bluuebunny/crossref_metadata_2025 huggingface dataset:
Zinc Fortification of Cereal Flours: Current Recommendations and Research Needs
Authors: Brown Kenneth H. , Hambidge K. Michael , Ranum Peter
Published: November 2015

Background

Zinc fortification is recommended as an appropriate strategy to enhance population zinc status, but guidelines are needed on the appropriate types and levels of zinc fortification of cereal flours for mass fortification programs.

Objective

To review available information on the scientific rationale, efficacy, and effectiveness of zinc fortification programs, and to develop guidelines on appropriate levels of fortification of cereal flours, based on simulations of the amount of zinc absorbed under different dietary conditions and information on possible adverse effects.

Methods

Systematic review of scientific literature and application of an existing prediction equation to estimate zinc absorption.

Results

Previously completed research demonstrates that zinc intake and absorption are increased when zinc-fortified foods are consumed, but little information is, as yet, available on the biologic impact of large-scale fortification programs. Studies suggest that there are no disadvantages of the recommended ranges of zinc fortification with regard to the sensory properties of zinc-fortified foods, and most research indicates that there are no adverse effects of zinc fortification on the utilization of other minerals.

Conclusions

Zinc fortification of cereal flour is a safe and appropriate strategy for enhancing the zinc status of population subgroups who consume adequate amounts of fortified cereal flour, although additional information is needed to confirm the efficacy and effectiveness of large-scale zinc fortification programs to control zinc deficiency. The appropriate level of fortification depends on the population subgroup, their usual amount of flour intake, the degree of milling and fermentation that is practiced, and the usual intakes of zinc and phytate from other food sources. Fortification recommendations are presented for different dietary scenarios.
The Role of the Codex Alimentarius Process in Support of New Products to Enhance the Nutritional Health of Infants and Young Children
Authors: Zlotkin Stanley , Siekmann Jonathan , Lartey Anna , Yang Zhenyu
Published: November 2015

The Codex Alimentarius is a collection of internationally recognized standards, codes of practice, guidelines, and other recommendations relating to foods, food production, and food safety. Among other functions, it is responsible for setting international standards for safety and hygiene. Codex food standards and guidelines directed at foods produced primarily for young infants and children have important implications for maintaining nutritional status and health, especially given the positioning of these products as components of established World Health Organization (WHO)/UNICEF-recommended feeding strategies. Recently, new products targeted at this age group (e.g., lipid-based nutrient supplements and micronutrient powders) have been produced and used, but these are not totally covered under existing Codex guidelines or standards. The objective of this paper is to review the role of the Codex process and specifically to suggest revisions to existing Codex guidelines on formulated complementary foods (Guidelines for Formulated Supplementary Foods for Older Infants and Young Children, CAC/GL 08–1991) to encompass this new category of fortified complementary foods and home fortificants. In reviewing the existing guidelines, potential areas for revision included the sections on the recommended nutrients in these foods and their intended use. Updating the Codex guidelines provides the opportunity to encourage production and use of new products for children and help ensure that such foods, when used as directed, do not interfere with breastfeeding. The revised guidelines would help governments develop national regulations covering all forms of formulated complementary foods. They would also lessen impediments to international trade by providing clear guidance for foods used in feeding programs and for young children, particularly in developing countries.
A Review of Phytate, Iron, Zinc, and Calcium Concentrations in Plant-Based Complementary Foods Used in Low-Income Countries and Implications for Bioavailability
Authors: Gibson Rosalind S. , Bailey Karl B. , Gibbs Michelle , Ferguson Elaine L.
Published: November 2015

