Search

Micronutrient deficiencies result in irreversible physical and cognitive consequences. Fortification of flour is widely applied to address micronutrient deficiencies, but vitamin losses can occur during the storage of fortified products. This work aimed at assessing the combined influence of different factors on vitamin A retention and the oxidative status of wheat flours: storage duration (up to 6 months), temperature during storage, relative humidity within storage facilities, type of packaging (oxygen-permeable or not), and premix composition (with or without ferrous sulphate). Vitamin A degradation was high and occurred rapidly: more than 45% was lost within 3 months in the mildest conditions, whereas over 85% was lost within 3 months in the most severe conditions. Vitamin A retention was related to the extent of oxidation reactions that occurred in flours during storage, and the factors that mostly affected vitamin A retention were the storage duration, the type of packaging and the temperature.

ObjectiveTo assess oil consumption, vitamin A intake and retinol status before and a year after the fortification of unbranded palm oil with retinyl palmitate.DesignPre–post evaluation between two surveys.SettingTwenty-four villages in West Java.SubjectsPoor households were randomly sampled. Serum retinol (adjusted for subclinical infection) was analysed in cross-sectional samples of lactating mothers (baselinen324/endlinen349), their infants aged 6–11 months (n318/n335) and children aged 12–59 months (n469/477), and cohorts of children aged 5–9 years (n186) and women aged 15–29 years (n171), alongside food and oil consumption from dietary recall.ResultsFortified oil improved vitamin A intakes, contributing on average 26 %, 40 %, 38 %, 29 % and 35 % of the daily Recommended Nutrient Intake for children aged 12–23 months, 24–59 months, 5–9 years, lactating and non-lactating women, respectively. Serum retinol was 2–19 % higher at endline than baseline (PP=0·057 in children aged 24–59 months). Retinol in breast milk averaged 20·5 μg/dl at baseline and 32·5 μg/dl at endline (PP≤0·011). In multivariate regressions adjusting for socio-economic differences, vitamin A intake from fortified oil predicted improved retinol status for children aged 6–59 months (P=0·003) and 5–9 years (P=0·03).ConclusionsAlthough this evaluation without a comparison group cannot prove causality, retinyl contents in oil, Recommended Nutrient Intake contributions and relationships between vitamin intake and serum retinol provide strong plausibility of oil fortification impacting vitamin A status in Indonesian women and children.

ObjectiveTo examine the relationship between homestead food production and night blindness among pre-school children in rural Bangladesh in the presence of a national vitamin A supplementation programme.DesignA cross-sectional study.SettingA population-based sample of six rural divisions of Bangladesh assessed in the Bangladesh Nutrition Surveillance Project 2001–2005.SubjectsA total of 158 898 children aged 12–59 months.ResultsThe prevalence rates of night blindness in children among those who did and did not receive vitamin A capsules in the last 6 months were 0·07 % and 0·13 %, respectively. Given the known effect of vitamin A supplementation on night blindness, the analysis was stratified by children's receipt of vitamin A capsules in the last 6 months. Among children who did not receive vitamin A capsules in the last 6 months, the lack of a home garden was associated with increased odds of night blindness (OR = 3·16, 95 % CI 1·76, 5·68; P = 0·0001). Among children who received vitamin A capsules in the last 6 months, the lack of a home garden was not associated with night blindness (OR = 1·28, 95 % CI 0·71, 2·31; P = 0·4).ConclusionsHomestead food production confers a protective effect against night blindness among pre-school children who missed vitamin A supplementation in rural Bangladesh.

Unbranded palm cooking oil has been fortified for several years and can be found in the market with different oxidation levels. This study aimed to investigate the stability and shelf life of unbranded, bulk, vitamin A-fortified palm oils with the most commonly observed oxidation levels in Indonesia. Three types of cooking oils were tested: (i) cooking oil with a peroxide value (PV) below 2 mEq O2/kg (PO1), (ii) cooking oil with a PV around 4 mEq O2/kg (PO2), and (iii) cooking oil with a PV around 9 mEq O2/kg (PO3). The oil shelf life was determined by using accelerated shelf life testing (ASLT), where the product was stored at 60, 75 and 90 °C, and then PV, free fatty acid and vitamin A concentration in the oil samples were measured. The results showed that PO1 had a shelf life of between 2–3 months, while PO2’s shelf life was a few weeks and PO3’s only a few days. Even given those varying shelf lives, the vitamin A loss in the oils was still acceptable, at around 10%. However, the short shelf life of highly oxidized cooking oil, such as PO3, might negatively impact health, due to the potential increase of free radicals of the lipid peroxidation in the oil. Based on the results, the Indonesian government should prohibit the sale of highly-oxidized cooking oil. In addition, government authorities should promote and endorse the fortification of only cooking oil with low peroxide levels to ensure that fortification is not associated with any health issues associated with high oxidation levels of the cooking oil.

