The potential role of micronutrient powders to improve complementary feeding practices.

Micronutrient powder (MNP) interventions are often integrated within infant and young child feeding (IYCF) programmes to improve micronutrient intake from complementary foods. This review aims to describe country experiences with MNP interventions and their impact on IYCF practices and develop a framework for how MNP may strengthen complementary feeding practices. A literature review and key informant interviews were used to gather data on complementary feeding practices in MNP programme design, implementation, and evaluation. Findings from 11 MNP programmes in different geographic regions reinforced the potential of MNP interventions to add renewed focus and resources to existing IYCF programmes. MNP plays an important role in ensuring adequate micronutrient intake and reducing anaemia in young children. In some programmes, MNP users had improved IYCF practices, such as breastfeeding to 24 months and children receiving complementary foods with adequate consistency, frequency, and diversity. Our framework highlights how behaviour change communication is an essential component for influencing household actions, not only to generate demand and promote correct and sustained MNP use but also raise awareness of IYCF practices. The actions at MNP policy, delivery, and behaviour change communication levels collectively influence household IYCF practices, and formative research and monitoring and evaluation serve to inform programme design and optimize impact. In conclusion, a limited but growing body of evidence suggests that MNP interventions can contribute to improve complementary feeding practices. However, there is scope for improvement even among integrated MNP and IYCF programmes in order to realize the full potential of MNP interventions for IYCF practices.

The legislative framework for salt iodization in Asia and the Pacific and its impact on programme implementation.

OBJECTIVE: Fortification of food-grade (edible) salt with iodine is recommended as a safe, cost-effective and sustainable strategy for the prevention of iodine-deficiency disorders. The present paper examines the legislative framework for salt iodization in Asian countries. DESIGN: We reviewed salt iodization legislation in thirty-six countries in Asia and the Pacific. We obtained copies of existing and draft legislation for salt iodization from UNICEF country offices and the WHO's Global Database of Implementation of Nutrition Actions. We compiled legislation details by country and report on commonalities and gaps using a standardized form. The association between type of legislation and availability of iodized salt in households was assessed. RESULTS: We identified twenty-one countries with existing salt iodization legislation, of which eighteen were mandatory. A further nine countries have draft legislation. The majority of countries with draft and existing legislation used a mandatory standard or technical regulation for iodized salt under their Food Act/Law. The remainder have developed a 'stand-alone' Law/Act. Available national surveys indicate that the proportion of households consuming adequately iodized salt was lowest in countries with no, draft or voluntary legislation, and highest in those where the legislation was based on mandatory regulations under Food Acts/Laws. CONCLUSIONS: Legislation for salt iodization, particularly mandatory legislation under the national food law, facilitates universal salt iodization. However, additional important factors for implementation of salt iodization and maintenance of achievements include the salt industry's structure and capacity to adequately fortify, and official commitment and capacity to enforce national legislation.

The Rise and Fall of Universal Salt Iodization in Vietnam: Lessons Learned for Designing Sustainable Food Fortification Programs With a Public Health Impact.

BACKGROUND: In 2005, more than 90% of Vietnamese households were using adequately iodized salt, and urinary iodine concentration among women of reproductive age was in the optimal range. However, household coverage declined thereafter to 45% in 2011, and urinary iodine concentration levels indicated inadequate iodine intake. OBJECTIVE: To review the strengths and weaknesses of the Vietnamese universal salt iodization program from its inception to the current day and to discuss why achievements made by 2005 were not sustained. METHODS: Qualitative review of program documents and semistructured interviews with national stakeholders. RESULTS: National legislation for mandatory salt iodization was revoked in 2005, and the political importance of the program was downgraded with consequential effects on budget, staff, and authority. CONCLUSIONS: The Vietnamese salt iodization program, as it was initially designed and implemented, was unsustainable, as salt iodization was not practiced as an industry norm but as a government-funded activity. An effective and sustainable salt iodization program needs to be reestablished for the long-term elimination of iodine deficiency, building upon lessons learned from the past and programs in neighboring countries. The new program will need to include mandatory legislation, including salt for food processing; industry responsibility for the cost of fortificant; government commitment for enforcement through routine food control systems and monitoring of iodine status through existing health/nutrition assessments; and intersectoral collaboration and management of the program. Many of the lessons would apply equally to universal salt iodization programs in other countries and indeed to food fortification programs in general.

