Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries.

Background: Large-scale food fortification (LSFF) of commonly consumed food vehicles is widely implemented in low- and middle-income countries. Many programs have monitoring information gaps and most countries fail to assess program coverage.Objective: The aim of this work was to present LSFF coverage survey findings (overall and in vulnerable populations) from 18 programs (7 wheat flour, 4 maize flour, and 7 edible oil programs) conducted in 8 countries between 2013 and 2015.Methods: A Fortification Assessment Coverage Toolkit (FACT) was developed to standardize the assessments. Three indicators were used to assess the relations between coverage and vulnerability: 1) poverty, 2) poor dietary diversity, and 3) rural residence. Three measures of coverage were assessed: 1) consumption of the vehicle, 2) consumption of a fortifiable vehicle, and 3) consumption of a fortified vehicle. Individual program performance was assessed based on the following: 1) achieving overall coverage ≥50%, 2) achieving coverage of ≥75% in ≥1 vulnerable group, and 3) achieving equity in coverage for ≥1 vulnerable group.Results: Coverage varied widely by food vehicle and country. Only 2 of the 18 LSFF programs assessed met all 3 program performance criteria. The 2 main program bottlenecks were a poor choice of vehicle and failure to fortify a fortifiable vehicle (i.e., absence of fortification).Conclusions: The results highlight the importance of sound program design and routine monitoring and evaluation. There is strong evidence of the impact and cost-effectiveness of LSFF; however, impact can only be achieved when the necessary activities and processes during program design and implementation are followed. The FACT approach fills an important gap in the availability of standardized tools. The LSFF programs assessed here need to be re-evaluated to determine whether to further invest in the programs, whether other vehicles are appropriate, and whether other approaches are needed.

Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based Nutrient Supplements (iLiNS) Project.

The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.

Rapid direct analysis of retinyl palmitate (vitamin A) in fortified vegetable oils by HPLC-FLD.

Large-scale food fortification of vegetable oils with vitamin A has been implemented successfully for decades in numerous African and Asian countries, contributing demonstrably to reductions in vitamin A deficiency. For these programmes, reliable and validated analytical data are essential to demonstrate compliance with legal standards and fortification levels. Commonly, many analytical laboratories use a saponification method for the quantitative analysis of retinyl palmitate (the mostly used form of vitamin A for fortification) in fortified oils, which implies a multiple-step procedure with long analysis times and the potential risk of analyte loss. The aim of the present study was to develop and validate a direct High-performance Liquid Chromatography (HPLC) method that reduces these sample preparation steps, leading to the cost- and time-efficient quantification of retinyl palmitate in fortified oils. Oil samples are dissolved into the HPLC solvents, then injected directly into a common C18 column, and subsequently detected by a fluorescence detector. The limit of quantification (1.0 mg retinyl palmitate kg-1) and the working range of 1.0-100 mg retinyl palmitate kg-1 with a linearity of R2 = 0.9989 are appropriate to analyse fortified oil samples. The method also showed adequate precision (RSD between 1.1% and 3.1%) and recoveries (86-103%) at two different concentration levels. The accuracy of the direct HPLC method was additionally proven by the comparison of spiked samples with two external laboratories that used the saponification method. The robustness of the method was confirmed by the analysis of various spiked edible oils. The HPLC column is not deteriorated by the lipid matrix and shows excellent stability and long lifetime. Also, 9-cis-retinyl palmitate formed mainly by light exposure could be detected by this method. The direct HPLC method is a well-suited alternative to the saponification method for the rapid and reliable routine analysis of fortified oil samples.

Vitamin A Fortification Quality Is High for Packaged and Branded Edible Oil but Low for Oil Sold in Unbranded, Loose Form: Findings from a Market Assessment in Bangladesh.

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

Estimating reach of social impact products: A model to standardize the calculation of product reach in data-scarce settings.

