Comparing two simplified questionnaire-based methods with 24-h recalls for estimating fortifiable wheat flour and oil consumption in Mandaluyong City, Philippines.

Information on fortifiable food consumption is essential to design, monitor and evaluate fortification programmes, yet detailed methods like 24-h recalls (24HRs) that provide such data are rarely conducted. Simplified questionnaire-based methods exist but their validity compared with 24HRs has not been shown. We compared two simplified methods (i.e., a household food acquisition and purchase questionnaire [FAPQ] and a 7-day semiquantitative food frequency questionnaire [SQ-FFQ]) against 24HRs for estimating fortifiable food consumption. We assessed the consumption of fortifiable wheat flour and oil using a FAPQ and, for wheat flour only, a 7-day SQ-FFQ and compared the results against 24HRs. The participants included children 12-18 months (n = 123) and their mothers 18-49 years selected for a study assessing child vitamin A intake and status in Mandaluyong City, Philippines. For fortifiable wheat flour, the FAPQ estimated considerably lower mean intakes compared to 24HRs for children and mothers (2.2 vs. 14.1 g/day and 5.1 vs. 42.3 g/day, respectively), while the SQ-FFQ estimated slightly higher mean intakes (15.7 vs. 14.1 g/day and 51.5 vs. 42.3 g/day, respectively). For fortifiable oil, the FAPQ estimated considerably higher mean intakes compared to 24HRs for children and mothers (4.6 vs. 1.8 g/day and 12.5 vs. 6.1 g/day, respectively). The SQ-FFQ, but not the FAPQ, generated useful information on fortifiable food consumption that can inform fortification programme design and monitoring decisions in the absence of more detailed individual-level data. Potential adaptations to improve the FAPQ, such as additional questions on foods prepared away from home and usage patterns, merit further research.

Consumption of Micronutrient Powder, Syrup or Fortified Food Significantly Improves Zinc and Iron Status in Young Mexican Children: A Cluster Randomized Trial.

The objective of this study was to compare the effect of three micronutrient products on biomarkers of iron and zinc status of Mexican children 6−12 months of age. As part of research to improve the impact of a national program, 54 communities were randomly assigned to receive: (1) fortified food (FF), provided by the program at the time, or (2) micronutrient powders (MNP) or (3) syrup. Each product contained 10 mg each of zinc and iron, plus other micronutrients. Children consumed the product 6 days/week for four months. Primary outcomes were changes in serum zinc, ferritin, soluble transferrin receptor, hemoglobin concentrations, and their deficiencies. Zinc concentration increased significantly from baseline to follow-up in all groups, with the largest change in the syrup group (geometric mean difference: +4.4 µmol/L; 95%CI: 3.2, 5.5), followed by MNP (+2.9 µmol/L; 95%CI: 2.1, 3.6) and FF (+0.9 µmol/L; 95%CI: 0.3, 1.6). There was a significant increase in hemoglobin concentration (+5.5 g/L; 2.5, 8.4) and a significant reduction in anemia prevalence (44.2% to 26.8%, p < 0.01) only in the MNP group. Compliance differed significantly among groups (MNP vs. FF, p = 0.04; MNP vs. syrup, p = 0.04), but may not fully explain the greater improvement in zinc and iron status in the syrup and MNP groups. The food matrix may influence nutrient utilization from supplements.

Critical assessment of the current indicator for antenatal iron-containing supplementation coverage: Insights from a mixed-methods study.

Daily consumption of iron-containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron-containing supplement consumption is questionable. The WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron-containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron-containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron-containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%-75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron-containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Vitamin A Fortification Quality Is High for Packaged and Branded Edible Oil but Low for Oil Sold in Unbranded, Loose Form: Findings from a Market Assessment in Bangladesh.

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

Can Double Fortification of Salt with Iron and Iodine Reduce Anemia, Iron Deficiency Anemia, Iron Deficiency, Iodine Deficiency, and Functional Outcomes? Evidence of Efficacy, Effectiveness, and Safety.