Plant-based complementary foods often contain high levels of phytate, a potent inhibitor of iron, zinc, and calcium absorption. This review summarizes the concentrations of phytate (as hexa- and penta-inositol phosphate), iron, zinc, and calcium and the corresponding phytate:mineral molar ratios in 26 indigenous and 27 commercially processed plant-based complementary foods sold in low-income countries. Phytate concentrations were highest in complementary foods based on unrefined cereals and legumes (∼600 mg/100 g dry weight), followed by refined cereals (∼100 mg/100 g dry weight) and then starchy roots and tubers (< 20 mg/100 g dry weight); mineral concentrations followed the same trend. Sixty-two percent (16/26) of the indigenous and 37% (10/27) of the processed complementary foods had at least two phytate:mineral molar ratios (used to estimate relative mineral bioavailability) that exceeded suggested desirable levels for mineral absorption (i.e., phytate:iron < 1, phytate:zinc < 18, phytate:calcium < 0.17). Desirable molar ratios for phytate:iron, phytate:zinc, and phytate:calcium were achieved for 25%, 70%, and 57%, respectively, of the complementary foods presented, often through enrichment with animal-source foods and/or fortification with minerals. Dephytinization, either in the household or commercially, can potentially enhance mineral absorption in high-phytate complementary foods, although probably not enough to overcome the shortfalls in iron, zinc, and calcium content of plant-based complementary foods used in low-income countries. Instead, to ensure the World Health Organization estimated needs for these minerals from plant-based complementary foods for breastfed infants are met, dephytinization must be combined with enrichment with animal-source foods and/or fortification with appropriate levels and forms of mineral fortificants.
The Management of Conflict in Nutrition Policy Formulation: Choosing Growth-Monitoring Indicators in the Context of Dual Burden
Authors: Hoey Lesli , Pelletier David L.
Published: November 2015

We argue in this paper that a shared desire to find a solution to malnutrition and agreement at a broad level concerning priority, evidence-based interventions are important but not sufficient conditions for effective policy development. This paper illustrates this point, and draws out general implications, through a detailed analysis of a case in which conflict emerged when committed nutrition policy actors began discussing the details of program design and implementation. The case involves one country's effort to select “the best” anthropometric indicator for use in its national child growth-monitoring program. In this case the interested parties approached this deceptively simple decision for different reasons, using different sources and standards of evidence and focusing their attention on opposite, but equally critical, operational considerations, while being heavily influenced by global, national, and interorganizational events and relationships. We suggest that actors seeking to translate political commitment for nutrition into effective action should recognize the technical and sociopolitical complexity of seemingly simple decisions related to intervention design and employ more systematic, intentional, and inclusive decision-making procedures. Without attention to such practical matters, the current window of opportunity to reduce malnutrition on a global scale may quickly close.
The Formulation of Consensus on Nutrition Policy: Policy Actors' Perspectives on Good Process
Authors: Hill Renée , Gonzalez Wendy , Pelletier David L.
Published: November 2015

Food security and nutrition are ascendant issues on global and national policy agendas in recent years, as a result of the global food crisis and growing recognition of the magnitude and consequences of these problems for human and economic development. The translation of this attention into effective action at the country level will require multistakeholder agreements concerning priority problems, interventions, delivery strategies, roles and responsibilities, and other matters, but this has proven to be a difficult and contentious process in many countries. This study explores stakeholders' perspectives on the characteristics of a good process in Guatemala, a country that has encountered difficulties deciding such matters in recent years, as well as their views on decision acceptance and the feasibility of implementing a good process. Semistructured interviews were conducted with 20 participants in earlier policy deliberations who were identified through snowball sampling. The constant comparative method was used for analysis. These partici- pants attach great importance to the quality of decision processes, have strong support for decision principles derived from theory and experience elsewhere, would be willing to participate in such a process and accept the resulting decisions, and feel such a process would be challenging but feasible in the Guatemalan context. These findings, together with experiences elsewhere, suggest that countries would do well to seek agreement on the design of a multistakeholder decision-making process before they seek agreement on priority nutrition problems, target groups, interventions, delivery strategies, and other matters that have proven contentious in many settings.
Sweet Potato-Based Complementary Food for Infants in Low-Income Countries
Authors: Amagloh Francis Kweku , Hardacre Allan , Mutukumira Anthony N. , Weber Janet L. , Brough Louise , Coad Jane
Published: November 2015

Background

In low-income countries, most infants are given cereal-based complementary foods prepared at the household level. Such foods are high in phytate, which limits the bioavailability of nutrients, including iron, calcium, zinc, and in some cases proteins, which are crucial to the development of infants.

Objective

To compare the levels of macronutrients (protein, fat, and carbohydrate), gross energy, and fructose in sweet potato-based (denoted ComFa) formulations and enriched Weanimix (dehulled maize–dehulled soybean–groundnut blend with fish powder and sugar incorporated). The phytate level was also compared.

Methods

A composite flour of sweet potato and soybeans containing fish powder was processed by oven toasting as a home-based complementary food. Another blend containing skim milk powder was processed by extrusion cooking or roller drying as industrial-based prototypes. The macronutrient composition and the levels of fructose and phytate were determined in the ComFa formulations and enriched Weanimix.

