Prospects for better nutrition in India.

Being home to 31% of the world's children who are stunted and 42% of those who are underweight, and with many children and adults affected by micronutrient deficiencies, India is facing huge challenges in the field of nutrition. Even though the Indian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the Integrated Child Development Services program alone costs 3 billion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons for this reduction are not unambiguous and appear to include state government commitment, focus on the 'window of opportunity', improved status and education of women, a lowered fertility rate, and combinations of nutrition- specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked with a range of partners to improve access to nutritious foods for large parts of the population, through public and private delivery channels. This supplement presents a selection of these activities, ranging from a capacityassessment of frontline workers in the ICDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.

Treatment of moderate acute malnutrition with ready-to-use supplementary food results in higher overall recovery rates compared with a corn-soya blend in children in southern Ethiopia: an operations research trial.

BACKGROUND: Moderate and severe acute malnutrition affects 13% of children <5 y of age worldwide. Severe acute malnutrition affects fewer children but is associated with higher rates of mortality and morbidity. Supplementary feeding programs aim to treat moderate acute malnutrition and prevent the deterioration to severe acute malnutrition. OBJECTIVE: The aim was to compare recovery rates of children with moderate acute malnutrition in supplementary feeding programs by using the newly recommended ration of ready-to-use supplementary food (RUSF) and the more conventional ration of corn-soya blend (CSB) in Ethiopia. DESIGN: A total of 1125 children aged 6-60 mo with moderate acute malnutrition received 16 wk of CSB or RUSF. Children were randomly assigned to receive one or the other food. The daily rations were purposely based on the conventional treatment rations distributed at the time of the study in Ethiopia: 300 g CSB and 32 g vegetable oil in the control group (1413 kcal) and 92 g RUSF in the intervention group (500 kcal). The higher ration size of CSB was provided because of expected food sharing. RESULTS: The HR for children in the CSB group was 0.85 (95% CI: 0.73, 0.99), which indicated that they had 15% lower recovery (P = 0.039). Recovery rates of children at the end of the 16-wk treatment period trended higher in the RUSF group (73%) than in the CSB group (67%) (P = 0.056). CONCLUSION: In comparison with CSB, the treatment of moderate acute malnutrition with RUSF resulted in higher recovery rates in children, despite the large ration size and higher energy content of the conventional CSB ration.

Can multi-micronutrient food fortification improve the micronutrient status, growth, health, and cognition of schoolchildren? A systematic review.

Micronutrient deficiencies compromise the health and development of many school-age children worldwide. Previous research suggests that micronutrient interventions might benefit the health and development of school-age children and that multiple micronutrients might be more effective than single micronutrients. Fortification of food is a practical way to provide extra micronutrients to children. Earlier reviews of (multiple) micronutrient interventions in school-age children did not distinguish between supplementation or fortification studies. The present review includes studies that tested the impact of multiple micronutrients provided via fortification on the micronutrient status, growth, health, and cognitive development of schoolchildren. Twelve eligible studies were identified. Eleven of them tested the effects of multiple micronutrients provided via fortified food compared to unfortified food. One study compared fortification with multiple micronutrients to fortification with iodine alone. Multi-micronutrient food fortification consistently improved micronutrient status and reduced anemia prevalence. Some studies reported positive effects on morbidity, growth, and cognitive outcomes, but the overall effects on these outcomes were equivocal.

The nutritional status of school-aged children: why should we care?

BACKGROUND: The nutritional status of school-aged children impacts their health, cognition, and subsequently their educational achievement. The school is an opportune setting to provide health and nutrition services to disadvantaged children. Yet, school-aged children are not commonly included in health and nutrition surveys. An up-to-date overview of their nutritional status across the world is not available. OBJECTIVE: To provide a summary of the recent data on the nutritional status of school-aged children in developing countries and countries in transition and identify issues of public health concern. METHODS: A review of literature published from 2002 to 2009 on the nutritional status of children aged 6 to 12 years from Latin America, Africa, Asia, and the Eastern Mediterranean region was performed. Eligible studies determined the prevalence of micronutrient deficiencies or child under- and overnutrition using biochemical markers and internationally accepted growth references. RESULTS: A total of 369 studies from 76 different countries were included. The available data indicate that the nutritional status of school-aged children in the reviewed regions is considerably inadequate. Underweight and thinness were most prominent in populations from South-East Asia and Africa, whereas in Latin America the prevalence of underweight or thinness was generally below 10%. More than half of the studies on anemia reported moderate (> 20%) or severe (> 40%) prevalence of anemia. Prevalences of 20% to 30% were commonly reported for deficiencies of iron, iodine, zinc, and vitamin A. The prevalence of overweight was highest in Latin American countries (20% to 35%). In Africa, Asia, and the Eastern Mediterranean, the prevalence of overweight was generally below 15%. CONCLUSIONS: The available data indicate that malnutrition is a public health issue in school-aged children in developing countries and countries in transition. However, the available data, especially data on micronutrient status, are limited. These findings emphasize the need for nutrition interventions in school-aged children and more high-quality research to assess nutritional status in this age group.

