Design, development, and local production of lipid-based nutritional supplements to enhance the complementary feeding diet: A model for collaboration for a feeding trial in Bangladesh.

Background: Lipid-based nutrient supplements (LNS) are effective for treating childhood wasting and for preventing stunting, wasting, and anemia, but large-scale production and programmatic use are a barrier. Locally-developed and produced LNS may be more affordable and reduce logistical procurement and importation hurdles, while promoting private sector engagement and partnership. Methods: In northwestern Bangladesh, we conducted a community-based trial of complementary food supplementation to test its efficacy to reduce childhood stunting. Two locally-developed, small-quantity LNS (20g/day, rice-lentil and chick-pea based) were designed, developed first at small scale in the 'kitchen' laboratory under controlled conditions, followed by taking them to a local food manufacturer for larger production for the study. We describe here the partnership, required expertise and capacity, experiences, and lessons learned that made this uniquely complex undertaking possible Results: Key steps in the journey included addressing the dynamics of clear communication between partners, executing on carefully assigned tasks and roles, correcting course when needed, and maintaining timeliness and roadmaps. Knowledge of food science and technology was key in solving many food-production challenges that were encountered in taking the laboratory recipe to the factory. Factory production was established and had to meet quality and hygiene criteria set for young children. Conclusions: We provide documentation of this experience as a model to describe the various steps and considerations and what is entailed in local LNS production. We highlight the importance of a well-conceived collaboration with clear roles that created a 'win-win' situation for all partners for achieving common goals, establishing improved technology at the factory, and building new capacity to produce such products for children in a low resource setting. Key words: micronutrient, lipid-based nutrient supplements, maternal and child, malnutrition, multiagency collaboration.

Situation analysis of procurement and production of multiple micronutrient supplements in 12 lower and upper middle-income countries.

Globally, there are few vitamin and mineral ingredient manufacturers. To support local, in-country or regional procurement and production of multiple micronutrient supplements (MMS), the following production scenarios are possible: (a) straight ingredients of vitamins and minerals forms imported or locally produced that are mixed, tableted, or encapsulated and packaged by a local manufacturer; (b) import or local production of a vitamin and minerals premix that is tableted or encapsulated and packaged locally; (c) import of a bulk, finished product (tablets or capsules) that is packaged and branded; and (d) or import of a branded packaged product. This paper is a situation analysis of the market, manufacturing, and policy factors that are driving the production of MMS in 12 lower and upper middle-income countries. Key informants completed a self-administered structured questionnaire, which examined the local context of products available in the market and their cost, regulations and policies, in Brazil, Colombia, Guatemala, Mexico, Peru, Bangladesh, India, Vietnam, Ghana, Kenya, Nigeria, and South Africa. Our study found that although most countries have the capacity to produce locally MMS, the major barriers observed for sustainable and affordable production include (a) poor technical capacity and policies for ensuring quality along the value chain and (b) lack of policy coherence to incentivize local production and lower the manufacture and retail price of MMS. Also, better guidelines and government oversight will be required because not one country had an MMS formulation that matched the globally recommended formulation of the United Nations Multiple Micronutrient Preparation (UNIMMAP).

Vitamin A is rapidly degraded in retinyl palmitate-fortified soybean oil stored under household conditions.

Oil fortification with retinyl palmitate is intended to lower the prevalence of vitamin A deficiency in populations at risk. Although the stability of vitamin A in vegetable oil has been shown to depend on environmental factors, very little information is known about the stability of vitamin A in preoxidized vegetable oils. The present study investigated the stability of retinyl palmitate in mildly oxidized (peroxide value < 2 mequiv O2/kg) and highly oxidized (peroxide value > 10 mequiv O2/kg) soybean oil stored under domestic and retail conditions. Soybean oil was filled in transparent bottles, which were exposed to cold fluorescent light at 22 or 32 °C for 56 days. Periodic oil sampling increased the headspace, thereby mimicking consumer handling. Loss of retinyl palmitate in soybean oil by a maximum of 84.8 ± 5.76% was accompanied by a decrease of vitamin E by 53.3 ± 0.87% and by an increase of the peroxide value from 1.20 ± 0.004 to 24.3 ± 0.02 mequiv O2/kg. Fortification of highly oxidized oil with 31.6 IU/g retinyl palmitate led to a doubling of the average decrease of retinol per day compared to fortification of mildly oxidized oil. In conclusion, oil fortification programs need to consider the oxidative status of the oil used for retinyl palmitate fortification.