Results

The ComFa formulations and the enriched Weanimix met the stipulated values in the Codex Alimentarius Commission standard for energy (400 kcal/100 g), protein (15 g/100 g), and fat (10 to 25 g/100 g) for complementary food, with the exception of the industrial-based ComFa formulations, which satisfied 83% of the protein requirement (15 g/100 g). The ComFa formulations had a quarter of the phytate level of enriched Weanimix. The fructose level in the sweet potato-based complementary foods was more than five times that in enriched Weanimix.

Conclusions

The sweet potato-based formulations were superior to enriched Weanimix as complementary foods for infants in low-income countries, based on the fructose (which makes the porridge naturally sweet) and phytate levels.
United Nations High Commissioner for Refugees Feeding Program Performance in Kenya and Tanzania: A Retrospective Analysis of Routine Health Information System Data
Authors: Tappis Hannah , Doocy Shannon , Haskew Christopher , Wilkinson Caroline , Oman Allison , Spiegel Paul
Published: November 2015

Background

The United Nations High Commissioner for Refugees (UNHCR) Health Information System is a primary source of routine nutrition program data and provides a comprehensive assessment of UNHCR selective feeding programs in more than 90 refugee camps in 18 countries worldwide.

Objective

To evaluate the coverage and effectiveness of UNHCR supplementary and therapeutic feeding programs for malnourished children under 5 years of age in Kenya and Tanzania refugee camps.

Methods

Analysis of Kenya and Tanzania refugee camp population, growth monitoring, and nutrition program data from the UNHCR Health Information System.

Results

UNHCR-supported implementing partners in Kenya and Tanzania admitted nearly 45,000 malnourished refugee children in selective feeding programs between January 2006 and May 2009. Average recovery rates of 77.1% and 84.6% in the therapeutic and supplementary programs, respectively, mortality rates of less than 1%, and average readmission below 5% suggest that feeding programs had a beneficial effect on enrolled children.

Conclusions

Increasing admission and enrollment in supplementary feeding programs was successful in preventing cases of severe malnutrition in some camps. Further attention to these camps would be likely to yield sizeable benefits in terms of absolute reductions in malnutrition prevalence and mortality rates.
Methods of Using Household Consumption and Expenditures Survey (HCES) Data to Estimate the Potential Nutritional Impact of Fortified Staple Foods
Authors: Imhoff-Kunsch Beth , Flores Rafael , Dary Omar , Martorell Reynaldo
Published: November 2015

Background

Micronutrient malnutrition, caused largely by inadequate dietary intake, is a global public health problem that adversely affects health, child growth and development, work capacity, and quality of life. Mass fortification of widely consumed edible products has the potential to increase micronutrient intakes and thus alleviate some nutritional deficiencies. Although individual-level data about food consumption patterns are ideal for informing the design of food fortification programs, they are often unavailable. Household Consumption and Expenditures Surveys (HCES) are nationally representative cross-sectional surveys conducted over a 12-month period every 2 to 5 years, primarily to characterize household expenditures.

Objective

We describe how expenditure data from HCES can serve as a proxy for household food consumption and thus aid in choosing which foods to fortify and in determining how much of a micronutrient to add to that food.

Methods

We describe methods of using HCES data to characterize apparent food consumption patterns among different strata within a population.

Results

There are several limitations of using HCES data to describe apparent food consumption. HCES do not directly capture information about true food intake, but rather describe food expenditures. We assume that purchased foods are not shared with guests, wasted, fed to animals, gifted, or stockpiled for later use. We also assume that foods are allocated within each household based on energy needs.

Conclusions

Despite the limitations of using HCES data to estimate apparent food consumption, the dearth of individual-level data about food intake renders HCES data useful in designing food fortification programs.
Still Waiting for Godot? Improving Household Consumption and Expenditures Surveys (HCES) to Enable More Evidence-Based Nutrition Policies
Authors: Fiedler John L. , Carletto Calogero , Dupriez Olivier
Published: November 2015

Background

The constrained evidence base of food and nutrition policy-making compromises nutrition programs. Nutrition policy-making must do better than relying exclusively on Food and Agriculture Organization Food Balance Sheets. The strategy of relying on observed-weighed food record or 24-hour recall surveys has not proven practical either; they remain few in number, generally not nationally representative, and of dubious external validity. Although Household Consumption and Expenditures Surveys (HCES) have shortcomings, they are increasingly being used to address this information gap.

