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.

To what Extent Can Food-based Approaches Ensure Dietary Adequacy for Women and Young Children in SE Asia.

Objectives: To predict whether food-based approaches can ensure dietary adequacy for 6-23 month old children and women of reproductive age in SE Asia and to identify problem nutrients. Methods: Linear programming was used to determine whether nutritionally adequate diets based on locally available non-fortified foods (11 micronutrients ≥ WHO/FAO RNI, assuming moderate iron and zinc bioavailability) could be formulated for women and young children in 5 countries. Model parameters were defined using nationally representative (Indonesia, Thailand, Vietnam, Cambodia) or locally representative (Laos, Cambodian children<12 months) 24-hour recall dietary data. Problem nutrients were defined as those <100% RNI in a diet where intakes were maximised. Nutrient adequacies, for food-based recommendations (FBR), were defined as those >65% RNI, when intakes were minimised, in diets achieving the FBR. Results: Numbers of problem nutrients ranged from 2-9, 1-8 and 0-5, for 6-8 mo, 9-11 mo and 12- 23 mo old children; and from 3-7, 2-4 and 1-4 for pregnant, lactating and non-pregnant- nonlactating women, respectively, depending on the country. In most countries, modeled FBRs ensured adequacy for ≥7 (children) and ≥5 (women) nutrients. In all countries, FBRs did not ensure adequate iron (all groups) and folate (women) intakes. Conclusions: Interventions, such as food fortification or the promotion of unutilized nutrient dense foods, are likely required to ensure dietary adequacy, for women and young children, in SE Asia. Funding: The European Commission, FP7, GA-2896-16.

Iron Suplementation Starting at 12 Months of Age and Developmental Outcomes: Who Benefits.

Objectives: Iron deficiency has been linked with reduced developmental outcomes in children, however results are varied. This study aims to investigate the benefit of iron supplementation on developmental outcomes in under-two year old children. Methods: A randomized, double-blinded controlled trial was conducted in Lombok, West Nusa Tenggara Province, Indonesia (ClinicalTrials.gov Identifier: NCT01504633). Two groups (n=44/group) of 12-17 mo children were compared: Placebo and Fe-group (16mg elemental iron/day). Indicators of sub-clinical inflammation (CRP, AGP), iron status (serum ferritin/SF, transferin receptor/sTfR, body iron store/BIS), hemoglobin and development (using BSID II as mental/MDI, psychomotor/PDI and behavior/BRS scores) were assessed at baseline and after 24- week supplementation (endline). Results: Both groups were comparable at baseline (92% anemia, 66% iron deficiency/ID, 62% IDA). Hemoglobin and iron status indicators were significantly higher at endline in Fe-group, also there were significant decrease in prevalence of anemia, ID and IDA (p<0.001). However there is no difference in MDI, PDI and BRS scores between placebo and Fe-group at the endline nor change of these scores. When stratified by ID and anemia at baseline, iron supplementation can only prevent significant decrease in MDI in the initially non-anemic subjects. Conclusions: Within the regime of iron dosage used in this study (equivalent to 2mg/kg.day) iron supplementation improved hemoglobin and iron status indicators but did not benefit developmental outcomes. Iron intervention delivered for children <12mo may be too late due to prolonged deficiency. Further studies when iron intervention is started at earlier age or even prenatally are needed.

Iron Folate Supplementation is Necessary but not Sufficient to Reduce Anemia in Myanmar Adolescent Girls.

Objectives: Anaemia is a major nutritional problem in Myanmar and it is important to improve the preconceptional iron status of young women. In this study we assessed the beneficial effect of iron, folate and vitamin A supplementation on anaemia of adolescent girls. Methods: A randomized, double-blinded, placebo-controlled study (NCT: 01198574) was conducted among anaemic adolescent schoolgirls (n=402) in Ayeyarwady region, Myanmar. The schoolgirls were recruited from 6 schools after screening for anemia (Hb<120g/L) among 1269 subjects. They were assigned into one of four groups: all groups received folate (F, 2.5 mg of folate), other groups received Vitamin A (FVA, 15,000 IU), Iron (IF, 60 mg elemental iron and folate) and IF+Vitamin A (IFVA). Supplementation was done once a week for 12 weeks. Iron, vitamin A, folate and inflammation status were measured. Serum ferritin (SF) and retinol (SR) were corrected for inflammation. Results: The prevalence of iron deficiency (ID) (SF<15μg/L), low vitamin A status (SR<1.05μmol/L) and folate deficiency (serum folate<6.6nmol/L) were ~20%, 30% and 52% respectively at baseline. Compared with folate, ID was reduced significantly by IF (OR 0.24; 95%CI 0.06, 0.92) and IFA (OR 0.15; 95%CI 0.04, 0.57) respectively. Although Hb significantly increased in all groups, risk of anaemia did not differ between groups that received iron and those who received folate alone or folate plus vitamin A. Conclusions: Multiple micronutrient deficiencies coexist among adolescent girls. Weekly iron supplementation combined with folate and vitamin A alleviated only some of the anaemia and should be implemented but other causes also need to be urgently investigated.

Iron Supplementation with or without Optimized Complementary Feeding Recommendations: Effect on Micronutrient Status and Growth of 1-2 Year Old Myanmar Children.

Objectives: Children under 2-years of age are at high risk of micronutrient deficiencies and growth faltering due partly to poor complementary feeding. This study aimed to compare the effect of optimized complementary feeding recommendations (CFRs) to iron supplementation on micronutrient status and growth of Myanmar children. Methods: A randomized, partially-blinded, placebo-controlled trial (NCT01758159) was conducted for 24 weeks among 1-2 year old children from Ayeyarwady, Myanmar. Optimized CFRs were developed by Linear Programming using locally available foods. Randomization by village for CFRs or non-CFRs and by child (n=432) for iron supplements or placebo, created: 1.CFR+Fe; 2.CFR-alone; 3.Fe-alone; or 4.Placebo-control groups. Mother from CFRs received regular training on optimized CFRs and children from Fe received 15mg Ferric-NaEDTA daily. Serum ferritin(SF), transferrin-receptor(sTfR), zinc(Zn), retinol-binding-protein(RBP); C-reactive protein, α-1 acid glycoprotein and anthropometry were assessed at baseline and endline. Results: At baseline, 88.4% of children had anemia (Hb<110g/L); after adjusting for infection, 36.1% had iron-deficiency-anemia(IDA) (Hb<110g/L, SF<12μg/L), 37.2% iron-deficiency(ID) (SF<12μg/L), 33.6% zinc-deficiency (Zn<9.9μmol/L), 54.9% low vitamin-A status (RBP<1.05μmol/L); and 27.7% were stunted. At endline, anemia was reduced by all 3 interventions. Fe-alone reduced ID and IDA [OR=0.02, 95%CI(0.02,0.44), P=0.002] and [OR=0.06, 95%CI(0.01,0.41) P=0.004] respectively but increased stunting [OR=2.96, 95%CI(1.05, 8.33), P=0.04]. There was no between-groups difference for zinc and vitamin-A deficiencies at endline. Conclusions: Optimized CFRs with or without iron supplementation can reduce anemia. Iron supplementation reduce ID and IDA but also increase stunting. It is interesting to study about competitive absorption of supplemental iron or dietary iron with dietary zinc with potential to zinc deficiency and stunting.