BACKGROUND: Anemia, iron deficiency, and iodine deficiency are problems of important public health concern in many parts of the world, with consequences for the health, development, and work capacity of populations. Several countries are beginning to implement double fortified salt (DFS) programs to simultaneously address iodine and iron deficiencies. OBJECTIVE: Our objective was to summarize the evidence for efficacy and effectiveness of DFS on the full range of status and functional outcomes and across different implementation and evaluation designs essential to successful interventions. METHODS: We conducted a systematic review and meta-analysis of published and gray literature examining the effects of DFS on nutritional status, cognition, work productivity, development, and morbidity of all population groups. We searched for articles in Medline, Embase, CINAHL, Cochrane Central Register, and ProQuest for randomized trials, quasi-randomized trials, and program effectiveness evaluations. RESULTS: A total of 22 studies (N individuals = 52,758) were included. Efficacy studies indicated a significant overall positive effect on hemoglobin concentration [standardized mean difference (95% CI): 0.33 (0.18, 0.48)], ferritin [0.42 (0.08, 0.76)], anemia [risk ratio (95% CI): 0.80 (0.70, 0.92)], and iron deficiency anemia [0.36 (0.24, 0.55)]. Effects on urinary iodine concentration were not significantly different between DFS and iodized salt. The impact on functional outcomes was mixed. Only 2 effectiveness studies were identified. They reported programmatic challenges including low coverage, suboptimal DFS quality, and storage constraints. CONCLUSIONS: Given the biological benefits of DFS across several populations in efficacy research, additional evaluations of robust DFS programs delivered at scale, which consider effective implementation and measure appropriate biomarkers, are needed.

Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries.

BACKGROUND: Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified. OBJECTIVES: We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA). METHODS: In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI). RESULTS: Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda. CONCLUSIONS: Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.

Household coverage of vitamin A fortification of edible oil in Bangladesh.

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis.

BACKGROUND: Micronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts. OBJECTIVES: The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs. METHODS: All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs. RESULTS: LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential. CONCLUSIONS: Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.

Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries.

Background: Large-scale food fortification (LSFF) of commonly consumed food vehicles is widely implemented in low- and middle-income countries. Many programs have monitoring information gaps and most countries fail to assess program coverage.Objective: The aim of this work was to present LSFF coverage survey findings (overall and in vulnerable populations) from 18 programs (7 wheat flour, 4 maize flour, and 7 edible oil programs) conducted in 8 countries between 2013 and 2015.Methods: A Fortification Assessment Coverage Toolkit (FACT) was developed to standardize the assessments. Three indicators were used to assess the relations between coverage and vulnerability: 1) poverty, 2) poor dietary diversity, and 3) rural residence. Three measures of coverage were assessed: 1) consumption of the vehicle, 2) consumption of a fortifiable vehicle, and 3) consumption of a fortified vehicle. Individual program performance was assessed based on the following: 1) achieving overall coverage ≥50%, 2) achieving coverage of ≥75% in ≥1 vulnerable group, and 3) achieving equity in coverage for ≥1 vulnerable group.Results: Coverage varied widely by food vehicle and country. Only 2 of the 18 LSFF programs assessed met all 3 program performance criteria. The 2 main program bottlenecks were a poor choice of vehicle and failure to fortify a fortifiable vehicle (i.e., absence of fortification).Conclusions: The results highlight the importance of sound program design and routine monitoring and evaluation. There is strong evidence of the impact and cost-effectiveness of LSFF; however, impact can only be achieved when the necessary activities and processes during program design and implementation are followed. The FACT approach fills an important gap in the availability of standardized tools. The LSFF programs assessed here need to be re-evaluated to determine whether to further invest in the programs, whether other vehicles are appropriate, and whether other approaches are needed.