Fortification of staple foods and commonly used condiments with vitamins and minerals has been considered one of the most cost-effective interventions to prevent and control micronutrient deficiencies. Because of its wide local consumption, acceptability, reach, and quantum of consumption, rice (Oryza sativa) far exceeds the requirements of a staple food vehicle that can be considered for fortification purposes at a population-level intervention. The World Health Organization (WHO) has the mandate to develop evidence-informed guidelines for the fortification of staple foods as a public health intervention, including rice fortification with micronutrients. The WHO, in collaboration with the Global Alliance for Improved Nutrition (GAIN), convened a consultation on “Technical Considerations for Rice Fortification in Public Health” in Geneva, Switzerland on October 9–10, 2012 to provide technical inputs to the guideline development process, particularly with reference to feasibility and implementability. The industrial and regulatory technical considerations in rice fortification, as well as the considerations for implementing it as a public health strategy and assuring equitable access and universal coverage, were reviewed in this consultation. This paper summarizes the discussions and priority research areas for the forthcoming years.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. However, it is unknown whether differences in cooking methods or in production of rice premix affect the final amount of micronutrient consumed. This paper presents a study that quantified the losses of five different micronutrients (vitamin A, iron, zinc, folic acid, and vitamin B12) in fortified rice that was produced using three different techniques (hot extrusion, cold extrusion, and coating) during cooking and five different cooking methods (absorption method with or without soaking, washing before cooking, cooking in excess water, and frying rice before cooking). Fortified rice premix from six different producers (two for each technique) was mixed with normal rice in a 1:100 ratio. Each sample was prepared in triplicate, using the five different cooking methods, and retention of iron, zinc, vitamin A, vitamin B12, and folic acid was determined. It was found that the overall retention of iron, zinc, vitamin B12, and folic acid was between 75% and 100% and was unaffected by cooking method, while the retention of vitamin A was significantly affected by cooking method, with retention ranging from 0% (excess water) to 80% (soaking), depending on the cooking method and producer of the rice premix. No systematic differences between the different production methods were observed. We conclude that different cooking methods of rice as used in different regions of the world do not lead to a major loss of most micronutrients, with the exception of vitamin A. The factors involved in protecting vitamin A against losses during cooking need to be identified. All production techniques of rice premix yielded similar results, showing that coating is not inferior to extrusion techniques. Standard overages (50%) for vitamin B12 and folic acid are too high.

Vitamin A deficiency continues to be an international public health problem with several important health consequences including blindness and overall increased rates of morbidity and mortality. To address this widespread issue, a series of strategies have been put into place from dietary diversification to supplementation and fortification programs. Retinyl palmitate has been used successfully for decades as a supplement as well as a way to fortify numerous foods, including vegetable oil, rice, monosodium glutamate, cereal flours and sugar. Recently, there has been rising interest in using a natural source of carotenoids, β-carotene from red palm oil (RPO), for fortification. Although RPO interventions have also been shown to effectively prevent Vitamin A deficiency, there are numerous challenges in using beta-carotene from RPO as a fortification technique. β-Carotene can induce significant changes in appearance and taste of the fortified product. Moreover, costs of fortifying with beta-carotene are higher than with retinyl palmitate. Therefore, RPO should only be used as a source of Vitamin A if it is produced and used in its crude form and regularly consumed without frying. Furthermore, refined RPO should be fortified with retinyl palmitate, not β-carotene, to ensure that there is adequate Vitamin A content.

Background Vitamin D is vital for bone health and has important roles in nonskeletal health and organ function. Most vitamin D is generated in the body by exposure to sunlight, with limited amounts added by the diet. Despite the presence of regular sunshine in Southeast Asia, vitamin D deficiency or insufficiency is being found there more commonly, primarily due to reduction of sunlight exposure as a result of lifestyle changes. Some of these lifestyle changes are unlikely to be reversed, and foods naturally containing vitamin D are not widely consumed, so fortification of foods with vitamin D may raise vitamin D status. Methods The literature database was searched for studies of vitamin D fortification, and we estimated potential vitamin D intakes from fortified vegetable oil. Results Almost all of the studies showed that circulating vitamin D (25-hydroxyvitamin D [(25OHD]) increased in a dose-dependent manner with increased intake of vitamin D–fortified foods. However, in a number of studies the additional intake was insufficient to increase vitamin D levels to 50 nmol/L. Vegetable oil fortified with vitamin D at a level of 10 μg/100 g could provide 3.9% to 21% of the Institute of Medicine Estimated Average Requirement (EAR) of vitamin D for adults in Southeast Asia. Conclusions Fortification of widely consumed foods, such as edible oil, with vitamin D could contribute to improved vitamin D status in Southeast Asian countries. Intake modeling studies should be conducted to calculate the resulting additional intakes, and fortification of additional foods should be considered. More nationally representative studies of vitamin D status in the region are urgently needed.