Quality criteria for micronutrient powder products: report of a meeting organized by the World Food Programme and Sprinkles Global Health Initiative.

Distribution of micronutrient powder (MNP), also known as Sprinkles", is becoming a preferred strategy for addressing micronutrient deficiencies. In response, different formulations are being developed, different producers manufacture MNP and several organizations coordinate distribution. However, as yet, the supply of MNP as well as experience with large-scale MNP programs is limited. To facilitate expansion of MNP use such that acceptability and compliance are high and effectiveness maintained, product quality, of both powder and packaging, good advocacy among decision makers, and providing good information to the target population are crucial. A meeting was organized in Toronto by the Sprinkles Global Health Initiative and the World Food Programme to review and reach consensus on quality criteria for composition, manufacturing, packaging, and labeling of MNP propose guidelines for wide-scale production, and discuss MNP program experience. It was recognized that the durability of some of the more sensitive micronutrients in their powdered form in the harsh climatic conditions of many countries has implications for formulation, packaging, storage, and handling of the MNP product. A question-and-answer manual would greatly facilitate program design and implementation. It was agreed to form an interim Technical Advisory Group to prepare for formation of a Technical Advisory Group with agreed-upon tasks and responsibilities. The MNP manufacturing manual of the Sprinkles Global Health Initiative can continue to be used, with reference to the recommendations from the Toronto Meeting outlined in this paper. Meanwhile, the Sprinkles Global Health Initiative will not place any encumbrances on production using its manual; however, the brand name Sprinkles" will stay protected under various trademark laws.

Maize meal fortification is associated with improved vitamin A and iron status in adolescents and reduced childhood anaemia in a food aid-dependent refugee population.

OBJECTIVE: To assess changes in the Fe and vitamin A status of the population of Nangweshi refugee camp associated with the introduction of maize meal fortification. DESIGN: Pre- and post-intervention study using a longitudinal cohort. SETTING: Nangweshi refugee camp, Zambia. SUBJECTS: Two hundred and twelve adolescents (10-19 years), 157 children (6-59 months) and 118 women (20-49 years) were selected at random by household survey in July 2003 and followed up after 12 months. RESULTS: Maize grain was milled and fortified in two custom-designed mills installed at a central location in the camp and a daily ration of 400 g per person was distributed twice monthly to households as part of the routine food aid ration. During the intervention period mean Hb increased in children (0.87 g/dl; P < 0.001) and adolescents (0.24 g/dl; P = 0.043) but did not increase in women. Anaemia decreased in children by 23.4% (P < 0.001) but there was no significant change in adolescents or women. Serum transferrin receptor (log10-transformed) decreased by -0.082 microg/ml (P = 0.036) indicating an improvement in the Fe status of adolescents but there was no significant decrease in the prevalence of deficiency (-8.5%; P = 0.079). In adolescents, serum retinol increased by 0.16 micromol/l (P < 0.001) and vitamin A deficiency decreased by 26.1% (P < 0.001). CONCLUSIONS: The introduction of fortified maize meal led to a decrease in anaemia in children and a decrease in vitamin A deficiency in adolescents. Centralised, camp-level milling and fortification of maize meal is a feasible and pertinent intervention in food aid operations.

Fortifying food in the field to boost nutrition: case studies from Afghanistan, Angola, and Zambia.

Deficiencies in micronutrients such as iron, vitamin A, and iodine affect billions of people worldwide, causing death, disease, and disability. The UN World Food Programme (WFP) has long been recognised for its ability to deliver food to some of the most remote locations, under the toughest conditions: refugees in border camps, populations cut off by conflict, extremely poor and marginalised people like ethnic minorities, orphans, and widows. Relatively little, however, is known about its efforts to ensure that the food it delivers not only provides enough calories for immediate survival but also provides the vitamins and minerals needed for healthy growth and development. Much of the food delivered by WFP is fortified with iron, vitamin A, and other micronutrients before being shipped. But there are several reasons to mill and fortify food as close to the beneficiaries as possible. For instance, milling and fortifying food locally helps to overcome the problems of the short shelf-life of whole fortified maizemeal. It also enhances the nutritional value of locally procured cereals. And it can foster demand for fortified foods among local consumers beyond WFP beneficiaries, thus nurturing an industry with potentially significant benefits for the health of entire communities. This paper outlines three approaches by WFP to fortifying cereals in Afghanistan, Angola, and Zambia. It examines the challenges faced and the outcomes achieved in an effort to share this knowledge with others dedicated to improving the nutritional status of poor and food-insecure people. In Afghanistan, attempts to mill and fortify wheat flour using small-scale chakki mills were successful but much larger-scale efforts would be needed to promote demand and reach the level of consumption required to address serious iron deficiencies across the country. In Angola, maize has been fortified to combat the persistent occurrence of pellagra, a micronutrient deficiency disease found among people whose diets are dominated by maize. By providing fortification equipment to a commercial mill at the port of Lobito and using a vitamin and mineral pre-mix provided by UNICEF, this project has overcome many of the difficulties common in countries emerging from conflict to provide monthly fortified maize rations to some 115,000 beneficiaries. In Zambia, iron deficiency anaemia was a serious problem among camp-restricted refugees. WFP and its partners imported, installed, and trained workers in the use of two containerized milling and fortification units (MFUs), halved iron-deficiency anaemia, and reduced vitamin A deficiency among camp residents. In addition, WFP dramatically reduced waiting times for refugees who used to have their whole grain maize rations milled at small local facilities with insufficient milling capacity. The context and scale of each of the three case-studies described in this paper was different, but the lessons learned are comparable. All projects were succesful in their own right, but also required a considerable amount of staff time and supervision as well as external technical expertise, limiting the potential for scaling up within the WFP operational context. In order to expand and sustain the provision of fortified cereal flour to WFP beneficiaries and beyond, getting the private milling sector as well as governments on board would be crucial. Where this is not possible, such as in very isolated, difficult to reach locations, strong, specialized partners are a prerequisite, but these are few in number. Alternatively, in such contexts or in situations where the need is urgent and cannot be met through local flour fortification in the short term, or through local purchases of fresh foods, other approaches to improve the diet, such as the use of multimicronutrient formulations, packed for individual or household use, may be more appropriate.

