Vitamin A-fortified cooking oil reduces vitamin A deficiency in infants, young children and women: results from a programme evaluation in Indonesia.

OBJECTIVE: To assess oil consumption, vitamin A intake and retinol status before and a year after the fortification of unbranded palm oil with retinyl palmitate. DESIGN: Pre-post evaluation between two surveys. SETTING: Twenty-four villages in West Java. SUBJECTS: Poor households were randomly sampled. Serum retinol (adjusted for subclinical infection) was analysed in cross-sectional samples of lactating mothers (baseline n 324/endline n 349), their infants aged 6-11 months (n 318/n 335) and children aged 12-59 months (n 469/477), and cohorts of children aged 5-9 years (n 186) and women aged 15-29 years (n 171), alongside food and oil consumption from dietary recall. RESULTS: Fortified 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 (P<0·001 in infants aged 6-11 months, children aged 5-9 years, lactating and non-lactating women; non-significant in children aged 12-23 months; P=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 (P<0·01). Deficiency prevalence (serum retinol <20 µg/dl) was 6·5-18 % across groups at baseline, and 0·6-6 % at endline (P≤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). CONCLUSIONS: Although 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.

Legal framework for food fortification: examples from Vietnam and Indonesia.

BACKGROUND: Food fortification is a cost-effective, powerful, and sustainable strategy to combat micronutrient deficiency, with the potential to reach large sections of the population with minimal cost and effort. However, the implementation of food fortification on a systematic and large scale, for instance in national programs, has often been challenging. OBJECTIVE: This paper takes a closer look at food fortification efforts and legislation mechanisms in Vietnam and Indonesia in order to determine specific factors and components in the legal framework that are crucial to the success of fortification programs. METHODS: Fortification efforts in Indonesia and Vietnam are evaluated using published data as well as unpublished data from detailed evaluation reports, and compared with respect to the specific circumstances, constraints, objectives and results in each country. RESULTS: The legal framework is a crucial factor for the success of food fortification programs, as it shapes to a large extent the implementation of food fortification. The legal framework is instrumental to ensure the quality, safety, availability, cost-effectiveness, and sustainability of food fortification. In the first place, the legal framework should specify the fortificants and fortification levels, as well as the food vehicles and the fortification procedures. In addition, it should ensure the commitment of policy makers and producers to fortification, regulate the costing, describe and ensure information and communication such as product labeling integrate social marketing into the implementation, and provide the means to monitor and enforce fortification. A clear public health objective, together with careful consideration of the choices and restrictions dictated by the specific national environments, will help to develop legal frameworks that optimize the potential success of food fortification strategies. CONCLUSIONS: The lessons from these experiences show that a mandatory approach to fortification, with costing, monitoring and enforcement, and social marketing clearly defined and well embedded in the legal framework and in the implementation structures, is the best foundation for an effective, sustainable, and feasible food fortification program.

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

BACKGROUND: To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified. OBJECTIVE: Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia. METHODS: Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries. RESULTS: Between 1990-2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation. CONCLUSIONS: In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.

Ready-to-Use Therapeutic Foods (RUTFs) Based on Local Recipes Are as Efficacious and Have a Higher Acceptability than a Standard Peanut-Based RUTF: A Randomized Controlled Trial in Indonesia.

To strengthen community-based treatment of severe acute malnutrition (SAM) in Indonesia, locally produced ready-to-use therapeutic foods (RUTFs) are needed, but data on their acceptability and effectiveness are lacking. We conducted an individually randomized controlled trial in 302 children (6-59 months old) with uncomplicated SAM receiving 8 weeks of a standard RUTF (CON) or one of four alternative RUTFs produced with locally available ingredients: soybean (SOY), mungbean (MUN1, MUN2) or peanuts (PEA). The main outcomes were weight gain and product acceptability. Children consumed on average 2.2 kg of standard RUTF, but up to 4.5 kg of the local products (MUN2, p < 0.05). Mean weight gain did not differ across the groups (p > 0.05). Controlled for consumption, children receiving either CON or SOY RUTF gained >2 g/kg body weight (BW)/day compared with 1.6 g/kg BW/day in children receiving the other RUTF products (p > 0.05). Overall drop-out was 29.1%, ranging from 21.3% (MUN2) to 38.3% (CON, p > 0.05). Mean time to drop out was 19 days in the CON group, significantly shorter than in the PEA group (33.6 days, p < 0.05). Thus, with no difference in weight gain and better acceptance, the development of locally produced RUTFs in Indonesia is warranted to strengthen the community-based treatment of SAM.

Solutions to Enhance Health with Alternative Treatments (SEHAT) protocol: a double-blinded randomised controlled trial for gut microbiota-targeted treatment of severe acute malnutrition using rice bran in ready-to-use therapeutic foods in Indonesia.

