Multi-stakeholder’s Analysis of Micronutrient Intervention Strategies and Public Health Measures to Prevent Micronutrient Deficiencies in South East Asia (SMILING Project).

Objectives: The SMILING EU project aims at introducing state-of-the-art knowledge into policy to alleviate micronutrient malnutrition in women of reproductive age (WRA) and young children in five SEA countries: Cambodia, Indonesia, Laos PDR, Thailand and Vietnam. The objective of the present study was to appraise multi-stakeholders viewpoints on intervention strategies to prevent micronutrient deficiencies. Methods: Multi criteria mapping (MCM) was used to evaluate stakeholder’s point of views on asset of priority interventions for an appropriate, timely, feasible and effective prevention of micronutrient deficiencies. MCM technique was realized through a face-to-face computer-assisted interview. Twenty interviews have been conducted in each 5 SEA countries. Stakeholders were selected: government, academic, civil society, NGO, private sector and international institutions. Results: The number of interventions presented to stakeholders differed between SEA countries (6 in Indonesia, 8 in Lao PDR, 9 in Cambodia and Thailand and 11 in Vietnam) and was country specific. Interventions were grouped into 6 clusters; supplementation, fortification, food based approach, educational initiatives, indirect interventions and global strategies, allowing comparison among countries. Cambodia included specific options on education; Lao PDR appraised the homestead food production system and Vietnam the intermittent supplementation. Conclusions: Each SEA country had specific approach and focused on different strategies to prevent micronutrients deficiencies. Stakeholder’s analysis allowed to underline consensus and differences between the different groups of stakeholders and to define the best strategy to be implemented in each of the five SEA countries. Funding: European Commission, FP7, GA-2896-16.

A North-South-South Collaborative Action to Prevent Micronutrient Deficiencies in Women and Young Children in South-East Asia: The SMILING Project.

Objectives: SMILING "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional status and General Health in Asia" (FP7), is a transnational collaboration of research institutions and implementation agencies in five SEA countries: Cambodia, Indonesia, Laos PDR, Thailand and Vietnam, with European partners, to introduce state-of-the-art knowledge into policy to alleviate micronutrient malnutrition in SEA women of reproductive age (WRA) and young children. Objectives were to: build capacity on problem analysis; identify priority interventions and develop roadmaps for national policies. Methods: SMILING has been built around a consortium that worked on Optifood software to identify nutrient gaps; nutritional problem analysis and potential interventions by reviewing current situation and program, and knowledge on effective interventions and multi-criteria mapping for stakeholder analysis to develop national guidelines. Results: Iron, zinc, vitamin A and iodine deficiency remain common in SEA. Even though the five SEA countries differ in nutritional situation and stages of development, iron intake in young children in all countries was inadequate, as folate intake in WRA, even with theoretical best possible diets. Consequently, interventions including supplementation, food-based strategies and public health measures were appraised through multi-stakeholder analysis. Successful experiences and lessons in implementing nutrition programs in these countries were also critically reviewed. Policy roadmaps by country are being drafted accordingly. Conclusions: SMILING conducted an analysis of nutrition situation in each SEA country. Gaps in intake of several micronutrients cannot be currently solved by dietary solution and e.g. food fortification needs to be considered. Roadmaps for each country policy-makers are being formulated. Funding: European Commission-FP7, GA-2896-16.

Multi-micronutrient Fortified Rice Improved Vitamin A Status of Cambodian School Children.