Neither Preconceptional Weekly Multiple Micronutrient nor Iron-Folic Acid Supplements Affect Birth Size and Gestational Age Compared with a Folic Acid Supplement Alone in Rural Vietnamese Women: A Randomized Controlled Trial.

BACKGROUND: Maternal nutritional status before and during early pregnancy plays a critical role in fetal growth and development. The benefits of periconception folic acid (FA) supplementation in the prevention of neural tube defects is well recognized, but the evidence for preconception micronutrient interventions for improving pregnancy outcomes is limited. OBJECTIVE: This study aimed to evaluate whether preconception supplementation with weekly iron and folic acid (IFA) or multiple micronutrients (MMs) improves birth outcomes compared with FA alone. METHODS: We recruited 5011 women of reproductive age in a double-blind, randomized controlled trial in Vietnam and provided weekly supplements containing either 2800 µg FA, 60 mg Fe and 2800 µg FA (IFA), or the same amount of FA and iron plus other MMs until they conceived (n = 1813). All pregnant women received daily IFA through delivery, and were followed up for birth outcomes, including birth weight, gestational age, preterm delivery and small for gestational age (SGA). Group comparisons were done with the use of ANOVA or chi-square tests for both intention-to-treat (n = 1599) and per-protocol analyses (women consumed supplements ≥26 wk before conception; n = 824). Effect modification by baseline underweight or anemia status was tested with the use of generalized linear models. RESULTS: The mean age of the women was 26 y, 30% were underweight, and <10% were nulliparous. The groups were similar for most baseline characteristics. The mean ± SD duration of the preconception intervention was 33 ± 25 wk and compliance was high (>90%). Infants born to the 3 groups of women did not differ (P ≥ 0.05) on mean ± SD birth weight (3076.8 ± 444.5 g) or gestational age (39.2 ± 2.0 wk), or prevalence of SGA (12%), low birth weight (5%) and preterm delivery (10%). There were no significant differences in women who consumed supplements ≥26 wk before conception or by baseline underweight or anemia. CONCLUSION: Weekly supplementation with MMs or IFA before conception did not affect birth outcomes compared with FA in rural Vietnamese women. The trial was registered at clinicaltrials.gov as NCT01665378.

Complementary Feeding Diets Made of Local Foods Can Be Optimized, but Additional Interventions Will Be Needed to Meet Iron and Zinc Requirements in 6- to 23-Month-Old Children in Low- and Middle-Income Countries.

BACKGROUND: The question whether diets composed of local foods can meet recommended nutrient intakes in children aged 6 to 23 months living in low- and middle-income countries is contested. OBJECTIVE: To review evidence of studies evaluating whether (1) macro- and micronutrient requirements of children aged 6 to 23 months from low- and middle-income countries are met by the consumption of locally available foods ("observed intake") and (2) nutrient requirements can be met when the use of local foods is optimized, using modeling techniques ("modeled intake"). METHODS: Twenty-three articles were included after conducting a systematic literature search. To allow for comparisons between studies, findings of 15 observed intake studies were compared against their contribution to a standardized recommended nutrient intake from complementary foods. For studies with data on intake distribution, %< estimated average requirements were calculated. RESULTS: Data from the observed intake studies indicate that children aged 6 to 23 months meet requirements of protein, while diets are inadequate in calcium, iron, and zinc. Also for energy, vitamin A, thiamin, riboflavin, niacin, folate, and vitamin C, children did not always fulfill their requirements. Very few studies reported on vitamin B6, B12, and magnesium, and no conclusions can be drawn for these nutrients. When diets are optimized using modeling techniques, most of these nutrient requirements can be met, with the exception of iron and zinc and in some settings calcium, folate, and B vitamins. CONCLUSION: Our findings suggest that optimizing the use of local foods in diets of children aged 6 to 23 months can improve nutrient intakes; however, additional cost-effective strategies are needed to ensure adequate intakes of iron and zinc.

Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions.