Objective

To promote dialog within the nutrition community, and between it and the greater community of HCES stakeholders, in order to identify their shared agenda and develop a strategy to improve HCES for analyzing food and nutrition issues.

Methods

The diverse origins and objectives of HCES are described, the evolution of their use in addressing food and nutrition issues is traced, and their shortcomings are identified.

Results

The causes, relative importance, some potential solutions, and the strategic implications of three distinct categories of shortcomings are discussed. Elements of a possible approach and process for strengthening the surveys are outlined, including identifying best practices, developing guidelines and more rigorously analyzing the tradeoffs involved in common, key survey design and implementation decisions.

Conclusions

To date, the nutrition community's role in most HCES has been as a passive user of secondary data. The nutrition community must become more involved in the design, implementation, and analysis of HCES by identifying criteria for prioritizing countries, establishing assessment criteria, applying the criteria in retrospective assessments, identifying key shortcomings, and recommending alternatives to ameliorate the short-comings. Several trends suggest that this is a propitious time for improving the relevance and reliability of HCES.
Fortifying baladi Bread in Egypt: Reaching More than 50 Million People through the Subsidy Program
Authors: Elhakim Nadine , Laillou Arnaud , El Nakeeb Anwar , Yacoub Rukia , Shehata Magdy
Published: November 2015

Background

Micronutrient deficiencies, especially iron-deficiency anemia, are a public health problem in Egypt, where anemia rates almost doubled in the years from 2000 to 2005. In 2008, the Government of Egypt began implementation of a 5-year national program to fortify with iron and folic acid the wheat flour used in baking subsidized baladi bread, the staple food consumed by a majority of low-income groups.

Objective

To project the achievements of this national Wheat Flour Fortification Program.

Methods

This paper describes the program, estimates the production of fortified flour and consumption of fortified bread, and identifies program challenges and sustainability issues.

Results

Through the national Wheat Flour Fortification Program, ferrous sulfate and folic acid are now added to all wheat flour produced under the national Food Subsidy Program. Up to 50 million Egyptians nationwide are now consuming quality-assured fortified baladi bread on a daily basis. In 2011, 6.5 million MT of fortified wheat flour was produced by 143 participating public- and private-sector mills. Political changes in Egypt in 2011 did not seem to affect the program; the new leadership in the Ministry of Supply and Internal Trade remains committed to fortification of wheat flour.

Conclusions

The daily intake of approximately 12 mg of iron and 600 μg of folic acid through the consumption of baladi bread suggests that the impact of the program on the prevention and reduction of iron and folate deficiencies among the Egyptian population could be significant; the results of an end-line survey are pending.
Evolution of the Child Health Day Strategy for the Integrated Delivery of Child Health and Nutrition Services
Authors: Palmer Amanda C. , Diaz Theresa , Noordam Aaltje Camielle , Dalmiya Nita
Published: November 2015

Background

In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-to-reach and older children who are often missed by routine, fixed-site health services.

Objective

To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five.

Methods

We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010 from global monitoring databases for vitamin A and immunization.

Results

Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition.

Conclusions

The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.
Spatial Analysis of Undernutrition of Children in Léogâne Commune, Haiti
Authors: Spray Andrea L. , Eddy Brittany , Hipp James Aaron , Iannotti Lora
Published: November 2015

Background

Over a fifth (21.9%) of children under 5 years of age in Haiti suffer from chronic malnutrition, 11.4% are underweight, and 5.1% suffer from acute malnutrition. Léogâne Commune has one of the highest under-five mortality rates in the country. Ordinary least squares regression conducted using data from household surveys to assess the impact of causal factors on child undernutrition may mask important local variations.

Objective

To characterize the nutrition and health situation of children 6 to 35 months of age in Léogâne Commune, Haiti, using geographically weighted regression.

Methods

In July 2008, the Children's Nutrition Program of Haiti conducted a representative cross-sectional household survey ( N = 150) using a modified 33 × 6 alternative sampling design. Household questionnaires were administered to caregivers of children 6 to 35 months of age and anthropometric measurements were collected. Geographically weighted regression was employed to evaluate how undernutrition (weight-for-age) and its household determinants vary across the region. Geographically weighted regression and ordinary least squares regression models were compared.

Results

The residuals of the ordinary least squares regression model were spatially autocorrelated (Moran's I = 0.08, z = 1.90, p = .058), indicating that under-nutrition occurs in pockets rather than being evenly distributed throughout the population. There was no improvement in performance from the ordinary least squares regression model to the geographically weighted regression model.

