The Potential Impact of Climate Change on the Micronutrient-Rich Food Supply.

Micronutrient deficiencies are a major cause of morbidity and mortality in low- and middle-income countries worldwide. Climate change, characterized by increasing global surface temperatures and alterations in rainfall, has the capacity to affect the quality and accessibility of micronutrient-rich foods. The goals of this review are to summarize the potential effects of climate change and its consequences on agricultural yield and micronutrient quality, primarily zinc, iron, and vitamin A, of plant foods and upon the availability of animal foods, to discuss the implications for micronutrient deficiencies in the future, and to present possible mitigation and adaptive strategies. In general, the combination of increasing atmospheric carbon dioxide and rising temperature is predicted to reduce the overall yield of major staple crops, fruits, vegetables, and nuts, more than altering their micronutrient content. Crop yield is also reduced by elevated ground-level ozone and increased extreme weather events. Pollinator loss is expected to reduce the yield of many pollinator-dependent crops such as fruits, vegetables, and nuts. Sea-level rise resulting from melting of ice sheets and glaciers is predicted to result in coastal inundation, salt intrusion, and loss of coral reefs and mangrove forests, with an adverse impact upon coastal rice production and coastal fisheries. Global ocean fisheries catch is predicted to decline because of ocean warming and declining oxygen. Freshwater warming is also expected to alter ecosystems and reduce inland fisheries catch. In addition to limiting greenhouse gas production, adaptive strategies include postharvest fortification of foods; micronutrient supplementation; biofortification of staple crops with zinc and iron; plant breeding or genetic approaches to increase zinc, iron, and provitamin A carotenoid content of plant foods; and developing staple crops that are tolerant of abiotic stressors such as elevated carbon dioxide, elevated temperature, and increased soil salinity.

Adherence to HIV and TB care and treatment, the role of food security and nutrition.

Food security and nutrition play an important role in HIV and TB care and treatment, including for improving treatment outcomes, adherence and uptake of HIV and TB care. This AIDS and behaviour supplement on "Adherence to HIV and TB care and treatment, the role of food security and nutrition" provides an overview of the current evidence and knowledge about the barriers to uptake and retention in HIV and TB treatment and care and on whether and how food and nutrition assistance can help overcome these barriers. It contains nine papers on three topic areas discussing: (a) adherence and food and nutrition security in context of HIV and TB, their definitions, measurement tools and the current situation; (b) food and nutrition insecurity as barriers to uptake and retention; and (c) food and nutrition assistance to increase uptake and retention in care and treatment. Future interventions in the areas of food security, nutrition and social protection for increasing access and adherence should be from an HIV sensitive lens, linking the continuum of care with health systems, food systems and the community, complementing existing platforms through partnerships and integrated services.

Relationship of maternal knowledge of anemia with maternal and child anemia and health-related behaviors targeted at anemia among families in Indonesia.

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 <12 g/dL), and 62.3 and 54.0% of children were anemic (hemoglobin <11 g/dL). Maternal knowledge of anemia was associated with child anemia in urban and rural areas, respectively (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.79, 1.02, P = 0.10; OR 0.93, 95% CI 0.87, 0.98, P = 0.01) in multivariate logistic regression models adjusting for potential confounders. There was no significant association between maternal knowledge of anemia and maternal anemia. Maternal knowledge of anemia was significantly associated with iron supplementation during pregnancy and child consumption of fortified milk. There was no association of maternal knowledge of anemia with child deworming. Maternal knowledge of anemia is associated with lower odds of anemia in children and with some health behaviors related to reducing anemia.

Determinants of anemia clustering among mothers and children in Indonesia.

OBJECTIVES: To describe risk factors for clustering of anemia among mothers and children in Indonesia. METHODS: An anemia cluster was defined as hemoglobin <12 g/dl in the mother and <11 g/dl in the youngest child, aged 6-59 months. RESULTS: 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 and >4 individuals eating from the same kitchen were associated with greater odds of anemia clustering. CONCLUSION: 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.