Objectives: In rice-consuming countries, multi-micronutrient fortified rice (MMFR) is a promising cost-effective strategy to control micronutrient deficiencies. The FORISCA project evaluated the impact of MMFR distributed through the WFP school meal program (SMP) on micronutrient status, health, and cognition of Cambodian schoolchildren. Here, effects on anemia, iron and vitamin A (VA) status are presented. Methods: The FORISCA-UltraRice+NutriRice study was a cluster-randomized, double-blinded, placebo-controlled trial in 9500 schoolchildren. Sixteen schools participating in WFP-SMP were randomly assigned to receive either MMFR including VA (MMFR+VA), MMFR without VA (MMFRVA), or unfortified rice (placebo) as breakfast distributed 6 days/week for 6 months. Four additional schools not participating in WFP-SMP were randomly selected as control. Twenty-five percent of schoolchildren from grade 1-6 participated in the biochemical study. Hemoglobin (Hb), iron and VA status were measured at baseline, 3 and 6 months. Results: Baseline prevalence of iron deficiency (ID), anemia and (marginal) vitamin A deficiency (VAD) were 51.6%, 15.7% and 8.6% respectively. Hemoglobinopathy (OR 2.5) , VAD (OR 2.1) and total body iron (TBI) were the strongest predictors of anemia (all p<0.01). The intervention had no overall impact on Hb or anemia prevalence. MMFR+VA significantly reduced VAD from 13.5% to 7.1% (p<0.05), whereas VAD increased in the other groups over the intervention (6.1% to 12.7%). Conclusions: Micronutrient deficiencies were prevalent with especially hemoglobinopathy and VAD and to a lesser extent iron status being risk factors for anemia. Fortified rice containing VA significantly improved VA status of schoolchildren. Funded by USDA/FAS, WFP-DSM consortium and IRD.

Iron Status is Associated with Body Composition in Cambodian Infants and Young Children.

Objectives: Malnutrition in early childhood predisposes to a higher risk for non-communicable diseases such as obesity and cardio-vascular diseases later in life through not fully understood metabolic alterations. Little is known about body composition in early childhood in relation to micronutrient status. Methods: Infants were recruited through the WinFood project which studied the effectiveness of fortified complementary foods (FCF) in improving health and growth. Anthropometry (weight, height, MUAC, skinfolds), body composition (deuterium dilution) and micronutrient status (iron, zinc, vitamin A) were measured at 6 mo and 15 mo of age. Results: From 269 Cambodian infants data on body composition and micronutrient status were available for both time-points. Lean body mass increased with 1.96 ±0.59 kg, whereas percentage body fat decreased from 21.7% to 14.9% over the study period (P<0.001). At 6 and 15 mo of age, body fat was strongly correlated to ponderal growth (WHZ, P<0.01) but not to length growth (HAZ) or gender. Vitamin A and zinc status were not related to fat mass. Iron status at 6 and 15 months of age significantly correlated with body composition, with infants with no iron stores at endpoint having a higher fat mass (14.0% vs 15.5%, P=0.02). Infants without iron deficiency during the study had significant lower fat mass (13.3%) than infants who were iron deficient at both timepoints (16.4%, P<0.01) Conclusions: Iron status, but not vitamin A or zinc status, was related to body composition in Cambodian infants. FCF aimed at improving iron status in early childhood may have long-term health benefits.

Rice Fortified with Iron in School Meals Improves Cognitive Performance in Cambodian School Children.

Objectives: Nutritional status can have a large impact on schoolperformance in children, with micronutrient deficiencies affecting cognitive performance and school attendance through increased morbidity. The FORISCA-UltraRice+NutriRice Trial in Cambodia tested impact of multimicronutrient fortified rice (MMFR) through the WFP school meal program (SMP) on micronutrient status, health and cognitive performance. Methods: The FORISCA-UltraRice+NutriRice study was a cluster-randomized, double-blinded, placebo-controlled trial in 9500 schoolchildren. Sixteen schools participating in WFP-SMP were randomly assigned to receive either MMFR including vitamin A (MMFR+VA), MMFR without VA (MMFR-VA) or unfortified rice (placebo) as breakfast distributed 6 days/week for 6 months. Four additional schools not participating in SMP were randomly selected as control group. Cognitive performance (Raven's Colored Matrices, Block Design and Picture completion), and vitamin A and iron status were determined in 25% of the schoolchildren. Results: Cognitive performance was significantly correlated to stunting (P<0.05) and total body iron (TBI) at baseline and endline (P<0.05), but not to vitamin A status. Cognitive performance improved in all children (P<0.001). Children receiving MMFR-VA (iron without vitamin A) had significant higher improvements in Block Design scores as compared to children receiving MMFR+VA (iron plus vitamin A, P<0.001) or control (P=0.022), and tended to be higher than placebo (P=0.09). Conclusions: Iron status, as well as chronic nutritional deprivation (stunting) are both important determinants of cognitive performance in schoolchildren. Improving iron status through fortified SMP can enhance schoolperformance, but interactions with other micronutrients may modify this effect. The optimal dose of micronutrients needs to be established. Funded by USDA/FAS, WFPDSM consortium and IRD.