Conclusions

Despite some limitations, this study illustrates a promising approach for using geospatial data to improve the understanding of how a nutrition situation varies across a region and provide deeper insight into its underlying causes.
Eating Habits, Inactivity, and Sedentary Behavior among Adolescents in Iraq: Sex Differences in the Hidden Risks of Noncommunicable Diseases
Authors: Musaiger Abdulrahman O. , Al-Mufty Berivan A. , Al-Hazzaa Hazzaa M.
Published: November 2015

Background

Noncommunicable diseases have become the main causes of death in several developing countries. There is a severe shortage of information about the risk factors for these diseases in Iraq.

Objective

To explore the eating habits, physical activity, and sedentary behaviors of adolescents in Mosul City, Iraq, as risk factors for noncommunicable diseases.

Methods

A multistage stratified sampling method was carried out on adolescents aged 15 to 18 years in Mosul City, Iraq. A pretested and validated questionnaire was used to obtain information on frequency of intake of certain foods, physical activity, and screen time (television, video, and computer). Weight and height were measured to obtain the body composition status. The total sample included 723 adolescents (350 boys and 373 girls).

Results

There were significant differences between boys and girls in most eating habits and activity behaviors. The frequency of skipping breakfast and the intakes of fruits and vegetables, french fries, and sweets and chocolates were significantly higher among girls than boys ( p < .001). Boys were significantly more likely to consume fast foods, sugar-sweetened drinks, and energy drinks than girls. Boys spent more time in physical activity ( p < .001) and looking at screens than girls.

Conclusions

The health authorities of Iraq should focus not only on interventions for undernutrition among adolescents, but also on behavioral risk factors for diet-related noncommunicable diseases.
A Review of the Vitamin A Supplementation Program in India: Reasons for Success in the States of Bihar and Odisha
Authors: Rah Jee H. , Houston Robin , Mohapatra Biswajit D. , Kumar Shri Sanjay , Saiyed Farhat , Bhattacharjee Sourav , Aguayo Victor M.
Published: November 2015

Background

Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation.

Objective

To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors.

Methods

A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners.

Results

Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff.

Conclusions

The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable.
Energy and Nutrient Intake and Acceptability of Nutritionally Balanced School Meals in Filipino Students
Authors: Angeles-Agdeppa Imelda , Neufingerl Nicole , Magsadia Clarita , Hiemstra Harry , Patalen Chona , Eilander Ans
Published: November 2015

Background

School meals provide an excellent opportunity to improve children's diet.

Objective

To investigate dietary intakes and acceptance of nutritionally balanced school meals (“nutrimeals”) as compared with regular (“baseline”) school meals among Filipino students.

Methods

The study employed a before—after intervention design with one group. Students 13 to 16 years of age from a public school in Metro Manila ( n = 112) consumed baseline school meals for 2 weeks followed by consumption of nutri-meals for 7 weeks. Served meals and plate waste were weighed to calculate food and nutrient intakes. Acceptability of meals was assessed daily in a random subsample using a seven-point hedonic scale. Analysis of covariance corrected for age and sex was conducted to test for differences in nutrient intakes and acceptability between nutri-meals and baseline meals.

Results

Feeding nutri-meals resulted in a higher intake of vegetables (95.3 ± 13.8 g), fruit (76.5 ± 6.3 g), and fish (19.1 ± 3.3 g) than baseline meals. Energy and protein intakes significantly increased by 140.7 ± 2.8 kcal and 3.2 ± 0.1 g, respectively. The quality of fat intake improved compared with baseline meals ( p < .001). Micronutrient intake from nutri-meals was significantly higher than that from baseline meals (except for zinc), contributing 6% to 79% of recommended daily intakes. Most students (> 90%) liked both baseline and nutri-meals; however, the mean acceptability score for baseline meals was slightly higher (0.2 ± 0.07 points, p = .004).

Conclusions

Nutritionally balanced nutri-meals may be a healthier and acceptable alternative to regular Filipino school meals. Further optimization of nutri-meals is required to meet the nutritional needs of adolescents and reduce sodium content.
Short-Term Nutrition Education Reduces Low Birthweight and Improves Pregnancy Outcomes among Urban Poor Women in Bangladesh
Authors: Jahan Khurshid , Roy S. K. , Mihrshahi Seema , Sultana Nigar , Khatoon Soofia , Roy Hema , Datta Laboni Rani , Roy Anjana , Jahan Sania , Khatun Wajiha , Nahar Naimun , Steele Jessica
Published: November 2015

Background

Maternal malnutrition and poor gestational weight gain are the most important causes of low birthweight and infant mortality in Bangladesh.