Background Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake. Objective To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported . Methods Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil. Results Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Average Requirement (EAR) for an Ethiopian woman, 30.9% and 46.9% of the EAR for a Bangladeshi child and woman, respectively, and 17.5% of the EAR for a Cambodian woman. Although concerns about obesity are valid, fortification of existing vegetable oil supplies does not promote overconsumption of oil but rather promotes consumption of vegetable oil of higher nutrient quality. Conclusions Fortifying vegetable oil on a large scale in Malaysia and Indonesia can reach millions of people globally, including children less than 5 years old. The levels of fortification used are far from reaching the Tolerable Upper Intake Level (UL). Vegetable oil fortification has the potential to become a global public health intervention strategy.

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.

The Global Alliance for Improved Nutrition (GAIN) was established in 2002 with a mandate to galvanize efforts by the public and private sectors to end malnutrition. GAIN launched its first large-scale fortification program in 2003, and in less than a decade has scaled its operations to reach more than 600 million people with nutritionally enhanced food. GAIN has evolved considerably as an organization, expanding beyond large-scale food fortification into new program areas, focusing on maternal, infant, and young child nutrition and improvements in agricultural practices to enhance nutrition. This paper describes GAIN's evolution from a large-scale food fortification program focus to a broader nutrition program portfolio directed toward improving access and affordability of nutritious foods for the poor. As GAIN enters its second decade, it continues to respond to the challenges of a changing nutrition landscape by introducing new programs and novel partnerships and by refining its innovative program delivery models.

Background Despite improved economic conditions, vitamin A deficiency remains a public health problem in Indonesia. Objective This paper aims to describe the development of the Indonesian unbranded cooking oil fortification program and to discuss lessons learned to date and future steps necessary for implementation of mandatory, large-scale oil fortification with vitamin A. Methods An historic overview of the steps involved in developing the Indonesian unbranded cooking oil fortification program is given, followed by a discussion of lessons learned and next steps needed. Results Indonesia's low-income groups generally consume unbranded vegetable oil, with an average consumption of approximately 25 g/day. Unbranded oil constitutes approximately 70% of the total oil traded in the country. In 2007–10, a pilot project to fortify unbranded vegetable oil was carried out in Makassar, and an effectiveness study found that the project significantly improved the serum retinol concentrations of schoolchildren. In 2010, the pilot was expanded to two provinces (West Java and North Sumatra) involving the biggest two national refineries. In 2011, a draft national standard for fortified oil was developed, which is currently under review by the National Standard Body and is expected to be mandated nationally in 2013 as announced officially by the Government of Indonesia in national and international meetings. Conclusions Indonesia is a leading world supplier of cooking oil. With stakeholder support, the groundwork has been laid and efforts are moving forward to implement mandatory fortification. This project could encourage Indonesian industry to fortify more edible oils for export, thus expanding their market potential and potentially reducing vitamin A deficiency in the region.

Background Wheat and maize flours are widely used delivery vehicles for mass fortification. In lower-income countries, most, if not all, national-level cereal flour fortification programs routinely fortify with iron; however, cofortification with other micronutrients is common. Little information is available on the cost implications programs face when considering current fortification practices versus what the World Health Organization (WHO) interim consensus statement recommends. Objective The objectives of the present paper are to provide information on the costs of adding different chemical forms of iron and/or other micronutrients to premix formulations, and to discuss some of the issues that should be considered regarding which micronutrients to include in the premix. Methods Nine countries in Latin America, Africa, and Asia (three countries per region) that currently cofortify with multiple micronutrients including iron were selected based on low (< 75 g/day), medium (75 to 149 g/day), and high (≥ 150 g/day) mean population flour consumption levels. Premix costs per metric ton of flour produced were estimated for improving iron formulations and for following WHO recommendations for other micronutrients. Results For the selected programs to maintain current premix formulations and improve iron compounds, premix costs would increase by between 155% and 343% when the iron compound was switched from electrolytic iron to sodium iron ethylenediaminetetraacetate (NaFeEDTA), by 6% to 50% when it was switched from electrolytic iron to ferrous sulfate, and by 4% to 13 when iron addition rates were adjusted without switching the compound. To meet WHO recommendations for other micronutrients, premix costs would increase the most when the amounts of vitamins B12 and A were increased. Conclusions For programs that currently cofortify with iron and additional micronutrients, the quality of the iron fortificant should not be overlooked simply to be able to afford to add more micronutrients to the premix. Micronutrients should be selected according to population needs, costs, and potential beneficial synergistic reactions the added micronutrients may have.