What is the Right Indicator to Evaluate Impact of Interventions? Examples from a Rice Fortification Trial in Cambodia.

Objectives: Large-scale programs often use proxy indicators for evaluation purposes but little is known on whether use of these indicators might lead to erroneous conclusions regarding impact of programs. In the FORISCA-UltraRice+NutriRice trial in Cambodia, fortified rice was introduced through the WFP schoolmeal program (WFP-SMP). A wide range of impact indicators collected during the study was explored to test the usefulness of 2 proxy indicators (anemia and stunting) for program evaluation. Methods: In a placebo-controlled, double blinded trial, 20 schools (n=9500) were randomly allocated to no SMP (control, 4 schools), normal schoolmeal (placebo, 4 schools) or a schoolmeal with fortified rice (3 different types, 4 schools each). Data on absenteeism and morbidity was available for all schoolchildren, whereas biochemical data (hemoglobin, iron, zinc and vitamin A status), anthropometry, parasite infection and cognitive performance was available for ~25% of children. Results: At baseline, anemia prevalence was significantly lower in non-SMP (9.5% vs 16.6%, P<0.05) and iron status significantly higher in non-SMP schools than in intervention schools (P<0.005). Stunting prevalence was high (41.5%) and not different among the schools. After 6 months of consumption, fortified rice had no overall impact on anemia prevalence or hemoglobin concentrations, but improved micronutrient status and cognitive performance in some intervention groups. Conclusions: Anemia prevalence is a valid indicator to select schools for SMP, but stunting prevalence had little value in this study. Changes in anemia prevalence did not correspond to changes in functional outcomes, showing that program evaluation requires better proxy indicators. Funded by USDA/FAS, WFP-DSM consortium and IRD.

Post-partum High-dose Vitamin A Supplementation to Improve Vitamin A Status of Mother and Infant: The Role of Timing and Inflammation.

Objectives: Vitamin A deficiency (VAD) in infancy remains an important health problem. Postpartum maternal high-dose vitamin A supplementation (MHDVAS) was recommended but recently cancelled by WHO as efficacy was unclear. We investigated effects of inflammation and timing of MHDVAS on VA status in mothers and newborns. Methods: In a randomized, double-blinded placebo-controlled trial, 400 pregnant women were randomly assigned at 28–32 weeks gestation, to receive MHDVAS within 1 week after delivery (WK1) or 6 weeks post-partum (WK6). Breastmilk, plasma VA and inflammation markers were measured at several time-points during the first 6 months post-partum. Results: Retinol concentrations during pregnancy and 6 months post-partum were strongly correlated (R=0.53, P<0.001). Prevalence of VAD(<0.70 μmol/L) in mothers 6 months post-partum was low (2.7%), but high in infants (33.6%), regardless of intervention. 77.6% of infants had retinol concentrations <1.05 μmol/L. Breastmilk vitamin A concentrations (<1.05 μmol/L) were deficient in only 5% of the women first week post-partum, but increased to 28% of the women 6 months postpartum and tended to be higher in the WK1 compared to the WK6 (31.4% and 24.5%,P<0.10). Retinol liver stores were significantly higher in children from mothers receiving MHDVAS at WK6 as compared to WK1 (P<0.001), with 27% and 46.9% of the infants having insufficient VA liver stores respectively. Conclusions: Lactation caused depletion of vitamin A stores in mothers. Delaying the high-dose VAS post-partum from WK1 to WK6 did not affect circulating retinol, but did significantly increased VA liver stores in infants 6 months after birth. Health-benefits should be evaluated in a larger trial.

