What is food-to-food fortification? A working definition and framework for evaluation of efficiency and implementation of best practices.

Food-to-food fortification (FtFF) is an emerging food-based strategy that can complement current strategies in the ongoing fight against micronutrient deficiencies, but it has not been defined or characterized. This review has proposed a working definition of FtFF. Comparison with other main food-based strategies clearly differentiates FtFF as an emerging strategy with the potential to address multiple micronutrient deficiencies simultaneously, with little dietary change required by consumers. A review of literature revealed that despite the limited number of studies (in vitro and in vivo), the diversity of food-based fortificants investigated and some contradictory data, there are promising fortificants, which have the potential to improve the amount of bioavailable iron, zinc, and provitamin A from starchy staple foods. These fortificants are typically fruits and vegetables, with high mineral as well as ascorbic acid and ß-carotene contents. However, as the observed improvements in micronutrient bioavailability and status are relatively small, measuring the positive outcomes is more likely to be impactful only if the FtFF products are consumed as regular staples. Considering best practices in implementation of FtFF, raw material authentication and ingredient documentation are critical, especially as the contents of target micronutrients and bioavailability modulators as well as the microbiological quality of the plant-based fortificants can vary substantially. Also, as there are only few developed supply chains for plant-based fortificants, procurement of consistent materials may be problematic. This, however, provides the opportunity for value chain development, which can contribute towards the economic growth of communities, or hybrid approaches that leverage traditional premixes to standardize product micronutrient content.

Effects of food supplementation on cognitive function, cerebral blood flow, and nutritional status in young children at risk of undernutrition: randomized controlled trial.

OBJECTIVE: To assess the effects of food supplementation on improving working memory and additional measures including cerebral blood flow in children at risk of undernutrition. DESIGN: Randomized controlled trial. SETTING: 10 villages in Guinea-Bissau. PARTICIPANTS: 1059 children aged 15 months to 7 years; children younger than 4 were the primary population. INTERVENTIONS: Supervised isocaloric servings (≈1300 kJ, five mornings each week, 23 weeks) of a new food supplement (NEWSUP, high in plant polyphenols and omega 3 fatty acids, within a wide variety and high fortification of micronutrients, and a high protein content), or a fortified blended food (FBF) used in nutrition programs, or a control meal (traditional rice breakfast). MAIN OUTCOME MEASUREMENTS: The primary outcome was working memory, a core executive function predicting long term academic achievement. Additional outcomes were hemoglobin concentration, growth, body composition, and index of cerebral blood flow (CBFi). In addition to an intention-to-treat analysis, a predefined per protocol analysis was conducted in children who consumed at least 75% of the supplement (820/925, 89%). The primary outcome was assessed by a multivariable Poisson model; other outcomes were assessed by multivariable linear mixed models. RESULTS: Among children younger than 4, randomization to NEWSUP increased working memory compared with the control meal (rate ratio 1.20, 95% confidence interval 1.02 to 1.41, P=0.03), with a larger effect in the per protocol population (1.25, 1.06 to 1.47, P=0.009). NEWSUP also increased hemoglobin concentration among children with anemia (adjusted mean difference 0.65 g/dL, 95% confidence interval 0.23 to 1.07, P=0.003) compared with the control meal, decreased body mass index z score gain (-0.23, -0.43 to -0.02, P=0.03), and increased lean tissue accretion (2.98 cm2, 0.04 to 5.92, P=0.046) with less fat (-5.82 cm2, -11.28 to -0.36, P=0.04) compared with FBF. Additionally, NEWSUP increased CBFi compared with the control meal and FBF in both age groups combined (1.14 mm2/s×10-8, 0.10 to 2.23, P=0.04 for both comparisons). Among children aged 4 and older, NEWSUP had no significant effect on working memory or anemia, but increased lean tissue compared with FBF (4.31 cm2, 0.34 to 8.28, P=0.03). CONCLUSIONS: Childhood undernutrition is associated with long term impairment in cognition. Contrary to current understanding, supplementary feeding for 23 weeks could improve executive function, brain health, and nutritional status in vulnerable young children living in low income countries. Further research is needed to optimize nutritional prescriptions for regenerative improvements in cognitive function, and to test effectiveness in other vulnerable groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT03017209.

Experiences and lessons learned for planning and supply of micronutrient powders interventions.

Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale-up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale-up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.

Experiences and lessons learned for delivery of micronutrient powders interventions.

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

A rapid assessment and response approach for socially marketed nutrition commodities in Viet Nam.

BACKGROUND: The leading cause of death in children in developing countries is protein-energy malnutrition. In Viet Nam, 25.9% of children under 5 experience stunted growth and 6.6% are moderately wasted. Iron deficiency anaemia and vitamin A deficiency contribute to these and other malnutrition conditions. OBJECTIVES: Given these factors, more evidence based approaches are required to improve understanding of current attitudes, opinions and behaviours of mothers with young children, in order to operationalise social marketing of nutrition commodities in Viet Nam. METHODS AND STUDY DESIGN: A literature review supported a rapid assessment and response method involving semi-structured interviews with 77 stakeholders and focus group discussions with 80 program beneficiaries from four geographic locations in the north and south of Viet Nam. Discussion agendas were developed to address key program issues with grounded theory utilized for data analysis. RESULTS: Data analysis highlighted challenges and opportunities within the six Ps of social marketing: Supply and demand side issues included: cost and the quality of products, the limited scale of interventions and promotional activities. Policy issues identified related to current policies that inhibited the broader promotion and distribution of micronutrient products, and opportunities for improved dialogue with policy partners. Partnerships further emphasized the need for public private partnerships to support the social change process. CONCLUSION: Implications for theory, policy, and practice indicates that rapid assessment and response is a cost-effective, pragmatic method of public health research, in resource constrained settings, to explore policies and behaviours amenable to change and build stakeholder engagement in the program.