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.

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.

Impact of Infant and Young Child Feeding (IYCF) Practices on Growth in Young Children in Rural Cambodia.

Objectives: To evaluate the impact of IYCF education and practices on growth compared to an ecological control. Methods: As part of a randomized controlled effectiveness trial of micronutrient Sprinkles and IYCF education, all mothers received IYCF education. Group and individual sessions were delivered by health staff and trained village health workers. Anthropometry and IYCF were recorded at baseline (age 6 mo), endline (age 12 mo), and at two follow up points (age 18 mo and 24 mo) and compared with same aged children in the same province from the 2005 Cambodia Demographic and Health Survey (CDHS). Results: There was no treatment effect on growth so intervention and control groups were combined. At 6, 12 and 18 mo, 59%, 86% and 73% of children met minimum adequate WHO IYCF practices respectively in the study group compared to 33%, 62% and 47% for CDHS children. Stunting (HAZ <-2) prevalence at 6, 12, 18 and 24 mo was 11%, 19%, 32% and 38% in the study group compared to 11%, 37%, 62%, and 44% for CDHS children. Underweight (WAZ <-2) prevalence at 6, 12, 18 and 24 mo was 14%, 16%, 21% and 26% in the study group compared to 18%, 28%, 37% and 21% for CDHS children. Differences for stunting and underweight were significant (p<0.05) at 12 and 18 mo. Conclusions: IYCF education to study mothers improved IYCF practices and slowed stunting and underweight significantly at 12 and 18 months of age compared to CDHS children. Strengthened IYCF education and practices improved growth in children in this low-income, rural population.

Impact of Genetic Hemoglobin (Hb) Disorders on the Effectiveness of Micronutrient Sprinkles in Reducing Anemia in Young Children in Rural Cambodia.

Objectives: To evaluate the impact of genetic Hb disorders on the effectiveness of 6 months of daily micronutrient Sprinkles for infants age 6-12 months on anemia. Methods: As part of a randomized controlled effectiveness trial, subjects were screened for genetic Hb disorders at aged 18 months on whole blood using the SEBIA MINICAP analyser, HEMOGLOBIN (E) program, and IC α THAL test to detect major Hb variants and α-thalassemia. Anemia (Hb < 110 g/L) was measured at baseline (age 6 mo), endline (age 12 mo), and at two follow up points (age 18 mo and 24 mo) for children with and without genetic Hb disorders. Results: Half of all children had a genetic haemoglobin disorder (at least 15 types). At baseline, overall prevalence of anemia for children with normal Hb was 81% versus 88% for those with any genetic Hb disorder. At endline, anemia prevalence for the intervention group with normal Hb vs genetic Hb disorder was 60.2% versus 72.0% (P = 0.02) and for the control group 81.1% versus 88.8% (P = 0.03), respectively. At further follow-up, anemia decreased in both the control and intervention groups. However those with any genetic Hb disorder remained more anemic with varying levels of anemia according to the disorder type. Conclusions: Sprinkles had a similar proportional effect regardless of overall genetic Hb status indicating that children with genetic Hb disorders can effectively utilize iron and micronutrients to reduce anemia. Sprinkles can be effective in populations with a high prevalence of genetic Hb disorders.