Effect of Home-Based Complementary Food Fortification on Prevalence of Anemia Among Infants and Young Children Aged 6 to 23 Months in Poor Rural Regions of China.

Following the 2008 Wenchuan earthquake, the Chinese government instituted an infant and young and child nutrition program that included promotion of in-home fortification of complementary food with ying yang bao (YYB), a soy-based powder containing iron, 2.5 mg as iron-EDTA and 5 mg as ferrous fumarate, and other micronutrients. Ying yang bao was provided to participating families in 8 poor rural counties in Sichuan, Shaanxi, and Gansu provinces by the Ministry of Health. We assessed hemoglobin levels among infants and young children (IYC) aged 6 to 23 months at baseline in May 2010 (n = 1290) and during follow-up in November 2010 (n = 1142), May 2011 (n = 1118), and November 2011 (n = 1040), using the Hemocue method. Interviewers collected basic demographic information and child feeding practices from the children's caretakers. Altitude-adjusted hemoglobin level averaged 10.8 g/dL, and total anemia prevalence was 49.5% at baseline. Average hemoglobin was 11.3 g/dL at 6 months, 11.6 g/dL at 12 months, and 11.7 g/dL at 18 months after introduction of YYB. Moderate anemia (hemoglobin: 70-99 g/dL) decreased from 20.3% at baseline to 7.5%, 5.8%, and 7.3% after 6, 12, and 18 months of home fortification, respectively (P < .001), whereas mild anemia (hemoglobin: 100-110 g/dL) decreased from 29.0% to 16.7%, 18.1%, and 15.4%, respectively (P < .001). Among infants aged 6 to 23 months, 95% had regularly been fed YYB during the observation period. Regression analysis showed that the duration of YYB consumption and number of sachets consumed per week correlated positively with hemoglobin levels and negatively with anemia rates. Home food fortification with YYB is feasible and effective for nutrition promotion among IYC in high-risk regions of China.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS: The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS: Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS: BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

Regulatory monitoring systems of fortified salt and wheat flour in selected ASEAN countries.

BACKGROUND: Considerable efforts have been made over the past decade to address vitamin and mineral deficiencies. An increasing number of countries in the Association of Southeast Asian Nations (ASEAN) are adopting mandatory food fortification as one of the primary strategies to overcome these deficiencies. Experience shows that fortified foods can reach large parts of the population, including the poor, if the fortification is done on a mandatory rather than a voluntary basis and if the food vehicle is widely consumed. OBJECTIVE: To review the importance of regulatory monitoring as an essential component of food fortification efforts in selected ASEAN countries, with special focus on the available information on regulatory monitoring systems for iodized salt and fortified wheat flour. METHODS: The role of regulatory monitoring in strengthening food fortification programs was discussed during a joint regional meeting of the World Health Organization, UNICEF, the Flour Fortification Initiative, the Global Alliance for Improved Nutrition, the Micronutrient Initiative, and the World Bank on regulatory monitoring of salt and wheat flour fortification programs in Asia, which took place in Manila, Philippines, on 27-29 September 2011. This paper reviews the regulatory monitoring systems of selected ASEAN countries that participated in this meeting. RESULTS: Problems and challenges in regulatory monitoring systems for iodized salt and fortified wheat flour in selected ASEAN countries are identified, and a description of the role of regulatory monitoring in strengthening food fortification initiatives, particularly of salt and flour, and highlights of areas for improvement are presented. CONCLUSIONS: Regulatory monitoring consists of monitoring activities conducted at the production level, at customs warehouses, and at retail stores by concerned regulatory authorities, and at the production level by producers themselves, as part of quality control and assurance efforts. Unless there are appropriate enforcement and quality assurance mechanisms in place to stimulate compliance by food producers, i.e., regulatory monitoring, having national legislation will not necessarily lead to increased coverage of fortified products and associated outcomes.