Vitamin and mineral deficiencies are ranked among the top causes of poor health and disability in the world. These deficiencies damage developing brains, impair learning ability, increase susceptibility to infections, and reduce the work productivity of nations. Food fortification is a sustainable, cost-effective approach to reducing vitamin and mineral deficiency. As the staple food for an estimated 3 billion people, rice has the potential to fill an obvious gap in current fortification programs. In recent years, new technologies have produced fortified rice kernels that are efficacious in reducing vitamin and mineral deficiency. There are opportunities to fortify a significant share of rice that comes from large mills supplying centralized markets and national welfare programs in major rice-growing countries. The rice export markets, which handle 30 million MT of rice annually, also present a key fortification opportunity. The cost of fortifying rice is only 1.5% to 3% of the current retail price of rice. Countries that mandate rice fortification have the strongest evidence for achieving wide coverage and impact. The Rice Fortification Resource Group (RiFoRG), a global network of public and private partners that offers technical and advocacy support for rice fortification, has a vision of promoting rice fortification worldwide. It has a targeted approach, engaging multisector partners in key countries where the opportunities are greatest and there is receptivity to early adoption of large-scale rice fortification. The challenges are real, the imperative to address them is powerful, and the opportunities to deliver the promise of rice fortification are clear.

Background Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. Objective To document the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam. Methods Independent end-of-project evaluations conducted for each project served as the primary data source and contain the history of, and project activities undertaken for, each fortification project. Other sources, including national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer-reviewed articles, were used to document the current responses to challenges and future project plans. Results All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects' design to address the challenges faced. Conclusions National fortification projects are dynamic and must be continually modified in response to specific performance issues and broader shifts in market structure and consumption patterns.

BACKGROUND: Many developing countries now face the double burden of malnutrition, defined as the coexistence of a stunted child and overweight mother within the same household. OBJECTIVE: This study sought to estimate the prevalence of the double burden of malnutrition and to identify associated maternal, child, and household characteristics in rural Indonesia and Bangladesh. DESIGN: A total of 247,126 rural households that participated in the Indonesia Nutrition Surveillance System (2000-2003) and 168,317 rural households in the Bangladesh Nutritional Surveillance Project (2003-2006) were included in the analysis. Maternal and child double burden (MCDB) and its association with individual and household characteristics were determined by using logistic regression models. RESULTS: MCDB was observed in 11% and 4% of the households in rural Indonesia and Bangladesh, respectively. Maternal short stature [Indonesia (OR: 2.32; 95% CI: 2.25, 2.40); Bangladesh (OR: 2.11; 95% CI: 1.96, 2.26)], and older age were strong predictors of MCDB. Child characteristics such as older age and being female were associated with an increased odds of MCDB, whereas currently being breastfed was protective against MCDB [Indonesia (OR: 0.84; 95% CI: 0.81, 0.84); Bangladesh (OR: 0.55; 95% CI: 0.52, 0.58)]. A large family size and higher weekly per capita household expenditure predicted MCDB [Indonesia (OR: 1.34; 95% CI: 1.28, 1.40); Bangladesh (OR: 1.94; 95% CI: 1.77, 2.12)]. CONCLUSIONS: Double burden is not exclusive to urban areas. Future policies and interventions should address under- and overweight simultaneously in both rural and urban developing country settings.

Our specific aim was to characterize maternal knowledge of anemia and its relationship to maternal and child anemia and to behaviors related to anemia reduction. We examined the relationship between maternal knowledge of anemia and anemia in the mother and the youngest child, aged 6–59 months, in 7,913 families from urban slums and 37,874 families from rural areas of Indonesia. Knowledge of anemia was defined based upon the mother’s ability to correctly name at least one symptom of anemia and at least one treatment or strategy for reducing anemia. Hemoglobin was measured in both the mother and the child. In urban and rural areas, respectively, 35.8 and 36.9% of mothers had knowledge of anemia, 28.7 and 25.1% of mothers were anemic (hemoglobin

Background Stunting is highly prevalent in developing countries and is associated with greater morbidity and mortality. Micronutrient deficiencies contribute to stunting, and micronutrient-fortified foods are a potential strategy to reduce child stunting. Objective To examine the relationship between the use of fortified powdered milk and noodles and child stunting in a large, population-based sample of Indonesian children. Methods Consumption of fortified milk and fortified noodles was assessed in children 6 to 59 months of age from 222,250 families living in rural areas and 79,940 families living in urban slum areas in Indonesia. Results The proportions of children who consumed fortified milk and fortified noodles were 34.0% and 22.0%, respectively, in rural families, and 42.4% and 48.5%, respectively, in urban families. The prevalence of stunting among children from rural and urban families was 51.8% and 48.8%, respectively. Children from rural and urban families were less likely to be stunted if they consumed fortified milk (in rural areas, OR = 0.87; 95% CI, 0.85 to 0.90; p < .0001; in urban areas, OR = 0.80; 95% CI, 0.76 to 0.85; p < .0001) or fortified noodles (in rural areas, OR = 0.95; 95% CI, 0.91 to 0.99; p = .02; in urban areas, OR = 0.95; 95% CI, 0.91 to 1.01; p = .08) in multiple logistic regression models adjusted for potential confounders. In both rural and urban families, the odds of stunting were lower when a child who consumed fortified milk also consumed fortified noodles, or when a child who consumed fortified noodles also consumed fortified milk. Conclusions The consumption of fortified milk and noodles is associated with decreased odds of stunting among Indonesian children. These findings add to a growing body of evidence regarding the potential benefits of multiple micronutrient fortification on child growth.