Objective

To assess the effect of short-term nutrition education on weight gain in the third trimester of pregnancy, birth outcomes, and breastfeeding.

Methods

Three hundred pregnant women participated in this randomized, controlled trial during a 3-month intervention period. The study was conducted in two antenatal clinics in urban Dhaka. One group of women was given monthly education sessions during the third trimester of pregnancy to promote consumption of khichuri, while the control group received only routine services from the health facilities. Birthweight was recorded within 24 hours after delivery. Breastfeeding practices were observed for 1 month after delivery.

Results

In the intervention group, maternal weight gain in the third trimester was 60% higher (8.60 vs. 5.38 kg, p = .011), mean birthweight was 20% higher (2.98 vs. 2.49 kg, p < .001), the rate of low birth-weight was 94% lower (2.7% vs. 44.7%, p < .001), and the rate of initiation of breastfeeding within 1 hour after birth was 52% higher (86.0% vs. 56.7%, p < .001), in comparison with the control group. Birthweight was associated with frequency of intake of khichuri ( p < 0.001).

Conclusions

Nutrition education with a focus on promoting consumption of khichuri during the third trimester of pregnancy significantly reduced the rate of low birthweight and increased maternal weight gain.
Driving Social Impact with Common Global Indicators for Healthy Lifestyle Programs: Lessons Learned
Authors: Nicole R. Robinson , Gin Julia , Kamath-Jha Shilpa , Infantes Michel , Hernandez Ricardo , Alberg-Seberich Michael , Suri Devika , Pérez-Escamilla Rafael
Published: November 2015

Background

Partnerships between corporate entities and non-governmental organizations (NGOs) involved in delivering community focused health and well-being programs are becoming increasingly valuable especially in the context of promoting healthy lifestyles around the globe. The Mondelēz International Foundation (MIF) has funded healthy lifestyles community based programs targeting children and youth through partnership with seven global NGOs. To assess collective impact of these programs, it is crucial to identify best practices and common impact indicators that can be measured across programs. MIF therefore organized the Healthy Life-styles Evaluation Workshop to explore these pertinent questions.

Objective

Share best practices and identify common impact indicators to measure the success of current and future MIF funded healthy lifestyles programs.

Methods

Analysis of the Program Impact Pathways (PIPs) and measured output of each of the seven programs.

Results

Individual and combined analysis of PIPs of the seven NGO programs led to identification of three critical impact indicators: nutrition knowledge, physical activity, and healthier eating, and also enabled NGOs to identify pathways to improve program delivery among the target population.

Conclusions

This workshop enabled MIF and partner NGOs to came together to align on metrics and future engagement approaches for promoting and evaluating community based healthy lifestyles programs.
Maternal Preferences for Consistency of Complementary Foods in Guatemala
Authors: Parker Megan E. , Schroeder Dirk G. , Begin France , Hurtado Elena
Published: November 2015

Increasing the nutrient density of complementary food mixtures is a common strategy for improving child nutrition in developing countries. Such modification, however, typically increases the viscosity of the mixtures, which may not appeal to caretakers or children. To assess maternal preference for complementary food consistency, 46 rural Guatemalan mothers, each of whom had a child between 6 and 14 months of age, were interviewed by trained data collectors and participated in focus group discussions. Strong opinions regarding consistencies of complementary foods were identified, which varied according to the child's age and health status. Mothers preferred thinner complementary foods for children less than one year old and thicker foods for children more than one year old. When the child had a cough or fever, most mothers preferred thin, liquid complementary foods. When the child had diarrhoea, about half of the mothers believed thinner complementary foods would replace the water the child lost with diarrhoea, whereas other mothers believed that thicker complementary foods would harden the stool or stop diarrhoea. This information will help guide efforts to develop improved complementary foods, particularly those for use during illness in underprivileged populations of developing countries.
Emergency Nutrition
Authors: Katona-Apte Judit
Published: November 2015