BACKGROUND: Social impact interventions often involve the introduction of a product intended to create positive impact. Program decision makers need data to routinely review product delivery as well as predict potential outcomes and impact to optimize intervention plans and allocate resources effectively. We propose a novel model to support data-driven decision-making in data and budget-constrained settings and use of routine monitoring to ensure progress towards program outcomes and impact. METHODS: We present a complete model to estimate product reach of durable and fast-moving consumer products, which includes required inputs, potential data sources, formulas, trade-offs, and assumptions. RESULTS: We illustrate the use of the model by applying it to the case study of fortified rice introduction in Brazil and estimate that the intervention, which aimed to improve nutrition status and health outcomes reached 2.4 million consumers. CONCLUSIONS: The model can cover a broad range of social-purpose interventions that involve the introduction or scale-up of various types of consumer products. It provides a relatively simple, comprehensive, flexible, and usable framework to estimate product reach, an indicator that can be an input into impact estimates or, in many scenarios, the actual endpoint of the intervention.

Management of children with acute malnutrition in resource-poor settings.

Approximately 11% of children worldwide suffer from moderate or severe acute malnutrition, which is defined as low weight for height or mid-upper arm circumference with respect to international standards, or the presence of bipedal edema. These children have a considerably increased risk of dying. Experience from the past two decades indicates that children with uncomplicated moderate or severe acute malnutrition can be managed successfully as outpatients, by use of appropriate treatment of infections and either lipid-based, ready-to-use therapeutic foods or appropriately formulated home diets, along with psychosocial care. Children's caregivers prefer community-based treatment, which is also less costly than inpatient care. Children with severe acute malnutrition and life-threatening complications require short-term inpatient care for treatment of infections, fluid and electrolyte imbalances, and metabolic abnormalities. Initial dietary management relies on low-lactose, milk-based, liquid formulas but semi-solid or solid foods can be started as soon as appetite permits, after which children can be referred for ambulatory treatment. National programs for the community-based management of acute malnutrition (CMAM) provide periodic anthropometric and clinical screening of young children, and referral of those who meet established criteria. This Review describes the main components of the treatment of young children with acute malnutrition in resource poor settings and some recent advances in CMAM programs.

Eight-year trends in food, energy and macronutrient intake in a sample of elderly German subjects.

Time trends in the food and the corresponding energy and macronutrient intake between 1994 and 2002 are investigated as part of the longitudinal study on nutrition and health status in an ageing population in Giessen, Germany (GISELA study). The dietary intake is assessed via a 3 d estimated dietary record especially developed and validated for this study. A total of 2135 records from 532 subjects, aged 60 years and over, are analysed separately according to sex and age groups (born 1904-1928 and born 1929-1942). Results show that the food, energy and macronutrient intake of the GISELA subjects stayed fairly stable over the study period. However, some significant changes in the consumption pattern are observed, predominantly in the women and the younger age groups, which correspond to the national trends in Germany. Most obvious changes observed among the GISELA subjects are the increased intake of water (between +21.05 and +41.61 ml/d per year) and vegetables (between +2.94 and +3.38 g/d per year) and a reduced consumption of coffee and tea (between -10.65 and -15.99 ml/d per year) as well as of meat (between -1.79 and -2.56 g/d per year). The healthier food choices and the ability to change food habits could be related to the relatively high health-awareness of the GISELA subjects compared to the federal average of equivalent age groups.

Voluntary lifestyle changes and knowledge about healthy lifestyles of chilean primary health care workers

Se evaluaron los cambios en los estilos de vida y conocimientos en alimentación saludable y actividad física en profesionales de atención primaria de salud. Se aplicó una encuesta a 194 profesionales (médicos, enfermeras, nutricionistas, matronas y asistentes sociales), de los cuales el 86 por ciento eran mujeres. Se observó que durante el último año, la mayoría de los profesionales modificó sus hábitos hacia estilos de vida mas saludables. Alrededor del 80 por ciento señalaron que consumen menos grasas y consumen mas verduras, dos tercios indicaron consumir menos azúcar, alrededor de la mitad menos alcohol y un 45 por ciento hacen más actividad física. La gente mas joven es la que ha hecho las mayores modificaciones, a pesar que aumentaron el consumo de bebidas gaseosas, alcohol y tabaco. Un 80 por ciento de los profesionales respondió correctamente las preguntas relacionadas con alimentación y actividad física. Se encontró diferencias estadísticamente significativas entre los diferentes grupos de profesionales. Se concluye que muchos profesionales han efectuado cambios hacia estilos de vida mas saludable, tienen un buen conocimiento de hábitos alimentarios y actividad física. Estos resultados indican la importancia del trabajo en equipo para contribuir a la prevención de las enfermedades crónicas no transmisibles