To describe risk factors for clustering of anemia among mothers and children in Indonesia.An anemia cluster was defined as hemoglobin12 g/dl in the mother and11 g/dl in the youngest child, aged 6-59 months.Anemia clustering occurred in 4907 (18.3%) of 26 809 urban families and 12 756 (15.5%) of 82 291 rural families. Maternal overweight/obesity, older child age, consumption of fortified milk by the child, use of iodized salt, vitamin A supplementation, paternal smoking and greater expenditure on animal and plant source foods were associated with lower odds of anemia clustering. Older maternal age, maternal underweight, ≥2 children in the family and4 individuals eating from the same kitchen were associated with greater odds of anemia clustering.Fortified milk, iodized salt, vitamin A supplementation and greater expenditure on plant and animal foods are among modifiable risk factors associated with lower risk of anemia clustering in Indonesia.

We characterized the relationship of the presence of an improved latrine with diarrhea and under-five child mortality in Indonesia. The proportion of rural and urban families, respectively, without an improved latrine was 52.1% and 16.2%, with a child with a history of diarrhea in the last 7 days was 8.2% and 9.7%, and with a history of under-five child mortality was 11.1% and 8.5%. Among rural and urban families, respectively, lack of an improved latrine was associated with a child history of diarrhea in the last 7 days (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.18–1.29, P < 0.0001; OR = 1.20, 95% CI = 1.13–1.27, P < 0.0001) and under-five child mortality (OR = 1.29, 95% CI = 1.25–1.31, P < 0.0001; OR = 1.22, 95% CI = 1.12–1.32, P < 0.0001) in separate multivariable logistic regression models adjusting for covariates. The lack of a household improved latrine is associated with diarrhea and under-five child mortality in Indonesia.

Dietary diversity is associated with overall quality and nutrient adequacy of the diet in low-income countries. We determined the association between dietary diversity and stunting among children aged 6–59 months in rural Bangladesh. In total, 165 111 under-fives who participated in the National Surveillance Project in 2003–2005 were included in the analysis. Dietary diversity score (DDS) was constructed through the summation of the number of days each of the nine food groups was consumed in the previous week. The association between stunting and DDS was determined adjusting for confounders using logistic regression models. All analyses were performed separately for children aged 6–11, 12–23 and 24–59 months. One-half of the children were stunted. In multivariate analyses, compared with low DDS, high dietary diversity was associated with a 15, 26 and 31% reduced odds of being stunted among children aged 6–11, 12–23 and 24–59 months, respectively, after adjusting for all potential confounders (odds ratio (OR)=0.85, 95% confidence interval (CI): 0.76–0.94; OR=0.74, 95% CI: 0.69–0.79; OR=0.69, 95% CI: 0.66–0.73). In all groups, children who were still breastfed were more likely to have limited diversity (OR=1.88, 95% CI: 1.32–2.67; OR=1.71, 95% CI: 1.52–1.92; OR=1.15, 95% CI: 1.11–1.19). Those having diarrhea in the past week and coming from families with low socioeconomic status were more likely to have decreased diversity (P

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesia's rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

Vitamin A deficiency (VAD) is a major health problem, particularly in low-resource countries, putting an estimated 125-130 million preschool-aged children at increased risk of morbidity and mortality from infectious diseases. Vitamin A supplementation reduces VAD and increases child survival; it is complemented by fortifying foods with vitamin A. Concern over increased risk of bone fracture associated with vitamin A intakes below the tolerable upper intake level (UL) among populations in affluent countries conflicts with the need to increase intakes in less developed countries, where populations are at greater risk of VAD and intakes are unlikely to reach the UL as diets include fewer foods containing retinol while vitamin A from carotenoids poses no risk of overdose. With the implementation of recently developed risk management tools, vitamin A can be used safely in food fortification, including point-of-use fortification in the context of supplementation among specific target groups in low-resource countries.

Malnutrition is locked in a vicious cycle of increased mortality, poor health, impaired cognitive development, slow physical growth, reduced learning capacity, inferior performance, and ultimately lower adult work performance and productivity. The consensus of global scientific evidence indicates that lowering the rates of malnutrition will be an indispensable component of any successful program to raise the quality of human capital and resources. This study used a “consequence model” to apply the coefficient risk-deficit on economic losses, established in the global scientific literature, to Cambodian health, demographic, and economic data to develop a national estimate of the value of economic losses due to malnutrition. The impact of the indicators of malnutrition analyzed represent a burden to the national economy of Cambodia estimated at 266 million USD annually (1.7% of GDP). Stunting is reducing the Cambodian economic output by more than 120 million USD, and iodine deficiency disorders alone by 57 million USD. This economic burden is too high in view of Cambodia’s efforts to drive economic development. The government should rapidly expand a range of low-cost effective nutrition interventions to break the current cycle of increased mortality, poor health and ultimately lower work performance, productivity, and earnings.