Rice fortification: its potential for improving micronutrient intake and steps required for implementation at scale.

BACKGROUND: Micronutrient deficiencies affect over 2 billion people worldwide, with profound implications for health, cognitive development, education, economic development, and productivity. Fortification of staple foods is a cost-effective strategy to increase vitamin and mineral intake among the general population. Rice is consumed by billions of people (> 440 million MT/year) but is as yet rarely fortified. OBJECTIVE: To discuss the untapped opportunity of rice fortification. METHODS: Review literature and experience with rice fortification and compare to fortification of other staple foods. RESULTS: Most technologies used to fortify rice first produce the fortified kernels and then blend them with regular, polished rice. Technologies differ with regard to how nutrients are added to the rice kernels, required investment, production cost, and degree of resemblance to unfortified rice. There are, so far, limited success stories for rice fortification. Some of the main roadblocks appear to be high initial investment and associated cost; lack of government leadership; and consumer hesitation to accept variations in the characteristics of rice, or a higher price, without good understanding of the benefits. CONCLUSIONS: In countries with a large centralized rice milling industry, starting rice fortification is easier than in countries with many small mills. Countries with large safety nets that supply rice to the poorest, for free or subsidized, have a good channel to reach those most in need. Furthermore, key players from the public and private sectors should establish a coalition to support the use of fortified rice and address some of the barriers to its implementation.

Assessing the impact of micronutrient intervention programs implemented under special circumstances--meeting report.

INTRODUCTION AND OBJECTIVE: The World Food Programme and the Office of the United Nations High Commissioner for Refugees organized a meeting of experts to discuss evaluation of micronutrient interventions under special circumstances, such as emergency and refugee situations. RESULTS: Multimicronutrient interventions for groups with higher needs may include home fortification products for young children or supplements for pregnant and lactating women. The choice of preparation should be guided by target group needs, evidence of efficacy of a product or its compounds, acceptability, and cost-effectiveness. Different designs can be used to assess whether an intervention has the desired impact. First, program implementation and adherence must be ascertained. Then, impact on micronutrient status can be assessed, but design options are often limited by logistic challenges, available budget, security issues, and ethical and practical issues regarding nonintervention or placebo groups. Under these conditions, a plausibility design using pre- and postintervention cross-sectional surveys, a prospective cohort study, or a step-wedge design, which enrolls groups as they start receiving the intervention, should be considered. Post hoc comparison of groups with different adherence levels may also be useful. Hemoglobin is often selected as an impact indicator because it is easily measured and tends to respond to change in micronutrient status, especially iron. However, it is not a very specific indicator of micronutrient status, because it is also influenced by inflammation, parasitic infestation, physiological status (age, pregnancy), altitude, and disorders such as thalassemia and sickle cell disease. CONCLUSION: Given the constraints described above, replicability of impact in different contexts is key to the validation of micronutrient interventions.

Provision of micronutrient powder in response to the Cyclone Sidr emergency in Bangladesh: cross-sectional assessment at the end of the intervention.

BACKGROUND: Micronutrient powder has been endorsed as an effective means to improve the micronutrient status of emergency-affected populations. OBJECTIVE: To document the experience and findings of a cross-sectional assessment of the micronutrient powder program implemented as part of the emergency response to Cyclone Sidr. METHODS: Micronutrient powder was distributed to 100,714 children under 5 years of age and 59,439 pregnant or lactating women severely affected by Cyclone Sidr in Bangladesh. A cross-sectional assessment, including hemoglobin and anthropometric measurements, was conducted after the completion of the micronutrient powder program among children under 5 years of age, lactating mothers, and postmenarcheal adolescent girls in the intervention area. Comparison groups for each, drawn from the control area, which had not received micronutrient powder, were assessed at the same time. RESULTS: The prevalence of anemia among children under 5 years of age was approximately 80% in both areas. Among children in the intervention area, those who consumed at least 75% of the micronutrient powder sachets had a lower prevalence of stunting than those who consumed less than 75% of the sachets (40% vs. 52%, p < .05). Among lactating mothers in the intervention area, the prevalence rates of thinness and anemia were lower among those who consumed at least 75% of the sachets than among those who consumed less than 75% of the sachets (thinness, 31% vs. 46%, p < .05; anemia, 50% vs. 61%, p = .07). For adolescent girls in the intervention and control areas, none of whom had received micronutrient powder, the prevalence rates of anemia were 52% and 45%, respectively (p = .05). CONCLUSIONS: Micronutrient powder may reduce anemia among lactating mothers, when the compliance rate is high. Anemia prevalence prior to micronutrient powder distribution had not been investigated and could have been higher among children and lactating mothers in the intervention than in the control area, resulting in the negation of the potential positive impact of micronutrient powder on anemia.