Development and acceptability testing of ready-to-use supplementary food made from locally available food ingredients in Bangladesh.

BACKGROUND: Inadequate energy and micronutrient intake during childhood is a major public health problem in developing countries. Ready-to-use supplementary food (RUSF) made of locally available food ingredients can improve micronutrient status and growth of children. The objective of this study was to develop RUSF using locally available food ingredients and test their acceptability. METHODS: A checklist was prepared of food ingredients available and commonly consumed in Bangladesh that have the potential of being used for preparing RUSF. Linear programming was used to determine possible combinations of ingredients and micronutrient premix. To test the acceptability of the RUSF compared to Pushti packet (a cereal based food-supplement) in terms of amount taken by children, a clinical trial was conducted among 90 children aged 6-18 months in a slum of Dhaka city. The mothers were also asked to rate the color, flavor, mouth-feel, and overall liking of the RUSF by using a 7-point Hedonic Scale (1 = dislike extremely, 7 = like extremely). RESULTS: Two RUSFs were developed, one based on rice-lentil and the other on chickpea. The total energy obtained from 50 g of rice-lentil, chickpea-based RUSF and Pushti packet were 264, 267 and 188 kcal respectively. Children were offered 50 g of RUSF and they consumed (mean ± SD) 23.8 ± 14 g rice-lentil RUSF, 28.4 ± 15 g chickpea based RUSF. Pushti packet was also offered 50 g but mothers were allowed to add water, and children consumed 17.1 ± 14 g. Mean feeding time for two RUSFs and Pushti packet was 20.9 minutes. Although the two RUSFs did not differ in the amount consumed, there was a significant difference in consumption between chickpea-based RUSF and Pushti packet (p = 0.012). Using the Hedonic Scale the two RUSFs were more liked by mothers compared to Pushti packet. CONCLUSIONS: Recipes of RUSF were developed using locally available food ingredients. The study results suggest that rice-lentil and chickpea-based RUSF are well accepted by children. TRIAL REGISTRATION: ClinicalTrials.gov NCT01553877. Registered 24 January 2012.

Fortification of rice: technologies and nutrients.

This article provides a comprehensive review of the currently available technologies for vitamin and mineral rice fortification. It covers currently used technologies, such as coating, dusting, and the various extrusion technologies, with the main focus being on cold, warm, and hot extrusion technologies, including process flow, required facilities, and sizes of operation. The advantages and disadvantages of the various processing methods are covered, including a discussion on micronutrients with respect to their technical feasibility during processing, storage, washing, and various cooking methods and their physiological importance. The microstructure of fortified rice kernels and their properties, such as visual appearance, sensory perception, and the impact of different micronutrient formulations, are discussed. Finally, the article covers recommendations for quality control and provides a summary of clinical trials.

Cold fluorescent light as major inducer of lipid oxidation in soybean oil stored at household conditions for eight weeks.

Light, temperature, and oxygen availability has been shown to promote rancidity in vegetable oils. However, the contribution of each of these environmental factors to lipid oxidation in oil stored under household conditions is not known. We aimed to identify the major inducer of oxidative deterioration of soybean oil stored at constant (67.0 mL) or increasing (67.0-283 mL) headspace volume, 22 or 32 °C, with or without illumination by cold fluorescent light for 56 days by means of fatty acid composition, peroxide value, formation of conjugated dienes, lipid radicals, hexanal, and the decrease in the contents of tocopherols. Soybean oil stored in the dark for 56 days showed an increase of the peroxide value by 124 ± 0.62% (p = 0.006), whereas exposure of the oil to light in a cycle of 12 h light alternating with 12 h darkness for 56 days led to a rise of the peroxide value by 1473 ± 1.79% (p ≤ 0.001). Little effects on the oxidative status of the oil were observed after elevating the temperature from 22 to 32 °C and the headspace volume from 67.0 to 283 mL during 56 days of storage. We conclude that storing soybean oil in transparent bottles under household conditions might pose an increased risk for accelerated lipid oxidation induced by exposure to cold fluorescent light.

Multiple micronutrient-fortified rice affects physical performance and plasma vitamin B-12 and homocysteine concentrations of Indian school children.