Background Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification levels. Objective To assess the capacity of a portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) to quantify retinyl palmitate in fortified milks, flours (wheat, maize), and sugar. Methods The portable fluorometer was assessed in a three-step procedure to determine its working range and linearity, intra-assay precision, and interperson precision. Measurements were compared with the results obtained by high-performance liquid chromatography (HPLC), commonly regarded as the standard method for vitamin A analysis. Results The portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) precisely determined the vitamin A contents in fortified flours, sugar, and milks. Its working range was 1 to 10, 0.5 to 3.0, and 5 to 15 mg retinol equivalents (RE) kg−1 for flours (wheat and corn), milks, and sugar, respectively; these values are in accordance with the World Health Organization recommendations for food fortification in least developed countries. The limits of detection are higher than those of HPLC but are all satisfactory (< 1.46 mg RE kg−1). The coefficients of variation within and between observers were satisfactory, especially for sugar and milk. Conclusions The linear relationship between the data from the portable fluorometer and the HPLC data confirms that the portable fluorometer provides a good determination of the vitamin A content of the fortified products in the tested range.

Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D-3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3 weeks of storage in dark conditions. After 2 months, the vitamin A and D-3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D-3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.

Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3 weeks of storage in dark conditions. After 2 months, the vitamin A and D3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. However, it is unknown whether differences in cooking methods or in production of rice premix affect the final amount of micronutrient consumed. This paper presents a study that quantified the losses of five different micronutrients (vitamin A, iron, zinc, folic acid, and vitamin B12) in fortified rice that was produced using three different techniques (hot extrusion, cold extrusion, and coating) during cooking and five different cooking methods (absorption method with or without soaking, washing before cooking, cooking in excess water, and frying rice before cooking). Fortified rice premix from six different producers (two for each technique) was mixed with normal rice in a 1:100 ratio. Each sample was prepared in triplicate, using the five different cooking methods, and retention of iron, zinc, vitamin A, vitamin B12, and folic acid was determined. It was found that the overall retention of iron, zinc, vitamin B12, and folic acid was between 75% and 100% and was unaffected by cooking method, while the retention of vitamin A was significantly affected by cooking method, with retention ranging from 0% (excess water) to 80% (soaking), depending on the cooking method and producer of the rice premix. No systematic differences between the different production methods were observed. We conclude that different cooking methods of rice as used in different regions of the world do not lead to a major loss of most micronutrients, with the exception of vitamin A. The factors involved in protecting vitamin A against losses during cooking need to be identified. All production techniques of rice premix yielded similar results, showing that coating is not inferior to extrusion techniques. Standard overages (50%) for vitamin B12 and folic acid are too high.

Background Improving the nutritional status of an emergency-affected population is essential, because undernutrition increases infection risk and is linked to more than 50% of childhood deaths in developing coun- tries. Emergency food aid addresses nutritional needs, including micronutrient deficiencies, but is provided only for a limited time and uses few items, so the needs of specific target groups are often not fully met. Objective To describe the post-tsunami experience with distribution of Vitalita Sprinkles in Aceh and Nias and to analyze the monitoring data gathered for the emergency response. Methods International agencies such as Helen Keller International and partners provided micronutrients in response to the tsunami emergency in Aceh and Nias and to analyze the monitoring data gathered for the emergency response. Results In March and April 2006, the percentage of children aged 6 months to 59 months who had consumed Vitalita in the previous month was more than 70% in 5 of 11 districts evaluated, 40% to 70% in another five districts, and 32% in one district. An independent survey found 25% less anemia among recipients. Almost all mothers interviewed during March to April 2006 (96.3%) had heard about Vitalita and recognized its packaging, 69% said that Vitalita contained vitamins for under-fives, 86% knew the appropriate target group for Vitalita, and 83% said it had to be mixed with solid food. Of the 26% that reported not having given Vitalita to their child in the last month, 90.5% said that their child did not like it. Conclusions and lessons learned Because the prod- uct, including its concept, was new, appropriate infor- mation and training was required as well as a thorough introduction to the beneficiaries, particularly on proper use, to ensure acceptance. This experience demonstrates that providing micronutrients as part of emergency relief and transition programming, as recently recommended by the World Health Organization/UNICEF/World Food Program, is feasible.