Relationship of the availability of micronutrient powder with iron status and hemoglobin among women and children in the Kakuma Refugee Camp, Kenya.

BACKGROUND: Micronutrient powder is a potential strategy to improve iron status and reduce anemia in refugee populations. OBJECTIVE: To evaluate the effect of the availability of home fortification with a micronutrient powder containing 2.5 mg of sodium iron ethylenediaminetetraacetate (NaFeEDTA) on iron status and hemoglobin in women and children in the Kakuma Refugee Camp in northwest Kenya. METHODS: Hemoglobin and soluble transferrin receptor were measured in 410 children 6 to 59 months of age and 458 women of childbearing age at baseline (just before micronutrient powder was distributed, along with the regular food ration) and at midline (6 months) and endline (13 months)follow-up visits. RESULTS: At the baseline, midline, and endline visits, respectively, the mean (+/- SE) hemoglobin concentration in women was 121.4 +/- 0.8, 120.8 +/- 0.9, and 120.6 +/- 1.0 g/L (p = .42); the prevalence of anemia (hemoglobin < 120 g/L) was 42.6%, 41.3%, and 41.7% (p = .92); and the mean soluble transferrin receptor concentration was 24.1 +/- 0.5, 20.7 +/- 0.7, and 20.8 +/- 0.7 nmol/L (p = .0006). In children, the mean hemoglobin concentration was 105.7 +/- 0.6, 109.0 30322 1.5, and 105.5 +/- 0.3 g/L (p = .95), respectively; the prevalence of anemia (hemoglobin < 110 g/L) was 55.5%, 52.3%, and 59.8% (p = .26); and the mean soluble transferrin receptor concentration was 36.1 +/- 0.7, 29.5 +/- 1.9, and 28.4 +/- 3.2 nmol/L (p = .02), in models that were adjusted for age using least squares means regression. CONCLUSIONS: In children and in women of childbearing age, the availability of micronutrient powder was associated with a small improvement in iron status but no significant change in hemoglobin in this refugee camp setting.

Relationship of homestead food production with night blindness among children below 5 years of age in Bangladesh.

OBJECTIVE: To 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. DESIGN: A cross-sectional study. SETTING: A population-based sample of six rural divisions of Bangladesh assessed in the Bangladesh Nutrition Surveillance Project 2001-2005. SUBJECTS: A total of 158 898 children aged 12-59 months. RESULTS: The 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). CONCLUSIONS: Homestead food production confers a protective effect against night blindness among pre-school children who missed vitamin A supplementation in rural Bangladesh.

Consumption of micronutrient-fortified milk and noodles is associated with lower risk of stunting in preschool-aged children in Indonesia.

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.

Iron-fortified milk and noodle consumption is associated with lower risk of anemia among children aged 6-59 mo in Indonesia.