Paramount among the challenges to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance. The Integration to Effective Implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the food and nutrition enterprise. The 2014 Micronutrient Forum (MNF) Global Conference held in Addis Ababa, Ethiopia, in June 2014 offered the opportunity to apply the I-to-I approach with the use of current concerns about the safety and effectiveness of interventions to prevent and treat iron deficiency (ID) as a case study. ID is associated with a range of adverse outcomes, especially in pregnant and nonpregnant women, infants, and primary school-age children. Strategies to combat ID include iron supplementation, multiple micronutrient powders, and food-based interventions to enhance dietary iron intake. Recent reports indicate potential increased adverse risks when iron is provided in areas with high infection burdens (e.g., malaria). This paradox has weakened iron intervention programs. Furthermore, the selection and interpretation of available biomarkers for assessing iron nutrition have been found to be compromised by the inflammatory process. These issues highlight the need for a comprehensive approach that considers basic biology, assessment, interventions, and how these can be translated into appropriate programs and policies. The application of the I-to-I with the use of the MNF offered an opportunity to explore how that might be achieved.

The Associations of Maternal Weight Change with Breastfeeding, Diet and Physical Activity During the Postpartum Period.

OBJECTIVE: To determine the association between breastfeeding practices, diet and physical activity and maternal postpartum weight. METHODS: This was a secondary data analysis of a randomized community trial on beneficiaries of the Programa de Desarrollo Humano Oportunidades, recently renamed Prospera (n = 314 pregnant women), without any diseases that could affect body weight. Generalized estimating equations were used to determine the association between postpartum weight change and changes in diet, physical activity and type of breastfeeding. RESULTS: The mean postpartum weight change from the first to the third month was 0.6 ± 2.2 kg. Women who breastfed exclusively for 3 months had a 4.1 (SE = 1.9) kg weight reduction in comparison with women who did not provide exclusive breastfeeding or who discontinued breastfeeding before 3 months (p = 0.04). There was no association between postpartum weight change and physical activity (p = 0.24) or energy intake (p = 0.06). CONCLUSIONS: Exclusive breastfeeding was associated with maternal postpartum weight reduction. These results reinforce the World Health Organization recommendation of exclusive breastfeeding during the first 6 months of life in order to reduce the risk of weight retention or weight gain in postpartum women. It has been well established that exclusive breastfeeding is beneficial for both infants and mothers, but promoting breastfeeding as a strategy to promote postpartum weight loss is of paramount importance, especially in countries like Mexico where excessive weight in women of reproductive age is a public health problem.

Need for coordinated programs to improve global health by optimizing salt and iodine intake / Necesidad de programas coordinados para mejorar la salud a escala mundial mediante la optimización de la ingesta de sal y yodo

High dietary salt is a major cause of increased blood pressure, the leading risk for death worldwide. The World Health Organization (WHO) has recommended that salt intake be less than 5 g/day, a goal that only a small proportion of people achieve. Iodine deficiency can cause cognitive and motor impairment and, if severe, hypothyroidism with serious mental and growth retardation. More than 2 billion people worldwide are at risk of iodine deficiency. Preventing iodine deficiency by using salt fortified with iodine is a major global public health success. Programs to reduce dietary salt are technically compatible with programs to prevent iodine deficiency through salt fortification. However, for populations to fully benefit from optimum intake of salt and iodine, the programs must be integrated. This review summarizes the scientific basis for salt reduction and iodine fortification programs, the compatibility of the programs, and the steps that need to be taken by the WHO, national governments, and nongovernmental organizations to ensure that populations fully benefit from optimal intake of salt and iodine. Specifically, expert groups must be convened to help countries implement integrated programs and context-specific case studies of successfully integrated programs; lessons learned need to be compiled and disseminated. Integrated surveillance programs will be more efficient and will enhance current efforts to optimize intake of iodine and salt. For populations to fully benefit, governments need to place a high priority on integrating these two important public health programs.

