Mathematical modeling to inform the development of national guidelines on infant feeding in Thailand.

The development of national dietary guidelines promoting healthy food choices is a public health priority in Thailand. In developing the recent national complementary feeding guidelines (CFGs) for 6- to 12-month-old children, mathematical modeling was used to inform decisions. Model parameters were derived from nationally representative dietary data and analyzed for 11 micronutrients by age group, using linear programming analysis in Optifood. Models were run to identify micronutrients whose nutrient reference values could not be met using local foods as consumed (problem nutrients), evaluate the original 2012 Thai CFGs, and predict the nutritional benefits of a specific fortified complementary food. The results identified three problem nutrients (iron, calcium, and zinc), which, for 9- to 11-month-olds, were reduced to one when the fortified food was modeled. The number of servings/week of vegetables and meat, fish or eggs were higher, and of oil and fruit were lower, in the modeled nutritionally best rather than observed diets (medians). When modeled, the original Thai CFGs were not feasible because the energy constraint was exceeded; hence, in revising them, the recommended number of servings/week of oil and fruit were reduced. This study demonstrates the advantages of using mathematical modeling, when revising national CFGs, to evaluate and improve them.

Realistic Food-Based Approaches Alone May Not Ensure Dietary Adequacy for Women and Young Children in South-East Asia.

Objectives Micronutrient deficiencies, in southeast Asia (SE Asia), remain a public health challenge. We evaluated whether promoting the consumption of locally available nutritious foods, which is a low-risk micronutrient intervention, alone can ensure dietary adequacy, for women of reproductive age and 6-23 m old children. Methods Representative dietary data from Cambodia, Indonesia, Lao PDR, Thailand and Vietnam were analysed using linear programming analysis to identify nutrients that are likely low in personal food environments (problem nutrients), and to formulate food-based recommendations (FBRs) for three to six target populations per country. Results The number of problem nutrients ranged from zero for 12-23 m olds in Indonesia, Thailand and Vietnam to six for pregnant women in Cambodia. The FBRs selected for each target population, if adopted, would ensure a low percentage of the population was at risk of inadequate intakes for five to ten micronutrients, depending on the country and target population. Of the 11 micronutrients modelled, requirements for iron, calcium and folate were most difficult to meet (≥ 10 of the 24 target populations), using FBRs alone. The number of individual FBRs selected per set, for each target population, ranged from three to eight; and often included meat, fish or eggs, liver/organ meats, vegetables and fruits. Conclusions for practice Intervention strategies need to increase access to nutritious foods, including products fortified with micronutrients, in SE Asia, when aiming to ensure dietary adequacy for most individuals in the population.

Food Composition Tables in Southeast Asia: The Contribution of the SMILING Project.

Objectives Food composition data are key for many nutrition related activities in research, planning and policy. Combatting micronutrient malnutrition among women and young children using sustainable food based approaches, as aimed at in the SMILING project, requires high quality food composition data. Methods In order to develop capacity and to align procedures for establishing, updating and assessing the quality of key nutrient data in the food composition tables in Southeast Asia, a detailed roadmap was developed to identify and propose steps for this. This included a training workshop to build capacity in the field of food composition data, and alignment of procedures for selecting foods and nutrients to be included for quality assessment, and update of country specific food composition tables. The SEA partners in the SMILING project finalised a country specific food composition table (FCT) with updated compositional data on selected foods and nutrients considered key for designing nutrient dense and optimal diets for the target groups. Results Between 140 and 175 foods were selected for inclusion in the country specific FCTs. Key-nutrients were: energy, protein, total fat, carbohydrates, iron, zinc, (pro-)-vitamin A, folate, calcium, vitamin D, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B12 and vitamin C. A detailed quality assessment on 13 key-foods per nutrient was performed using international guidelines. Nutrient data for specific local food items were often unavailable and data on folate, vitamin B12 and vitamin B6 contents were mostly missing. For many foods, documentation was not available, thereby complicating an in-depth quality assessment. Despite these limitations, the SMILING project offered a unique opportunity to increase awareness of the importance of high quality well documented food composition data. Conclusion for Practise The self-reported data quality demonstrated that there is considerable room for improvement of the nutrient data quality in some countries. In addition, investment in sustainable capacity development and an urgent need to produce and document high quality data on the micronutrient composition of especially local foods is required.

Prevalence and incidence of child stunting from birth to two years of life in Thai children: based on the Prospective Cohort Study of Thai Children (PCTC).

OBJECTIVE: To determine the percentages of prevalence and incidence in child stunting at birth, 6, 12, 18, and 24 months of age and to investigate the association between factors and child stunting outcome MATERIAL AND METHOD: The Prospective Cohort Study of Thai Children (PCTC) was carried out during 2000-2002, data from five districts were examined, and anthropometric measurements were performed by the physician and research assistants. WHO's growth reference standard year 2005 was used. RESULTS: Four thousand two hundred forty five children were included at the start of the present study of which 3,898 were in the final analysis. The prevalence in child stunting presented an increasing percentage at birth 6, 12, 18, and 24 months was 6.0, 6.9, 9.5, 14.6, and 16.6%, and incidence indicated decreasing at birth, 6, 12, 18, and 24 months was 6.0, 4.3, 4.1, 5.2, and 3.2% respectively. The GEE analysis showed that gender mother height, mother education, income, and Nan-Hill Tribe areas were significantly correlated with child stunting (p < 0.001). CONCLUSION: Finding from the present study indicates that to reduce child stunting in Thailand in early infant's life, early nutritional interventions and quality antenatal care are vital.