BACKGROUND: Anemia is common among children in developing countries and is associated with decreased cognitive and physical development. Iron-fortified foods may decrease child anemia. OBJECTIVE: The objective was to describe the association between iron-fortified milk and iron-fortified noodle consumption and anemia in children aged 6-59 mo. DESIGN: Consumption of fortified milk and fortified noodles and child anemia were assessed in 81,885 families from rural and 26,653 families from urban slum areas in Indonesia. RESULTS: The proportions of children who received fortified milk and noodles were 30.1% and 22.6%, respectively, in rural families and 40.1% and 48.9%, respectively, in urban families. The prevalence of anemia among children from rural families was 55.9% and from urban families was 60.8%. Children from rural and urban families were less likely to be anemic if they received fortified milk [odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P < 0.0001) and OR: 0.79; 95% CI: 0.74, 0.86 (P < 0.0001), respectively] but not fortified noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95; 95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic regression models with adjustment for potential confounders. In rural families, the odds of anemia were lower when the child who consumed fortified milk also consumed fortified noodles or when the child who consumed fortified noodles also consumed fortified milk. CONCLUSIONS: In Indonesia, consumption of fortified milk and noodles was associated with decreased odds of child anemia. Iron-fortified milk and noodles may be a strategy that could be applied more widely as an intervention to decrease child anemia.

Coverage of vitamin A capsule programme in Bangladesh and risk factors associated with non-receipt of vitamin A.

Vitamin A supplementation reduces child morbidity, mortality, and blindness. The coverage of the national vitamin A programme and risk factors for not receiving vitamin A were characterized using data from the Bangladesh Demographic and Health Survey 2004. Of 3,745 children aged 18-59 months, 3,237 (86.4%) received a vitamin A capsule each within the last six months. Children who missed vitamin A were more likely to be stunted (prevalence ratio [PR] 0.97, 95% confidence interval [CI] 0.95-1.00) and come from a family with a previous history of mortality of children aged less than five years (PR 0.95, 95% CI 0.91-0.99). Maternal education of > or = 10 years (PR 1.09, 95% CI 1.04-1.13), 7-9 years (PR 1.08, 95% CI 1.04-1.12), and 1-6 years (PR 1.05, 95% CI 1.02-1.08) compared to no formal education was associated with the child not receiving vitamin A in a multivariate model, adjusting for potential confounders. Children missed by the vitamin A programme were more likely to come from families with lower maternal education. Special efforts are required to ensure that the coverage of the national vitamin A programme is increased further so that the most vulnerable children are also better protected against morbidity, mortality, and blindness.

The role of expanded coverage of the national vitamin A program in preventing morbidity and mortality among preschool children in India.

Higher food prices increase the risk of vitamin A deficiency among preschool children in poor families, because a larger part of the household food budget is spent on grain foods and less on vitamin A-rich foods. Vitamin A supplementation is an important source of vitamin A for children. Our objective was to characterize coverage of the India national vitamin A program for preschool children and identify risk factors for not receiving vitamin A. Anthropometric and demographic data were examined in 23,008 children aged 12-59 mo in the India National Family Health Survey, 2005-2006. Within the last 6 mo, 20.2% of children received vitamin A supplementation. The prevalence of stunting, severe stunting, underweight, and severe underweight was higher among children who did not receive vitamin A compared with those who received vitamin A (P < 0.0001). In families with a child who did and did not receive vitamin A, respectively, the proportion with a history of under-5 child mortality was 8.4 vs. 11.4% (P < 0.0001). By state, vitamin A program coverage was inversely proportional to the under-5 child mortality rate (r = -0.51; P = 0.004). Maternal education of > or =10 y [odds ratio (OR) 2.22; 95% CI 1.69-2.91], 7-9 y (OR 1.99; 95% CI 1.57-2.53), or 1-6 y (OR 1.65; 95% CI 1.28-2.13) compared with no education was an important factor related to receipt of vitamin A. Poor coverage of the vitamin A supplementation program in India has serious implications in the face of rising food prices. Expanded coverage of the vitamin A program in India will help protect children from morbidity, mortality, and blindness.

How to ensure nutrition security in the global economic crisis to protect and enhance development of young children and our common future.