El alto contenido de sal en la dieta es una causa principal de incremento de la presión arterial, el principal factor de riesgo de muerte a escala mundial. La Organización Mundial de la Salud (OMS) ha recomendado que el consumo de sal sea inferior a 5 g/d, una meta que solo logran una pequeña proporción de personas. La falta de yodo puede causar deficiencia cognoscitiva y motora y, si es grave, hipotiroidismo, con grave retraso mental y del crecimiento. Más de dos mil millones de personas en todo el mundo presentan riesgo de carencia de yodo. La prevención de la carencia de yodo mediante el empleo de sal yodada constituye una importante conquista de salud pública a escala mundial. Los programas cuyo objeto es reducir el contenido de sal en la dieta son técnicamente compatibles con los programas de prevención de la carencia de yodo mediante el enriquecimiento de la sal. Sin embargo, para que las poblaciones se puedan beneficiar plenamente de una ingesta óptima de sal y yodo, es preciso integrar ambos tipos de programa. Este estudio resume las bases científicas de los programas de reducción de sal y enriquecimiento con yodo, la compatibilidad de esos programas, y las medidas que deben adoptar la OMS, los gobiernos nacionales y las organizaciones no gubernamentales para garantizar que las poblaciones se beneficien plenamente de una ingesta óptima de sal y yodo. En concreto, es preciso reunir a grupos de expertos para ayudar a los países a aplicar programas integrados y llevar a cabo estudios de casos en contextos específicos de programas integrados eficaces; es preciso recopilar y difundir las enseñanzas extraídas. La integración de los programas de vigilancia los hará más eficaces y mejorará las iniciativas actuales para optimizar la ingesta de yodo y sal. Para que las poblaciones puedan beneficiarse plenamente, es preciso que los gobiernos asignen una alta prioridad a la integración de estos dos importantes tipos de programas de salud pública.

Iron deficiency and anemia control for infants and young children in malaria-endemic areas: a call to action and consensus among the research community.

WHO recommendations on iron supplementation for infants and young children in malaria-endemic areas changed dramatically from universal to targeted supplementation for iron-deficient children only, after a trial in a high malaria transmission area showed an increased risk of hospital admission and mortality among iron-replete children following iron and folic acid supplementation. Since this time, there has been much debate and little agreement among the nutrition research community on how to move forward, and country policy and program decision makers have been left with incomplete guidance on how to address young child iron deficiency and anemia in their countries. The focus of a recent symposium during the American Society for Nutrition annual meeting, held in Washington, DC, in April 2011, was on exploring options for addressing iron deficiency and anemia among infants and young children in malaria-endemic areas, now, with safe, effective, and feasible interventions that provide iron. Papers based on the invited presentations are included in this supplement. The first paper is a review of the relationship between iron and malaria. The second is an analysis of theoretical and practical considerations regarding the targeted approach of providing iron and includes results from field testing noninvasive screening devices. This is followed by a review of the safety of universal provision of iron through home-fortification products in malaria-endemic areas. The final papers provide a call to action by highlighting pending research issues (fourth paper) and feasible strategies to move programs forward (fifth paper).

Estimating the prevalence of iron deficiency in the first two years of life: technical and measurement issues.

National-level data on iron deficiency is not available for most countries and many rely on the prevalence of anemia as a proxy estimate, assuming that approximately 50% of anemia cases are caused by iron deficiency. Anemia, however, has multiple causal factors and the risk attributable to any one cause will depend on its relative importance in a population in relation to other causes. The present review summarizes current estimates on the prevalence of iron deficiency and anemia in children younger than 2 years and evaluates the strengths and weaknesses of currently available indicators of iron deficiency in children. Anemia prevalence is insufficient to estimate the prevalence of iron deficiency in children younger than 2 years. The methods widely used to assess iron deficiency at the population level rely on venous blood samples and are complicated and costly to implement.