Over the past two decades, the definition of poverty has been broadened to include social, economic, environmental, and human development dimensions. In line with this shift of thinking, all countries committed at the 2000 G-8 Summit in Okinawa to achieve the International Development Goals to alleviate poverty by 2015. Development organizations, such as the international development banks, have committed to provide support to countries to reach the International Development Goals, including two goals that specify significant reductions of child and maternal mortality. There is significant evidence that malnutrition, particularly micronutrient malnutrition, contributes to child mortality and growing evidence that malnutrition plays a similar role in maternal mortality. Inadequate dietary intake is an immediate cause of malnutrition, and thus it seems logical that food and agriculture activities could contribute to improvements in nutrition and micronutrient status. Global availability of cereals is adequate, but the rate of undernourishment (inadequate caloric intake) is still high, and child undernutrition still persists in many countries, suggesting that distribution of food is poor. Global availability of noncereal foods, such as animal and horticulture foods, is well below global requirements. Consequently, micronutrient deficiencies, which result mainly from inadequate intake of micronutrient-rich foods, particularly animal foods, are prevalent in most developing countries. Food-based strategies, such as home gardening, small-animal husbandry, poultry, and social marketing, lead to better food production, food consumption, and overall food security. Examining the relative contribution of the determinants of food security—availability, accessibility and consumption/choice—in a given setting provides insight into how the nutrition benefits from food-based strategies, as well as from macro food policies, might be maximized. When implemented in this context, food-based strategies can help countries achieve several of the International Development Goals.

Background Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs. Objective To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia. Methods A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time. Results The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fortification went down significantly compared with prices they would have been offered had they ordered vitamin A individually. In Indonesia, this consolidated procurement approach has allowed a 14.5% decrease in the unit price of vitamin A. Conclusions The GAIN Premix Facility demonstrated its effectiveness in acting as a global procurement platform by aggregating demand across different customers and leveraging improved prices through increased volumes. Building on the success of this effort, the GAIN Premix Facility is replicating this global approach for procurement of other standard items being procured across fortification programs worldwide.

Background The prevalence of micronutrient deficiencies in Cambodia is among the highest in Southeast Asia. Fortification of staple foods and condiments is considered to be one of the most cost-effective strategies for addressing micronutrient deficiencies at the population level. The Government of Cambodia has recognized the importance of food fortification as one strategy for improving the nutrition security of its population. Objective This paper describes efforts under way in Cambodia for the fortification of fish sauce, soy sauce, and vegetable oil. Methods Data were compiled from a stability test of Cambodian fish sauces fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA); analysis of fortified vegetable oils in the Cambodian market; a Knowledge, Attitudes, and Practices (KAP) study of fortified products; and food fortification program monitoring documents. Results At different levels of fortification of fish sauce with NaFeEDTA, sedimentation and precipitation were observed. This was taken into consideration in the government-issued standards for the fortification of fish sauce. All major brands of vegetable oil found in markets at the village and provincial levels are imported, and most are nonfortified. Conclusions Fish sauce, soy sauce, and vegetable oil are widely consumed throughout Cambodia and are readily available in provincial and village markets. Together with an effective regulatory monitoring system, the government can guarantee that these commodities, whether locally produced or imported, are adequately fortified. A communications campaign would be worth-while, once fortified commodities are available, as the KAP study found that Cambodians had a positive perception of fortified sauces.

In July 2011 the Global Alliance for Improved Nutrition (GAIN) and the World Food Programme (WFP) held a symposium to discuss important nutrition issues in the Association of Southeast Asian Nations (ASEAN) countries. With a focus on micronutrient deficiencies and stunting stakeholders ranging from Ministry of Health participants to leaders of local nongovernmental organization elaborated on pressing nutrition issues in the region and debated strategies to tackle the prevalence of malnutrition. The region still faces high prevalence rates of micronutrient deficiencies and stunting despite Southeast Asia’s progress in reducing mortality rates and its economic growth over the past few decades. Failure to achieve recommended daily intakes of at least some micronutrients (most commonly vitamin A iron calcium riboflavin and iodine) is documented by survey data from almost every part of the region. Stunting and micronutrient deficiencies have detrimental impacts on childhood development and morbidity and according to experts the situation is unlikely to drastically improve in the long term due to food supply shortages. In this context health and nutrition interventions need to synchronize with national government policies to reduce malnutrition as well as obesity. The 1000 Day Window of Opportunity Initiative and the Scaling up Nutrition (SUN) movement provide important strategic framework for these kinds of interventions. The role of the private sector is an integral part of the SUN movement to which some ASEAN countries have already signed up. This supplement highlights some of the pressing issues important for nutrition programming and shares highlights and experiences from ongoing programs addressing malnutrition and micronutrient deficiencies. In mirroring the diverse and rapidly changing ASEAN region the topics of the papers range widely from highlighting the problem of stunting to presenting models of more effective food fortification.