The global economic crisis, commodity price hikes, and climate change have worsened the position of the poorest and most vulnerable people. These crises are compromising the diet and health of up to 80% of the population in most developing countries and threaten the development of almost an entire generation of children ( approximately 250 million), because the period from conception until 24 mo of age irreversibly shapes people's health and intellectual ability. High food prices reduce diversity and nutritional quality of the diet and for many also reduce food quantity. Poor households are hit hardest, because they already spend 50-80% of expenditures on food, little on medicines, education, transport, or cooking fuel, and cannot afford to pay more. Reduced public spending, declining incomes, increased food and fuel prices, and reduced remittance thus impede and reverse progress made toward Millenium Development Goals 1, 4, and 5. Investments in nutrition are among the most cost-effective development interventions because of very high benefit:cost ratios, for individuals and for sustainable growth of countries, because they protect health, prevent disability, boost economic productivity, and save lives. To bridge the gap between nutrient requirements, particularly for groups with high needs, and the realistic dietary intake under the prevailing circumstances, the use of complementary food supplements to increase a meal's nutrient content is recommended. This can be in the form of, e.g., micronutrient powder or low-dose lipid-based nutrient supplements, which can be provided for free, in return for vouchers, at subsidized, or at commercial prices.

Low intake of vitamin A-rich foods among children, aged 12-35 months, in India: association with malnutrition, anemia, and missed child survival interventions.

OBJECTIVE: To determine whether children in India who have a low intake of vitamin A-rich foods are at higher risk of malnutrition, anemia, and not receiving child health interventions. METHODS: We analyzed data from the India National Family Health Survey, 2005-2006. RESULTS: Of 17 847 children (41.9%), aged 12-35 months, 7020 did not receive vitamin A-rich foods, based on 24-h recall. The prevalence of stunting, severe stunting, underweight, and severe underweight among children who did and did not receive vitamin A-rich foods was, respectively, 52.5% versus 59.0%, 26.7% versus 32.9%, 43.8% versus 48.5%, and 17.9% versus 21.6% (all P<0.0001). Children who did not receive vitamin A-rich foods were more likely to be anemic, not have completed childhood immunizations, and not to have received vitamin A supplementation in the previous 6 mo (all P<0.0001). Maternal education of ≥10, 7-9, and 1-6 y, respectively, compared with no formal education was associated with the child receiving vitamin A-rich foods (odds ratio 1.41, 95% confidence interval 1.20-1,67, P<0.0001; odds ratio 1.20, 95% confidence interval 1.04-1.37, P=0.01; odds ratio 1.16, 95% confidence interval 1.02-1.32, P=0.02) in a multivariate logistic regression model adjusting for maternal age, household size, socioeconomic status, and location. CONCLUSION: Children who did not receive vitamin A-rich foods were more likely to be malnourished and to have missed basic child health interventions, including vitamin A supplementation. Children were more likely to receive vitamin A-rich foods if their mothers had previously achieved higher primary or secondary education levels.

Castel Gandolfo workshop: an introduction to the impact of climate change, the economic crisis, and the increase in the food prices on malnutrition.

The global food supply system is facing serious new challenges from economic and related crises and climate change, which directly affect the nutritional well-being of the poor by reducing their access to nutritious food. To cope, vulnerable populations prioritize consumption of calorie-rich but nutrient-poor food. Consequently, dietary quality and eventually quantity decline, increasing micronutrient malnutrition (or hidden hunger) and exacerbating preexisting vulnerabilities that lead to poorer health, lower incomes, and reduced physical and intellectual capabilities. This article introduces the series of papers in this supplement, which explore the relationships between crises and their cumulative impacts among vulnerable populations, particularly through hidden hunger.

Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59-month-old children.