Prenatal multiple micronutrient supplementation impact on biochemical indicators during pregnancy and postpartum / Efecto de la suplementación prenatal con micronutrimentos múltiples en indicadores bioquímicos durante el embarazo y el posparto

Objective. The objective of this analysis was to test the impact of daily supplementation with multiple micronutrients (MM) during pregnancy on Zn, vitamin A and folate status compared to iron only (Fe). Material and Methods. The study was carried out during 1997-2000 in a semi-urban community in Morelos state, Mexico. Women were randomly assigned to MM (n= 249) or Fe (n= 258) and received supplements daily (6 d/wk) under supervision by the field team from recruitment (approximately 9 weeks pregnancy) until delivery. Blood samples were collected on a sub-sample of women at baseline, 32 weeks pregnancy and one month postpartum (1PP) and assessed for serum zinc, retinol and whole blood folate (baseline and 1PP only). A breast milk sample was extracted at 1PP and assessed for retinol content. Result. At baseline there was no significant difference between supplementation groups in mean Zn, retinol or folate concentrations or the prevalence of deficiencies (Zn 12.2%, vitamin A 2.8%, folate 5.3%). Mean change in Zn and retinol concentrations from baseline to 32 weeks pregnancy did not differ between groups or between baseline and 1PP for Zn, retinol or folate. At 1PP, there was a tendency (p= 0.09) towards a lower prevalence of folate deficiency/depletion in the MM group (10.0%) than the Fe group (18.5%). Conclusions. MM supplementation during pregnancy did not improve zinc or vitamin A status compared to Fe only. There is some indication that folate status may have improved with MM supplementation despite low prevalence of deficiency. While lack of response in serum retinol may be explained by generally adequate status, the lack of impact on zinc status requires further exploration.

Objetivo. Evaluar el efecto de la suplementación diaria con múltiples micronutrimentos (MM) durante el embarazo en el estado de zinc, vitamina A y folato comparado con la suplementación sólo con hierro (Fe). Material y métodos. El estudio se realizó en una comunidad semiurbana en el estado de Morelos, México, entre 1997 y 2000. Las mujeres fueron asignadas aleatoriamente a recibir un suplemento de MM (n= 249) o Fe (n= 258) diariamente (6 días/semana), cuyo consumo fue supervisado por personal de campo, desde la evaluación basal (aproximadamente 9 semanas de gestación) hasta el parto. En una submuestra de mujeres participantes, se tomaron muestras de sangre venosa, a las 9 y 32 semanas de embarazo y al mes posparto (1PP). Se midieron las concentraciones séricas de zinc y retinol y la concentración de folato en sangre total, esta última sólo en la evaluación basal y al 1PP. Además se colectó una muestra de leche materna al 1PP, en donde se midió la concentración de retinol. Resultados. En la evaluación basal no hubo diferencias significativas entre grupos en las concentraciones promedio de zinc y retinol, ni en la concentración de folato o en la prevalencia de deficiencias (Zn 12.2%, vitamina A 2.8%, folato 5.3%). El cambio promedio en zinc y retinol de la evaluación basal a la semana 32 de embarazo, no fue diferente entre grupos, tampoco entre la evaluación basal y al 1PP en zinc, retinol o folato. Al 1PP hubo una tendencia (p= 0.09) a menor prevalencia de deficiencia/depleción de folato en el grupo de MM (10.0%) que en el grupo Fe (18.5%). Conclusiones. La suplementación con MM durante el embarazo no mejoró el estado de zinc y vitamina A comparada con la suplementación sólo con Fe. Sin embargo, el estado de folato puede haber mejorado con la suplementación con MM, a pesar de la baja prevalencia de deficiencia de folato. La falta de efecto...

Improving enrollment and utilization of the Oportunidades program in Mexico could increase its effectiveness.