Background Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. Objectives To estimate vitamin A losses in oil with different chemical characteristics. Methods Samples of fortified oils with different chemical characteristics were collected from two Egyp- tian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during stor- age to determine losses over time, and peroxide values were determined. Results Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% ( p < .001), respectively. In semidark conditions, the vitamin A losses after 4 weeks in fortified oil B and fortified oil A were significantly different: 26.1% and 0.7% ( p < .001), respectively. In an accelerated storage test, the vitamin A loss in 8 days was 48.3% for fortified oil B and 4.2% for fortified oil A ( p < .001). Conclusions This study shows a significant effect of peroxide level (one indicator of the quality of oil) on the stability of vitamin A, regardless of storage conditions. To optimize and sustain vitamin A levels in fortified oil, governments and industries should minimize the perox- ide level to less than 2 mEq/kg at production.

Introduction In many developing countries including Vietnam, data are lacking on vitamin D and calcium deficiencies whereas those deficiencies can play an important role in the development of bone health and possibly non-communicable diseases. The purpose of this study was to determine the overall prevalence of vitamin D and calcium deficiencies in women and young children and their nutritional related risk factors. Methods A cross-sectional study conducted among 595 women of reproductive age and 532 children

BACKGROUND: The 2000 Vietnamese National Nutrition Survey showed that the population's dietary intake had improved since 1987. However, inequalities were found in food consumption between socioeconomic groups. As no national data exist on the prevalence of micronutrient deficiencies, a survey was conducted in 2010 to assess the micronutrient status of randomly selected 1526 women of reproductive age and 586 children aged 6-75 mo. PRINCIPAL FINDINGS: In women, according to international thresholds, prevalence of zinc deficiency (ZnD, 67.2 ± 2.6%) and vitamin B12 deficiency (11.7 ± 1.7%) represented public health problems, whereas prevalence of anemia (11.6 ± 1.0%) and iron deficiency (ID, 13.7 ± 1.1%) were considered low, and folate (

Targeted fortification programs for infants and young children are an effective strategy to prevent micronutrient deficiencies in developing countries, but the role of large-scale fortification of staple foods and condiments is less clear. Dietary modeling in children aged 6–60 months was undertaken, based on food consumption patterns described in the 2009 national food consumption survey, using a 24-h recall method. Consumption data showed that the median intake of a child for iron, vitamin A and zinc, as a proportion of the Vietnamese Recommended Dietary Allowance (VRDA), is respectively 16%–48%, 14%–49% and 36%–46%, (depending on the age group). Potential fortification vehicles, such as rice, fish/soy sauces and vegetable oil are consumed daily in significant amounts (median: 170 g/capita/day, 4 g/capita/day and 6 g/capita/day, respectively) by over 40% of the children. Vegetable oil fortification could contribute to an additional vitamin A intake of 21%–24% of VRDA recommended nutrient intake, while fortified rice could support the intakes of all the other micronutrients (14%–61% for iron, 4%–11% for zinc and 33%–49% of folate requirements). Other food vehicles, such as wheat flour, which is consumed by 16% of children, could also contribute to efforts to increase micronutrient intakes, although little impact on the prevalence of micronutrient deficiencies can be expected if used alone. The modeling suggests that fortification of vegetable oil, rice and sauces would be an effective strategy to address micronutrient gaps and deficiencies in young children.

Large-scale, forti cation, micronutrients, nutrition, program experiences.Despite improvements in a range of other indicators of global development [1],* progress in reducing malnu-trition has been slow, leaving over 2 billion people suf-fering from different forms of malnutrition.** Children and women of reproductive age, especially pregnant and lactating women, are most often affected, with children bearing the burden of irreversible damage to their development. Malnutrition statistics, to cite a few of them, are alarming: » Close to 1 billion people are undernourished, meaning that one out of seven people does not get enough food to be healthy and lead an active life [2]; » Undernutrition accounts for 11% of the global burden of disease and is the number one risk to health worldwide [3]; » Adults who were malnourished during childhood

Food insecurity is common in developing countries and related to the physical well being of families. Household food insecurity is intended to reflect a household's access, availability, and utilization of food. The relationship between paternal smoking and household food insecurity has not been well characterized. The objective of this study was to examine the relationship of paternal smoking with household food insecurity among poor families in rural Indonesia. In a cross-sectional study of 26,380 rural households in the Indonesian Nutrition Surveillance System in 2003, we examined the relationship between paternal smoking and household food insecurity score, as measured using a 9-item food security questionnaire. The prevalence of paternal smoking was 72.9%. In families with and without a father who smoked, the mean (standard error) household food insecurity score was 1.83 (0.01) and 1.48 (0.02), respectively (p0.0001). Paternal smoking was associated with greater household food insecurity score (p0.0001) in a multivariable linear regression model, adjusting for maternal age, maternal education, weekly household expenditure per capita, and province. Among poor families in rural Indonesia, households with a father who smokes are at greater risk of household food insecurity.