Reducing child malnutrition requires nutritious food, breastfeeding, improved hygiene, health services, and (prenatal) care. Poverty and food insecurity seriously constrain the accessibility of nutritious diets that have high protein quality, adequate micronutrient content and bioavailability, macrominerals and essential fatty acids, low antinutrient content, and high nutrient density. Diets based largely on plant sources with few animal-source and fortified foods do not meet these requirements and need to be improved by processing (dehulling, germinating, fermenting), fortification, and adding animal-source foods, e.g., milk, or other specific nutrients. Options include using specially formulated foods (fortified blended foods, commercial infant cereals, or ready-to-use foods [RUFs; pastes, compressed bars, or biscuits]) or complementary food supplements (micronutrient powders or powdered complementary food supplements containing micronutrients, protein, amino acids, and/or enzymes or lipid-based nutrient supplements (120 to 250 kcal/day), typically containing milk powder, high-quality vegetable oil, peanut paste, sugar, and micronutrients. Most supplementary feeding programs for moderately malnourished children supply fortified blended foods, such as corn-soy blend, with oil and sugar, which have shortcomings, including too many antinutrients, no milk (important for growth), suboptimal micronutrient content, high bulk, and high viscosity. Thus, for feeding young or malnourished children, fortified blended foods need to be improved or replaced. Based on success with ready-to-use therapeutic foods (RUTFs) for treating severe acute malnutrition, modifying these recipes is also considered. Commodities for reducing child malnutrition should be chosen on the basis of nutritional needs, program circumstances, availability of commodities, and likelihood of impact. Data are urgently required to compare the impact of new or modified commodities with that of current fortified blended foods and of RUTF developed for treating severe acute malnutrition.

Quality criteria for micronutrient powder products: report of a meeting organized by the World Food Programme and Sprinkles Global Health Initiative.

Distribution of micronutrient powder (MNP), also known as Sprinkles", is becoming a preferred strategy for addressing micronutrient deficiencies. In response, different formulations are being developed, different producers manufacture MNP and several organizations coordinate distribution. However, as yet, the supply of MNP as well as experience with large-scale MNP programs is limited. To facilitate expansion of MNP use such that acceptability and compliance are high and effectiveness maintained, product quality, of both powder and packaging, good advocacy among decision makers, and providing good information to the target population are crucial. A meeting was organized in Toronto by the Sprinkles Global Health Initiative and the World Food Programme to review and reach consensus on quality criteria for composition, manufacturing, packaging, and labeling of MNP propose guidelines for wide-scale production, and discuss MNP program experience. It was recognized that the durability of some of the more sensitive micronutrients in their powdered form in the harsh climatic conditions of many countries has implications for formulation, packaging, storage, and handling of the MNP product. A question-and-answer manual would greatly facilitate program design and implementation. It was agreed to form an interim Technical Advisory Group to prepare for formation of a Technical Advisory Group with agreed-upon tasks and responsibilities. The MNP manufacturing manual of the Sprinkles Global Health Initiative can continue to be used, with reference to the recommendations from the Toronto Meeting outlined in this paper. Meanwhile, the Sprinkles Global Health Initiative will not place any encumbrances on production using its manual; however, the brand name Sprinkles" will stay protected under various trademark laws.

Vitamin A supplementation in Cambodia: program coverage and association with greater maternal formal education.

Vitamin A supplementation reduces morbidity, mortality, and blindness among children in developing countries. The objective of this study is to characterize the coverage of the Cambodian national vitamin A program among preschool children and to identify risk factors for not receiving vitamin A supplementation. The study subjects were preschool children and their families who participated in the 2005 Cambodian Demographic and Health Survey (CDHS), a nationally representative survey. Of 1,547 preschool children, aged 12-59 months, 42.8% received a vitamin A capsule within the last six months. There were no significant differences in paternal education, child age, fever within the last 2 weeks, stunting, underweight, or wasting between children who did or did not receive a vitamin A capsule. Maternal education of > or =10 years (Odds Ratio [OR] 2.09, 95% Confidence Interval [CI] 1.02-4.29), 7-9 years (OR 1.46, 95% CI 0.99-2.15), 4-6 years (OR 1.71, 95% CI 1.26-2.32), and 1-3 years (OR 1.50, 95% CI 1.10-2.06) was associated with the child receiving a vitamin A capsule compared to no formal education in multivariate analyses adjusting for other potential confounders. The national vitamin A supplementation program in Cambodia did not reach over one-half of preschool children in 2005. Greater maternal formal education appears to be an important determinant for receipt of a vitamin A capsule by preschool children.