of mass (bio)-fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin.