An Ex-Ante Analysis of the Impact of Biofortified Zinc Rice on Dietary Zinc Inadequacy: Evidence from Bangladesh, Indonesia, and the Philippines.

BACKGROUND: South, East and Southeast Asia are among regions of the world with the highest estimated prevalence of inadequate zinc intake. Because populations in those regions eat rice as their main staple, zinc biofortification of rice has the potential to improve zinc intake especially among the most vulnerable OBJECTIVE: We modeled the impact of consumption of zinc-biofortified rice on zinc intake and inadequacy among women of childbearing age and young children nationally in Indonesia, and the Philippines, and at a sub-national level in Bangladesh METHODS: We conducted an ex-ante analysis by applying increments of zinc content in rice, from a baseline level of 16 parts per million (ppm) to 100 ppm, and based on rice consumption data to substitute levels of conventional rice with zinc-biofortified rice varying between 10% and 70% RESULTS: Among all datasets evaluated from these three countries, the prevalence of dietary zinc inadequacy at baseline was 94 to 99% among women of childbearing age, 77 to 100% among children 4-5 years old and 27 to 78% among children 1-3 years old. At the current breeding target of 28 ppm, zinc-biofortified rice has the potential to decrease zinc inadequacy by up to 50 percent among women and children in rural Bangladesh and among children in the Philippines where consumption of rice is higher compared to Indonesia CONCLUSIONS: Our analysis shows that increasing zinc content in rice up to 45 ppm reduces the burden of zinc inadequacy substantially, after which we encourage programs to increase coverage to reach the highest number of beneficiaries.

Intra-uterine exposure to lower maternal haemoglobin concentration is associated with impaired cognitive function in stunted adolescents: results from a 17-year longitudinal cohort study in Indonesia.

The long-term impact of maternal anaemia on cognitive performance remains unknown. Indonesian longitudinal cohort data of 363 paired pregnant mothers and their 10-14-year-old offspring were used to investigate the association between maternal haemoglobin (Hb) concentration and their offspring's cognitive function (assessed by Raven's Progressive Matrices test) during adolescence. The weighted anaemia prevalence was 49.3% in pregnant mothers and 22.2% in adolescents. Adolescents who were stunted, anaemic, or living in a rural area had significantly lower cognitive scores than their counterparts. Maternal Hb was not associated with adolescent cognitive function (ß: 0.14; 95%CI: -0.052-0.340). However, the effect of maternal Hb concentration on offspring's cognitive function was modified by stunting status (ß, stunted: 0.44; 95%CI: 0.05-0.82; non-stunted: 0.01; 95%CI: -0.02-0.24). This study shows adverse cognitive outcomes at adolescent age are likely multi-causal and can be partially explained by intra-uterine exposure to low maternal Hb concentrations.

Nutrient Density as a Dimension of Dietary Quality: Findings of the Nutrient Density Approach in a Multi-Center Evaluation.

The nutrient adequacy of a diet is typically assessed by comparing estimated nutrient intakes with established average nutrient requirements; this approach does not consider total energy consumed. In this multinational survey investigation in Indonesia, Mexico, and South Africa, we explore the applications of the "critical nutrient-density approach"-which brings energy requirements into the equation-in the context of public health epidemiology. We conducted 24 h dietary recalls in convenience samples of normal-weight (BMI 18.5-25 kg/m2) or obese (BMI > 30 kg/m2), low-income women in three settings (n = 290). Dietary adequacy was assessed both in absolute terms and using the nutrient density approach. No significant differences in energy and nutrient intakes were observed between normal-weight and obese women within any of the three samples (p > 0.05). Both the cut-point method (% of EAR) and critical nutrient density approach revealed a high probability of inadequate intakes for several micronutrients but with poor concordance between the two methods. We conclude that it may often require some approximate estimate of the habitual energy intake from an empirical source to apply a true critical nutrient density reference for a population or subgroup. This will logically signify that there would be more "problem nutrients" in the diets examined with this nutrient density approach, and efforts toward improved food selection or food- or biofortification will frequently be indicated.

Food Composition Tables in Southeast Asia: The Contribution of the SMILING Project.

Objectives Food composition data are key for many nutrition related activities in research, planning and policy. Combatting micronutrient malnutrition among women and young children using sustainable food based approaches, as aimed at in the SMILING project, requires high quality food composition data. Methods In order to develop capacity and to align procedures for establishing, updating and assessing the quality of key nutrient data in the food composition tables in Southeast Asia, a detailed roadmap was developed to identify and propose steps for this. This included a training workshop to build capacity in the field of food composition data, and alignment of procedures for selecting foods and nutrients to be included for quality assessment, and update of country specific food composition tables. The SEA partners in the SMILING project finalised a country specific food composition table (FCT) with updated compositional data on selected foods and nutrients considered key for designing nutrient dense and optimal diets for the target groups. Results Between 140 and 175 foods were selected for inclusion in the country specific FCTs. Key-nutrients were: energy, protein, total fat, carbohydrates, iron, zinc, (pro-)-vitamin A, folate, calcium, vitamin D, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B12 and vitamin C. A detailed quality assessment on 13 key-foods per nutrient was performed using international guidelines. Nutrient data for specific local food items were often unavailable and data on folate, vitamin B12 and vitamin B6 contents were mostly missing. For many foods, documentation was not available, thereby complicating an in-depth quality assessment. Despite these limitations, the SMILING project offered a unique opportunity to increase awareness of the importance of high quality well documented food composition data. Conclusion for Practise The self-reported data quality demonstrated that there is considerable room for improvement of the nutrient data quality in some countries. In addition, investment in sustainable capacity development and an urgent need to produce and document high quality data on the micronutrient composition of especially local foods is required.

Biofortified ß-carotene rice improves vitamin A intake and reduces the prevalence of inadequacy among women and young children in a simulated analysis in Bangladesh, Indonesia, and the Philippines.

BACKGROUND: Vitamin A deficiency continues to be a major public health problem affecting developing countries where people eat mostly rice as a staple food. In Asia, rice provides up to 80% of the total daily energy intake. OBJECTIVE: We used existing data sets from Bangladesh, Indonesia, and the Philippines, where dietary intakes have been quantified at the individual level to 1) determine the rice and vitamin A intake in nonpregnant, nonlactating women of reproductive age and in nonbreastfed children 1-3 y old and 2) simulate the amount of change that could be achieved in the prevalence of inadequate intake of vitamin A if rice biofortified with ß-carotene were consumed instead of the rice consumed at present. DESIGN: We considered a range of 4-20 parts per million (ppm) of ß-carotene content and 10-70% substitution levels for the biofortified rice. Software was used to estimate usual rice and vitamin A intake for the simulation analyses. RESULTS: In an analysis by country, the substitution of biofortified rice for white rice in the optimistic scenario (20 ppm and 70% substitution) decreased the prevalence of vitamin A inadequacy from baseline 78% in women and 71% in children in Bangladesh. In Indonesia and the Philippines, the prevalence of inadequacy fell by 55-60% in women and dropped by nearly 30% in children from baseline. CONCLUSIONS: The results of the simulation analysis were striking in that even low substitution levels and modest increases in the ß-carotene of rice produced a meaningful decrease in the prevalence of inadequate intake of vitamin A. Increasing the substitution levels had a greater impact than increasing the ß-carotene content by >12 ppm.

Dietary diversity, animal source food consumption and linear growth among children aged 1-5 years in Bandung, Indonesia: a longitudinal observational study.

Dietary diversity involves adequate intake of macronutrient and micronutrient. The inclusion of animal source foods (ASF) in the diet helps prevent multiple nutrient deficiencies and any resultant, linear growth retardation. The objective of the current study was to assess the relationship between dietary diversity, ASF consumption and height-for-age z-score (HAZ) among children aged 12-59 months old across a 1-year observation. This longitudinal observational study without controls was conducted among four age groups: 12-23 months (n 57), 24-35 months (n 56), 36-47 months (n 58) and 48-59 months (n 56). Anthropometry and dietary intake were measured during each of four visits at 16-20-week intervals. The general characteristics and other observations were only collected at baseline and endline. During the year-long study period, approximately 27 % of the children ate a diverse diet (consumed ≥6 out of 9 food groups) according to ≥3 visits. ASF consumption was high, particularly for eggs, poultry, processed meats and liquid milk. Yet, micronutrient intake inadequacy, especially of Zn, Ca, Fe and vitamin A, was highly prevalent. A multivariate regression analysis showed that the consumption of a diverse diet and ASF was not significantly associated with the HAZ at endline, after controlling for demographic characteristics and the baseline HAZ. The consumption of a diverse diet was significantly associated with Ca intake adequacy. Moreover, ASF consumption was significantly associated with adequate intake of protein and micronutrients, particularly vitamin A, Ca and Zn. Thus, the recommendation is to continue and strengthen the promotion of consuming a diverse diet that includes ASF in supporting the linear growth of young children.

Anaemia prevalence over time in Indonesia: estimates from the 1997, 2000, and 2008 Indonesia Family Life Surveys.

OBJECTIVE: To summarize anaemia prevalence data for children, women, and men using data from the second, third and fourth waves of the Indonesia Family Life Surveys (IFLS), which were conducted in 1997/8, 2000, and 2007/8, respectively. METHODS: Anaemia prevalence was determined for children 0 to 5 years, 5 to 12 years, 12 to 15 years, non-pregnant women at least 15 years, pregnant women at least 15 years, and men at least 15 years, based on haemoglobin adjusted for altitude and smoking status. RESULTS: Compared with 1997/8 estimates, anaemia prevalence estimates were lower in 2007/8 for all groups, with the greatest relative decline occurring in children 5 to 12 years (25.4%). Trend analysis found anaemia significantly declined over the survey years for all groups (χ² p=0.005 for pregnant women, χ² p<0.001 for all other groups). CONCLUSIONS: IFLS anaemia estimates for different population groups decreased between 1997/8 and 2007/8 and were consistent with estimates from Southeast Asia, and with other studies conducted in Indonesia. While the prevalence of anaemia consistently decreased in all groups, anaemia remains a moderate public health problem for children 0 to 5 years, children 5 to 12 years, and non-pregnant and pregnant women.

Cost of the Diet (CoD) tool: first results from Indonesia and applications for policy discussion on food and nutrition security.

BACKGROUND: The Minimum Cost of a Nutritious Diet (MCNut) is the cost of a theoretical diet satisfying all nutrient requirements of a family at the lowest possible cost, based on availability, price, and nutrient content of local foods. A comparison with household expenditure shows the proportion of households that would be able to afford a nutritious diet. OBJECTIVE: To explore using the Cost of Diet (CoD) tool for policy dialogue on food and nutrition security in Indonesia. METHODS: From October 2011 to June 2012, market surveys collected data on food commodity availability and pricing in four provinces. Household composition and expenditure data were obtained from secondary data (SUSENAS 2010). Focus group discussions were conducted to better understand food consumption practices. Different types of fortified foods and distribution mechanisms were also modeled. RESULTS: Stark differences were found among the four areas: in Timor Tengah Selatan, only 25% of households could afford to meet the nutrient requirements, whereas in urban Surabaya, 80% could. The prevalence rates of underweight and stunting among children under 5 years of age in the four areas were inversely correlated with the proportion of households that could afford a nutritious diet. The highest reduction in the cost of the child's diet was achieved by modeling provision of fortified blended food through Social Safety Nets. Rice fortification, subsidized or at commercial price, can greatly improve nutrient affordability for households. CONCLUSIONS: The CoD analysis is a useful entry point for discussions on constraints on achieving adequate nutrition in different areas and on possible ways to improve nutrition, including the use of special foods and different distribution strategies.

The SMILING project: a North-South-South collaborative action to prevent micronutrient deficiencies in women and young children in Southeast Asia.

BACKGROUND: The "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia" project (SMILING), funded by the European Commission, is a transnational collaboration of research institutions and implementation agencies in five Southeast Asian countries--Cambodia, Indonesia, Laos PDR, Thailand, and Vietnam--with European partners, to support the application of state-of-the art knowledge to alleviate micronutrient malnutrition in Southeast Asia. OBJECTIVE: The major expected outcomes are to improve micronutrient status on a large scale, to identify priority interventions in each Southeast Asian country, and to develop a road map for decision makers and donors for inclusion of these priority interventions into the national policy. METHODS: SMILING has been built around a strong project consortium that works on a constant and proactive exchange of data and analyses between partners and allows for the differences in contexts and development stages of the countries, as well as a strong North-South-South collaboration and colearning. RESULTS: The selection of Southeast Asian countries considered the range of social and economic development, the extent of micronutrient malnutrition, and capacity and past success in nutrition improvement efforts. SMILING is applying innovative tools that support nutrition policy-making and programming. The mathematical modeling technique combined with linear programming will provide insight into which food-based strategies have the potential to provide essential (micro) nutrients for women and young children. Multicriteria mapping will offer a flexible decision-aiding tool taking into account the variability and uncertainty of opinions from key stakeholders. The lessons learned throughout the project will be widely disseminated.

Fermented soyabean and vitamin C-rich fruit: a possibility to circumvent the further decrease of iron status among iron-deficient pregnant women in Indonesia.