Diagnosis of iron deficiency anemia in children of Northeast Brazil / Diagnóstico de anemia por deficiencia de hierro en niños del Noreste de Brasil

OBJETIVO: Diagnosticar anemia por deficiência de ferro em crianças. MÉTODOS: O estudo foi desenvolvido com uma amostra de 301 crianças com idade entre seis e 30 meses, usuárias de creches públicas de Recife, PE, em 2004. Para o diagnóstico da anemia utilizou-se a combinação de diferentes parâmetros hematológicos e bioquímicos: hemoglobina, volume corpuscular médio, ferritina, proteína C-reativa, saturação da transferrina e receptor da transferrina. Para a análise estatística empregou-se o teste do qui-quadrado e ANOVA. RESULTADOS: Do total de crianças, 92,4 por cento tinha anemia (Hb < 110g/L) e 28,9 por cento apresentou anemia moderada/grave (Hb<90g/L). Níveis mais baixos de hemoglobina foram observados em crianças de seis a 17 meses. Encontrou-se deficiência de ferro em 51,5 por cento das crianças, utilizando-se a ferritina (< 12µg/L) como parâmetro. Considerando a combinação da concentração de hemoglobina, ferritina e do receptor de transferrina, 58,1 por cento tinha anemia com deficiência de ferro, 34,2 por cento anemia sem déficit de ferro e 2,3 por cento deficiência de ferro sem anemia. A concentração média de ferritina foi significativamente maior em crianças com proteína C-reativa aumentada quando comparada com aqueles com níveis normais (22,1 versus 14,8 µg/L). CONCLUSÕES: A utilização de diversos parâmetros bioquímicos e hematológicos possibilitou diagnosticar anemia por deficiência de ferro em dois terços das crianças, revelando a necessidade de identificar outros determinantes de anemia sem deficiência de ferro.

OBJETIVO: Diagnosticar anemia por deficiência de ferro em crianças. MÉTODOS: O estudo foi desenvolvido com uma amostra de 301 crianças com idade entre seis e 30 meses, usuárias de creches públicas de Recife, PE, em 2004. Para o diagnóstico da anemia utilizou-se a combinação de diferentes parâmetros hematológicos e bioquímicos: hemoglobina, volume corpuscular médio, ferritina, proteína C-reativa, saturação da transferrina e receptor da transferrina. Para a análise estatística empregou-se o teste do qui-quadrado e ANOVA. RESULTADOS: Do total de crianças, 92,4% tinha anemia (Hb < 110g/L) e 28,9% apresentou anemia moderada/grave (Hb<90g/L). Níveis mais baixos de hemoglobina foram observados em crianças de seis a 17 meses. Encontrou-se deficiência de ferro em 51,5% das crianças, utilizando-se a ferritina (< 12µg/L) como parâmetro. Considerando a combinação da concentração de hemoglobina, ferritina e do receptor de transferrina, 58,1% tinha anemia com deficiência de ferro, 34,2% anemia sem déficit de ferro e 2,3% deficiência de ferro sem anemia. A concentração média de ferritina foi significativamente maior em crianças com proteína C-reativa aumentada quando comparada com aqueles com níveis normais (22,1 versus 14,8 µg/L). CONCLUSÕES: A utilização de diversos parâmetros bioquímicos e hematológicos possibilitou diagnosticar anemia por deficiência de ferro em dois terços das crianças, revelando a necessidade de identificar outros determinantes de anemia sem deficiência de ferro.

Anemia por deficiencia de hierro en la región Andina: definición y estrategias de intervención / Iron deficiency anemia in the Andean region: definition and interventions strategies

La anemia es una enfermedad sistémica que afecta a diferentes órganos y funciones. Puede estar causada por una inadecuada producción de eritrocitos, tener un origen congénito o deberse a infecciones o fenómenos inmunológicos. Sin embargo, su causa más frecuente es la deficiencia de hierro, desorden nutricional muy común a nivel internacional