Whole blood NAD and NADP concentrations are not depressed in subjects with clinical pellagra.

Population surveys for niacin deficiency are normally based on clinical signs or on biochemical measurements of urinary niacin metabolites. Status may also be determined by measurement of whole blood NAD and NADP concentrations. To compare these methods, whole blood samples and spot urine samples were collected from healthy subjects (n = 2) consuming a western diet, from patients (n = 34) diagnosed with pellagra and attending a pellagra clinic in Kuito (central Angola, where niacin deficiency is endemic), and from female community control subjects (n = 107) who had no clinical signs of pellagra. Whole blood NAD and NADP concentrations were measured by microtiter plate-based enzymatic assays and the niacin urinary metabolites 1-methyl-2-pyridone-5-carboxamide (2-PYR) and 1-methylnicotinamide (1-MN) by HPLC. In healthy volunteers, inter- and intra-day variations for NAD and NADP concentrations were much lower than for the urinary metabolites, suggesting a more stable measure of status. However, whole blood concentrations of NAD and NADP or the NAD:NADP ratio were not significantly depressed in clinical pellagra. In contrast, the concentrations of 2-PYR and 1-MN, expressed relative to either creatinine or osmolality, were lower in pellagra patients and markedly higher following treatment. The use of the combined cut-offs (2-PYR <3.0 micromol/mmol creatinine and 1-MN <1.3 micromol/mmol creatinine) gave a sensitivity of 91% and specificity of 72%. In conclusion, whole blood NAD and NADP concentrations gave an erroneously low estimate of niacin deficiency. In contrast, spot urine sample 2-PYR and 1-MN concentrations, relative to creatinine, were a sensitive and specific measure of deficiency.

Low and deficient niacin status and pellagra are endemic in postwar Angola.

BACKGROUND: Outbreaks of pellagra were documented during the civil war in Angola, but no contemporary data on the incidence of pellagra or the prevalence of niacin deficiency were available. OBJECTIVE: The objective was to investigate the incidence of pellagra and the prevalence of niacin deficiency in postwar Angola and their relation with dietary intake, poverty, and anthropometric status. DESIGN: Admissions data from 1999 to 2004 from the pellagra treatment clinic in Kuito, Angola, were analyzed. New patients admitted over 1 wk were examined, and urine and blood samples were collected. A multistage cluster population survey collected data on anthropometric measures, household dietary intakes, socioeconomic status, and clinical signs of pellagra for women and children. Urinary excretion of 1-methylnicotinamide, 1-methyl-2-pyridone-5-carboxymide, and creatinine was measured and hemoglobin concentrations were measured with a portable photometer. RESULTS: The incidence of clinical pellagra has not decreased since the end of the civil war in 2002. Low excretion of niacin metabolites was confirmed in 10 of 11 new clinic patients. Survey data were collected for 723 women aged 15-49 y and for 690 children aged 6-59 mo. Excretion of niacin metabolites was low in 29.4% of the women and 6.0% of the children, and the creatinine-adjusted concentrations were significantly lower in the women than in the children (P < 0.001, t test). In children, niacin status was positively correlated with the household consumption of peanuts (r = 0.374, P = 0.001) and eggs (r = 0.290, P = 0.012) but negatively correlated with socioeconomic status (r = -0.228, P = 0.037). CONCLUSIONS: The expected decrease in pellagra incidence after the end of the civil war has not occurred. The identification of niacin deficiency as a public health problem should refocus attention on this nutritional deficiency in Angola and other areas of Africa where maize is the staple.