OBJECTIVE: Increasing the consumption of Fe-rich foods and thus improving Fe bioavailability without significantly increasing diet cost is the most sustainable intervention for improving Fe intake. We assessed the effect of supplementary food consisting of fermented soyabean (tempeh) and vitamin C-rich fruit consumed during pregnancy on maternal iron deficiency (ID). DESIGN: Pregnant women were randomly allocated by village into optimized diet and control groups. Supplementary food was given 6 d/week at home. The average weekly food provided comprised 600 g of tempeh, 30 g of meat, 350 g of guava, 300 g of papaya and 100 g of orange. Hb, ferritin and transferrin receptor (TfR) concentrations were measured at 12-20 and at 32-36 weeks of gestation. SETTING: Thirty-nine villages in Indonesia. SUBJECTS: Pregnant women (12-20 weeks of gestation, n 252). RESULTS: At baseline, mean Hb, ferritin and TfR concentrations and body Fe concentration were within the normal range and did not differ between groups. At near term, mean Hb, ferritin and body Fe decreased, whereas mean TfR increased significantly in both groups. The mean changes in Fe status were similar in both groups. In Fe-deficient women, consumption of an optimized diet was associated with smaller decreases in Hb (1·02 (95% CI 0·98, 1·07) g/l; P = 0·058), ferritin (1·42 (95% CI 1·16, 1·75) µg/l; P = 0·046) and body Fe (2·57 (95% CI 1·71, 3·43) mg/kg; P = 0·073) concentrations, compared with a state of no intervention. Fe-deficient women at baseline benefited more from supplementary food compared with Fe-replete women. CONCLUSIONS: Daily supplementary food containing tempeh and vitamin C-rich fruits during pregnancy might have positive effects on maternal ID.

Red cell folate and predicted neural tube defect rate in three Asian cities.

BACKGROUND: Periconceptional folic acid reduces neural tube defect (NTD) risk. Red blood cell folate concentration is inversely associated with NTD risk. In many countries there is a lack of information on NTD rates. Red cell folate status in women of childbearing age may be a surrogate for NTD rates and may be helpful in identifying countries or regions most likely to benefit from improved folate status. OBJECTIVE: To predict NTD rates using red cell folate concentrations in women of childbearing age living in three Asian cities Design: Cross-sectional convenience samples of non-pregnant women living in Beijing (n=220), Kuala Lumpur (n=389), and Jakarta (n=129). RESULTS: Red cell folate concentrations were highest (p<0.001) in women from Jakarta at 872 nmol/L (95% CI; 833, 910) followed by Kuala Lumpur at 674 nmol/L (95% CI: 644, 704) and lowest in Beijing at 563 nmol/L (95% CI: 524, 601). Accordingly, predicted NTD rates were highest in Beijing at 30/10000 (95% CI: 27, 33), followed by Kuala Lumpur at 24/10000 (95% CI: 22, 25), and lowest in Jakarta at 15/10000 (95% CI: 14,15). CONCLUSION: Our red blood cell folate data suggests that of the three cities improving the folate status of women in Beijing would have the greatest impact on NTD rates.

Anaemia and iron deficiency anaemia among young adolescent girls from the peri urban coastal area of Indonesia.

Anaemia due to iron deficiency is still a widespread problem. Among adolescent girls, it will bring negative consequences on growth, school performance, morbidity and reproductive performance. This cross sectional study aimed to identify the different nutritional and iron status characteristics of young adolescent girls 10-12 years old with iron deficiency anaemia and anaemia without iron deficiency in the rural coastal area of Indonesia. Anaemic girls (N =133) were recruited out of 1358 girls from 34 elementary schools. Haemoglobin, serum ferritin, serum transferrin receptor and zinc protophorphyrin were determined for iron status, whilst weight and height were measured for their nutritional status. General characteristics and dietary intake were assessed through interview. Out of 133 anaemic subjects, 29 (21.8%) suffered from iron deficiency anaemia, which was not significantly related to age and menarche. About 50% were underweight and stunted indicating the presence of acute and chronic malnutrition. The proportion of thinness was significantly higher (P < 0.05) among subjects who suffered from iron deficiency anaemia (51.7% vs. 29.8%). Furthermore, thin subjects had a 5 fold higher risk of suffering from iron deficiency anaemia (P< 0.05) than non-thin subjects (OR: 5.1; 95%CI 1.34-19.00). Further study was recommended to explore other factors associated with anaemia and iron deficiency anaemia, such as the thalassemia trait and vitamin A deficiency. The current iron-folate supplementation program for pregnant women should be expanded to adolescent girls.