Fortifying rice with multiple micronutrients could be a promising strategy for combat micronutrient deficiencies in developing countries. We determined the efficacy of extruded rice grains fortified with multiple micronutrients on the prevalence of anemia, micronutrient status, and physical and cognitive performance in 6- to 12-y-old, low-income school children in Bangalore, India. In a randomized, double-blind, controlled trial, 258 children were assigned to 1 of 3 intervention groups to receive rice-based lunch meals fortified with multiple micronutrients with either low-iron (6.25 mg) or high-iron (12.5 mg) concentrations or identical meals with unfortified rice. The meals were provided 6 d/wk for 6 mo. Anthropometric, biochemical, physical performance, and cognitive assessments were taken at baseline and endpoint. At baseline, study groups were comparable, with 61% of the children being anemic. However, only <10% were deficient in iron, vitamin A, and zinc. After 6 mo, plasma vitamin B-12 and homocysteine concentrations (both P < 0.001) as well as physical performance (P < 0.05) significantly improved in the intervention arms. No between-group differences were observed in hemoglobin concentration, anemia, and deficiencies of other micronutrients or cognitive function after 6 mo, but paired analyses revealed a small reduction in anemia prevalence in children in the low-iron group. The fortified rice was efficacious in improving vitamin B-12 status and physical performance in Indian school children.

Program experience with micronutrient powders and current evidence.

The efficacy of micronutrient powders (MNP) in the treatment of anemia in moderately anemic children aged 6-24 mo has been clearly demonstrated. The evidence of the effectiveness of MNP in large-scale programs, however, is scarce. This article describes the program experience and findings of large-scale MNP distribution in refugee camps and in an emergency context in Bangladesh, Nepal, and Kenya. The MNP contained 15-16 micronutrients as per the WHO/World Food Programme/UNICEF joint statement, whereas the iron content was reduced to 2.5 mg from NaFeEDTA in a malaria-endemic area in Kenya. Hundreds of thousands of children aged 6-59 mo and pregnant and lactating women were targeted to consume MNP either daily or every other day over an extended period of time. Extensive social marketing campaigns were undertaken to promote regular use of the product. A number of studies were embedded in the programs to assess the impact of MNP on the nutritional status of target beneficiaries. Some improvements in anemia prevalence estimates were observed in particular subgroups, but other results did not show significant improvements. A significant decrease in the prevalence of stunting was observed in Nepal and Kenya but not in Bangladesh. Diarrhea episodes decreased significantly among children receiving MNP in Nepal. A key challenge is to ensure high MNP acceptance and adherence among beneficiaries. Investigation of non-nutritional causes of anemia is warranted in settings with high compliance but no improvement in hemoglobin status. Further investigation into the most appropriate manner to use MNP in malaria endemic settings is warranted.

Provision of micronutrient powder in response to the Cyclone Sidr emergency in Bangladesh: cross-sectional assessment at the end of the intervention.

BACKGROUND: Micronutrient powder has been endorsed as an effective means to improve the micronutrient status of emergency-affected populations. OBJECTIVE: To document the experience and findings of a cross-sectional assessment of the micronutrient powder program implemented as part of the emergency response to Cyclone Sidr. METHODS: Micronutrient powder was distributed to 100,714 children under 5 years of age and 59,439 pregnant or lactating women severely affected by Cyclone Sidr in Bangladesh. A cross-sectional assessment, including hemoglobin and anthropometric measurements, was conducted after the completion of the micronutrient powder program among children under 5 years of age, lactating mothers, and postmenarcheal adolescent girls in the intervention area. Comparison groups for each, drawn from the control area, which had not received micronutrient powder, were assessed at the same time. RESULTS: The prevalence of anemia among children under 5 years of age was approximately 80% in both areas. Among children in the intervention area, those who consumed at least 75% of the micronutrient powder sachets had a lower prevalence of stunting than those who consumed less than 75% of the sachets (40% vs. 52%, p < .05). Among lactating mothers in the intervention area, the prevalence rates of thinness and anemia were lower among those who consumed at least 75% of the sachets than among those who consumed less than 75% of the sachets (thinness, 31% vs. 46%, p < .05; anemia, 50% vs. 61%, p = .07). For adolescent girls in the intervention and control areas, none of whom had received micronutrient powder, the prevalence rates of anemia were 52% and 45%, respectively (p = .05). CONCLUSIONS: Micronutrient powder may reduce anemia among lactating mothers, when the compliance rate is high. Anemia prevalence prior to micronutrient powder distribution had not been investigated and could have been higher among children and lactating mothers in the intervention than in the control area, resulting in the negation of the potential positive impact of micronutrient powder on anemia.