Oportunidades, Mexico's most important antipoverty program, currently with 5 million enrolled households in all regions of the country, has been shown to significantly contribute to improving the nutrition, health, and education of the poor. Because the program has used different enrollment strategies in rural and urban areas and has both obligatory (e.g., health and nutrition education) and nonobligatory components (e.g., nutrition supplements for children younger than 2 y of age), it provides an excellent opportunity to study program enrollment and utilization of different program components. In urban areas enrollment was more complex, and hence enrollment was much lower then in rural areas where the process was quasiautomatic, and nearly all eligible households enrolled. Enrollment in urban areas was not associated with having a child younger than 2 y of age. Utilization was notably higher with the obligatory than with the nonobligatory program components, illustrated by the inadequate consumption of the nutrition program's supplement as compared with near-universal compliance with well-baby visits. Innovative approaches, some of which are currently being tested, are needed to further increase the program's impact.

Multiple micronutrient supplementation and dietary energy intake in pregnant women

OBJECTIVE: To compare dietary intake of women supplemented with multiple micronutrients (MM) or iron only during pregnancy. MATERIALS AND METHODS: Design: Randomized, double-blind, controlled community-based trial. Setting: One semi-urban community in Central Mexico. Subjects: Pregnant women identified before week 13 of pregnancy, willing to provide informed consent. Interventions: Women were randomly assigned to receive daily supplementation with MM or iron only from recruitment until delivery. Supplements were delivered to the participants' home and compliance observed daily. Dietary intake was assessed by repeat 24-hr recall. Data were analyzed using non-parametric tests and multiple regression analysis to determine the impact of MM supplementation on dietary intake of energy and select micronutrients. RESULTS: During the third trimester, women in the MM group consumed more energy and iron from dietary sources than women in the iron only group. After adjustment for differences between the groups at baseline, women in the MM group consumed 111.3 kcal/day more (p<0.05) energy. The difference in iron intake was not significant after adjusting for the increase in energy intake. CONCLUSIONS: Women consuming MM supplements during pregnancy increased energy intake from dietary sources without a concurrent increase in micronutrient density. Future studies should include measures of appetite and physical activity during pregnancy to determine the implications of additional energy intake for weight gain and retention.

OBJETIVO: Comparar la dieta de mujeres suplementada con múltiples micronutrimentos (MM) o sólo con hierro durante el embarazo. MATERIAL Y MÉTODOS: Diseño: ensayo comunitario, aleatorizado, controlado, doble ciego. Lugar: una comunidad semiurbana en el México central. Participantes: mujeres embarazadas identificadas antes de la semana 13 de embarazo, dispuestas a entregar el consentimiento informado. Actividades: las mujeres fueron asignadas en forma aleatoria a recibir suplementación diaria con MM o exclusivamente hierro desde el reclutamiento hasta el parto. Los suplementos se entregaron en la casa de las participantes y se observó su cumplimiento con frecuencia diaria. El consumo dietético fue valorado por mediciones repetidas de recordatorio de alimentos de 24 h. Los datos se analizaron mediante pruebas no paramétricas y análisis de regresión múltiple, para determinar el impacto de la suplementación MM en el consumo dietético de energía y micronutrimentos seleccionados. RESULTADOS: durante el tercer trimestre, la mujer asignada al grupo MM consumió más energía y hierro de fuentes dietéticas que la mujer asignada al grupo de sólo hierro. Después de los ajustes para las diferencias entre grupos en la línea basal, la mujer del grupo MM consumió 111.3 kcal/día más (p< 0.05) de energía. La diferencia en el consumo de hierro no fue significante después de los ajustes para el incremento en el consumo de energía. CONCLUSIONES: la mujer que consume suplementos MM durante el embarazo aumenta el consumo de energía a partir de fuentes dietéticas sin un incremento concurrente en la densidad de micronutrimentos. Estudios futuros deberían incluir mediciones del apetito y de la actividad física durante el embarazo para determinar las consecuencias del consumo de energía adicional en la ganancia de peso y la retención.