Process and outcome evaluation of a diabetes prevention education program for community healthcare workers in Thailand.

OBJECTIVE: To describe the development, process and outcome evaluation of a culturally tailored diabetes prevention education program for community healthcare workers (CHCWs) in Thailand. METHODS: A tailored diabetes prevention education program was designed based on formative research and implemented with 35 CHCWs in semi-urban areas in Chiang Mai province, Thailand. Modules were delivered over eight group classes and eight self-directed E-learning sessions (www.FitThai.org). The program incorporated problem-based learning, discussion, reflection, community-based application, self-evaluation and on-line support. The frequency that students accessed on-line materials, including videotaped lectures, readings, monthly newsletters and community resources, was documented. Participant satisfaction was assessed through three questionnaires. Knowledge was assessed through pre-post testing. RESULTS: Three-quarters of participants attended all eight classes and no participant attended fewer than six. On-line support and materials were accessed 3 to 38 times (median 13). Participants reported that program information and activities were fun, useful, culturally-relevant and applicable to diabetes prevention in their specific communities. Participants also appreciated the innovative technology support for their work. Comfort with E-learning varied among participants. Scores on pre-post knowledge test increased from a mean (sd) of 56.5% (6.26) to 75.5% (6.01) (p < .001). CONCLUSIONS: An innovative diabetes prevention education program was developed for CHCWs in Thailand. Interactive classroom modules and self-directed E-learning were generally well-received and supported better knowledge scores. Ongoing access to web-based materials and expert support may help sustain learning.

Factors associated with dual form of malnutrition in school children in Nakhon Pathom and Bangkok.

OBJECTIVE: The present study examined the influence of family characteristics and maternal feeding practices on eating behaviors, food consumption and nutritional status of children living in 6 districts of Nakhon Pathom province and 3 surrounding districts of Bangkok. MATERIAL AND METHOD: One hundred and ninety nine families were enrolled in the present study. Four specific mother-child pair groups were purposively selected: 62 obese child/overweight mother pairs, 49 obese child/ normal weight mother pairs, 37 wasted child/overweight mother pairs, and 51 normal weight child/normal weight mother pairs. Anthropometric measurements were performed on all subjects. Biological data, socioeconomic status, maternal feeding practices, as well as eating and lifestyle behaviors of the children were obtained from mothers and children using structured questionnaires and interviews. RESULT: Most mothers from all groups, 40.8%-62.2%, had a primary education, were non-manual workers, with families containing 4-6 persons per household, and a family income of < or = 20,000 baht per month. Multivariate logistic regression analysis showed that maternal overweight prior to pregnancy (OR11.85, 95%CI 2.16-64.99) child's high birth weight (OR 4.53, 95%CI 1.09-18.73) as well as maternal control over the consumption of high caloric food (OR13.07, 95%CI 4.08-41.86) and large amounts of food consumed by the children (OR12.58, 95%CI 4.30-36.80) were significant factors associated with childhood obesity. Compared to normal weight children, a higher proportion of obese children were not breast-fed and a higher proportion of normal weight mothers controlled the consumption of high caloric food in their obese children. Overweight mothers with wasted children also controlled their children's food intake. Higher proportion of wasted children had a higher snack consumption frequency but lower energy food intake than the normal weight children. CONCLUSION: Understanding the underlying causes of dual form of malnutrition in the households would have implication for policy makers to address and implement a nutrition action plan. It is suggested that a malnutrition, (under and over-nutrition) prevention program must involve strategies within families that focus on providing nutrition education and the powerful guidance to help parents foster appropriate patterns of food choice and eating in their children. Promotion of increased physical activity in children is also essential. These strategies are aimed to promote the optimal child's weight and health.

Dietary assessment of refugees living in camps: a case study of Mae La Camp, Thailand.

This study presents data on consumption patterns, methods of food procurement, and adequacy of dietary intake among Burmese refugee camp households living along Thailand's border with Burma. Households established for one or more years and with children under 15 years of age were sampled. A questionnaire was used to determine economic, food-consumption, and dietary intake patterns; foods consumed were weighed and measured using a 24-hour recall for the household unit; and nutritional status was determined by a Microtoise tape and digital standing scales. In total, 182 households containing 1,159 people were surveyed. The average household energy and protein intakes were 96.6% and 111.4%, respectively, of the recommended daily allowance (RDA) for healthy Thais. Twelve percent of protein was derived from animal sources. Carbohydrate, protein, and fat accounted for 84%, 9%, and 7% of total energy, respectively. The intake of vitamins A, B1, B2, and C and of calcium ranged from 24.2% to 53.1% of the RDA. Iron intake was 85.3% of the RDA, derived mainly from rice, fermented fish, mung beans, green leafy vegetables, and eggs. Ration foods supplied 60.5% to 98.18% of all nutrients consumed in the households, with the exception of vitamins A and C. Among children under five years of age, 33.7% were underweight, 36.4% were studied, and 8.7% were wasted. Although the refugees were able to procure some nonration foods by foraging, planting trees and vegetables, raising animals, and purchasing and exchanging ration foods for other items, the quantity and quality were not sufficient to compensate for the nutrients that were low or lacking in the ration. The overwhelming majority of dietary nutrients were provided by ration foods, and although the ration and the overall diet may be adequate for short-term subsistence, they do not suffice for long-term survival and optimal growth, especially for younger children.