Determination of discretionary salt intake in an iodine deficient area of East Java-Indonesia using three different methods.

As salt is a potential vehicle for delivering iodine to a population, study on salt intake is important. Many methods have been used to measure iodised-salt intake, but the methods were suspected to be inaccurate. A new method, called a lithium-marker technique, has been considered as suitable and safe; hence it has been proposed as a gold standard for measuring the actual salt intake of an individual. We conducted a study to determine discretionary salt intake using the lithium marker technique. The study shows that the total salt intake for children (N = 15) and mothers (N = 15) were 5.4+/-2.1 g/d and 5.8+/-1.7 g/d respectively in which 48.5+/-17.1% and 50.5?17.3% were discretionary salt. The discretionary salt intake measured using lithium marker (2.53 +/- 1.2 g/d for children and 2.99 +/- 1.5 g/d for mother) were significantly lower than using 24-hour salt recall (7.01+/-2.44 g/cap/d) and salt weighing (6.00+/-1.8 g/cap/d) (p<0.001). In conclusion, the discretionary salt intake by 24-hour salt recall and salt weighing were over estimated as compared to the lithium-labelled salt measurement. It is recommended that the level of iodine fortification in salt be increased up to 80-100 ppm of KIO3 to provide iodine intake of 150 microg/d.

Mental and psychomotor development in Indonesian infants of mothers supplemented with vitamin A in addition to iron during pregnancy.

Maternal nutrition is important for fetal development, but its impact on the functional outcome of infants is still unclear. The present study investigated the effects of vitamin A and Fe supplementation during gestation on infant mental and psychomotor development. Mothers of infants from five villages in Indonesia were randomly assigned to supervised, double-blind supplementation once per week from approximately 18 weeks of pregnancy until delivery. Supplementation comprised 120 mg Fe+500 microg folic acid with (n 94) or without (n 94) 4800 microg retinol in the form of retinyl acetate. Mothers of infants who participated in the national Fe+folic acid supplementation programme, but whose intake of supplements was not supervised, were recruited from four other villages (n 88). The mental and psychomotor development of infants was assessed, either at 6 or 12 months of age, using the Bayley Scales of Infant Development (BSID). We found no impact of vitamin A supplementation on mental or psychomotor development of infants. In addition, infants whose mothers had received weekly Fe supplementation had similar mental and psychomotor indices as those whose mothers had participated in the governmental Fe supplementation programme. The study population was moderately Fe and vitamin A deficient. The size of the treatment groups was large enough to detect a mean difference of 10 points on the BSID, which is less than 1 sd (15 points) of the average performance of an infant on the BSID. In conclusion, the present study did not find an impact of weekly supplementation of 4800 RE vitamin A in addition to Fe during gestation on functional development of Indonesian infants. However, smaller improvements in development may be seen if studied in a larger and/or more deficient population.

Nutritional status and linear growth of Indonesian infants in west java are determined more by prenatal environment than by postnatal factors.

One of the health problems in Indonesia is the high prevalence of stunting in infants. Determinants and specifically the relative contribution of prenatal and postnatal factors to growth and nutritional status of Indonesian infants were investigated. Newborn infants, from women recruited at approximately 18 wk of pregnancy from 9 rural villages in West Java, Indonesia, were followed until 12-15 mo of age. Weight, length, morbidity, breast-feeding and food intake were assessed monthly. Determinants of length and weight increase and nutritional status reflected by Z-scores were evaluated using multiple linear regression. Neonatal weight (3.2 +/- 0.5 kg) and length (49.7 +/- 2.2 cm) were reasonable. However, growth started to falter at 6-7 mo of age, resulting in prevalences of 24% stunting and 32% underweight at 12 mo of age. The multiple regression models explained 19-41% of the variation in growth and nutritional status of infants. Neonatal weight (beta = 0.285) and length (beta = 0.492) were the strongest positive predictors of weight-for-age and height-for-age Z-scores, respectively. Fever was negatively associated with weight increase (beta = -0.144) and weight-for-age (beta = -0.142) and weight-for-height Z-scores (beta = -0.255) but not with length increase or height-for-age Z-scores. Intake of complementary foods was positively associated with increases in weight (beta = 0.190) and length (beta = 0.179) and nutritional status of infants (beta = 0.136-0.194). In conclusion, in this rural population in West Java, neonatal weight and especially length, reflecting the prenatal environment, are the most important predictors of infant nutritional status.