INTRODUCTION: Current formulations of ready-to-use therapeutic foods (RUTFs) to treat severe acute malnutrition (SAM) in children focus on nutrient density and quantity. Less attention is given to foods targeting gut microbiota metabolism and mucosal barrier functions. Heat-stabilised rice bran contains essential nutrients, prebiotics, vitamins and unique phytochemicals that have demonstrated favourable bioactivity to modulate gut microbiota composition and mucosal immunity. This study seeks to examine the impact of RUTF with rice bran on the microbiota during SAM treatment, recovery and post-treatment growth outcomes in Jember, Indonesia. Findings are expected to provide insights into rice bran as a novel food ingredient to improve SAM treatment outcomes. METHODS AND ANALYSIS: A total of 200 children aged 6-59 months with uncomplicated SAM (weight-for-height z-scores (WHZ) <-3, or mid-upper arm circumference (MUAC) <115 mm or having bilateral pitting oedema +/++) or approaching SAM (WHZ<-2.5) will be enrolled in a double-blinded, randomised controlled trial. Children in the active control arm will receive a locally produced RUTF; those in the intervention arm will receive the local RUTF with 5% rice bran. Children will receive daily RUTF treatment for 8 weeks and be monitored for 8 weeks of follow-up. Primary outcomes include the effectiveness of RUTF as measured by changes in weight, WHO growth z-scores, MUAC and morbidity. Secondary outcomes include modulation of the gut microbiome and dried blood spot metabolome, the percentage of children recovered at weeks 8 and 12, and malnutrition relapse at week 16. An intention-to-treat analysis will be conducted for each outcome. ETHICS AND DISSEMINATION: The findings of this trial will be submitted to peer-reviewed journals and will be presented at relevant conferences. Ethics approval obtained from the Medical and Health Research Ethical Committee at the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Madain Yogyakarta Ref. No.: KE/FK/0546/EC/2022 and KE/FK/0703/EC/2023 and from Colorado State University IRB#1823, OHRP FWA00000647. TRIAL REGISTRATION NUMBER: NCT05319717.

Fortification of Indonesian unbranded vegetable oil: public-private initiative, from pilot to large scale.

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.

Legislation should support optimal breastfeeding practices and access to low-cost, high-quality complementary foods: Indonesia provides a case study.

It is important to support women to exclusively breastfeed for 6 months and continue breastfeeding for 24 months and beyond. It is also necessary to provide the poor with access to affordable ways to improve the quality of complementary foods. Currently, many countries do not have the legal and policy environment necessary to support exclusive and continued breastfeeding. Legislative and policy changes are also necessary for introducing complementary food supplements, allowing them to be marketed to those who need them, and ensuring that marketing remains appropriate and in full compliance with the International Code of Marketing of Breastmilk Substitutes. This paper aims to illustrate the above with examples from Indonesia and to identify legislative requirements for supporting breastfeeding and enabling appropriate access to high-quality complementary food supplements for children 6-24 months of age. Requirements include improved information, training, monitoring and enforcement systems for the International Code of Marketing of Breastmilk Substitutes; implementation and monitoring of the Baby-Friendly Hospital Initiative; establishment of a registration category for complementary food supplements to enhance availability of high-quality, low-cost fortified products to help improve young child feeding; clear identification and marketing of these products as complementary food supplements for 6-24-month-olds so as to promote proper use and not interfere with breastfeeding.

School Canteens in Selected Areas in Indonesia: A Situation Analysis.

BACKGROUND: The school canteen has a massive impact on the dietary intake and nutritional status of school-age children and adolescents. This study aimed at assessing the current situation of school canteens in selected areas in Indonesia and relevant knowledge, attitudes, and behaviors of school-going children and adolescents. METHODS: A qualitative study was implemented in a purposive sample of 18 schools in Klaten and West Lombok districts with 2 comparison schools in Jakarta and Klaten. Focus group discussions and in-depth interviews were conducted with a wide range of stakeholders to collect information on nutrition knowledge, food preferences, related policies and governance, and opinions toward school canteens. Data were analyzed using thematic synthesis and narrative analysis. RESULTS: Specific government guidelines on healthy foods and beverages to be sold in canteens are not yet in place. Many canteens had inadequate infrastructure and were managed informally, with limited rules, monitoring, and supervision. Although healthy options including vegetables and fruits were available in most canteens, unhealthy foods and beverages were abundant and cheap. Lack of awareness of the importance of nutrition of school-age children and adolescents was pervasive among all stakeholders. Personal preference and availability were main drivers of the students' food choices. CONCLUSIONS: Concerted multisectoral and multistakeholders' efforts are warranted to improve the quality of school canteens in Indonesia by developing a comprehensive relevant guideline, improving the capacity of related stakeholders and service providers, enhancing the implementation and monitoring, and generating demand for healthy canteens.

Strengthening Nutrition-Specific Policies for Adolescents in Indonesia: A Qualitative Policy Analysis.

BACKGROUND: There is a growing recognition of the importance of adolescent health and well-being. Yet, little attention has been paid to adolescent nutrition, and few policies and programs are targeting to improve adolescent nutrition in Indonesia. OBJECTIVE: This analysis aimed to identify (1) the extent to which adolescents are considered in nutrition policy in Indonesia and (2) opportunities to improve nutrition policy content to effectively target adolescents. METHODS: We collected data on policy content through a desk review of national and subnational level nutrition-specific strategic plans, laws, regulations, and program guidelines. We then conducted 74 key informant interviews with policy makers and program experts in health, education, and related sectors using semistructured interview guides based on policy theory to examine policy context and implementation. The policy content and interview data were analyzed using thematic synthesis and narrative analysis. RESULTS: Currently, 2 nutrition-specific policies and programs are designed to improve adolescent nutrition in Indonesia, one focusing on iron-folic acid supplementation for adolescent girls and another on obesity prevention and management in schools. These programs are yet to be implemented at scale. Overall, adolescent nutrition is not yet considered a priority in the national development agenda. An opportunity exists to improve action on adolescent nutrition in Indonesia through scaling up of district-level policies and through improving coordination mechanisms across sectors. CONCLUSIONS: Few policies and programs exist to support adolescent nutrition in Indonesia. Coordinated efforts across relevant sectors and levels of government should be made to mainstream adolescent nutrition into relevant policies.