Emergency nutrition is a specialization for strengthening the training and research capacities of developing countries to meet nutritional needs during natural and man-made disasters. Efforts are being made to prevent famines, especially those arising from natural disasters. However, there will be less food available in the future, although new emergency situations are developing constantly and lasting longer. It is important to train nutritionists, administrators, policy and decision makers, and others to be able to prioritize food needs and make the best use of available resources. Methodologies, techniques, expertise, and even theoretical frameworks that can be used in training programmes must be developed and strengthened. The paper discusses four areas where expertise in nutrition is weak and could be strengthened through short courses, workshops, and internships: assessment methodologies, monitoring and evaluation, conflict and post-conflict situations, and advocacy.
Overview: Rationale and Elements of a Successful Food-Fortification Programme
Authors: Darnton-Hill Ian
Published: November 2015

Over 2,000 million people, or more than one of three individuals throughout the world, are at risk for iron, vitamin A, or iodine deficiency. The three main approaches to addressing micronutrient deficiencies are fortification, supplementation, and dietary diversification. Although fortification of staple foods has played a significant role in the nutritional well-being and health of the more industrialized nations, it has not been considered an option for less developed countries because of the lack of centrally processed foods and poorly developed food-marketing systems. As food markets expand, however, fortification options are becoming increasingly available. This paper identifies past and present successes and failures, as well as the facilitating factors and constraints that need to be addressed. Based on recent experience and the lessons learned, successful programmes require at least the following: political will and support and the willingness to legislate or regulate; private-sector involvement; public-sector support; willingness of both sectors to enforce quality assurance programmes; good data on consumption patterns; social acceptability of fortified food, implying no change in organoleptic properties; and minimal change in cost.
Food Fortification: Safety and Legislation
Authors: Orriss Gregory D.
Published: November 2015

The Food and Agriculture Organization/World Health Organization (FAO/WHO) International Conference on Nutrition (ICN), held in Rome in December 1992, recognized the widespread occurrence of micronutrient deficiencies, particularly in developing countries. The conference recognized food-based approaches as the most effective way to address existing micronutrient deficiencies. These approaches must include appropriate strategies to assure dietary diversification, improved food availability, food preservation, nutrition education, and food fortification.

The final report of the conference included strategies and actions for preventing and controlling specific micronutrient deficiencies. It was proposed to ensure and legislate the fortification of foods or water with necessary micronutrients, where possible, when existing supplies fail to provide adequate levels in the diet. Food fortification has been successfully used in both developed and developing countries as one strategy to address micronutrient deficiencies.

The primary purposes of food legislation are to protect the health of the consumer, protect the consumer from fraud, and facilitate trade. In the case of fortified foods, the target population must be protected from receiving either toxic or nutritionally ineffective levels of micronutrients. Legislation may be necessary to require adequate control over this fortification process by the food processors to ensure that levels of micronutrients are consistently within acceptable limits. Legislation may also be required to prohibit the addition of nutrients to commodities where it is nutritionally unnecessary or unsafe or where fortification may create an erroneous impression as to the nutritional value of the food.

Any legislation regarding food fortification should incorporate the standards, recommendations, and guidelines of the Codex Alimentarius. The World Trade Organization (WTO) Agreement on the Application of Sanitary and Phytosanitary Measures (the SPS Agreement) and the WTO Agreement on Technical Barriers to Trade (the TBT Agreement) have placed new importance on Codex standards, guidelines, codes, and recommendations.
Fortification of Sugar with Vitamin A
Authors: Pineda Oscar
Published: November 2015

The technology for fortifying sugar with vitamin A was developed in Guatemala in the mid-1970s, and the Guatemalan government enacted legislation to make fortification mandatory in June 1974. This action was copied by other Central American governments. The fortification programme in Guatemala developed in two stages. In the first (1975–77), the fortification programme was evaluated four times at six-month intervals and was shown to be effective. The sugar industry was responsible for carrying out the programme, but the programme was suspended, mainly because of economic arguments. After 10 years of effort, the programme was restarted in 1989. At this time the programme was combined with an initial mass distribution of vitamin A capsules to pre-school children, which began the first successful social mobilization effort in the area. The programme was evaluated for six months and was shown to be effective in improving the vitamin A status of the Guatemalan population. This sec- ond stage has been active continuously since 1989. With improvements in the technology of fortification, new approaches have been tested, and now it is possible to obtain an excellent sugar doubly fortified with vitamin A and iron, using new iron products of high bioavailability that do not alter the organoleptic characteristics of the sugar and do not produce unwanted colour changes during processing. To avoid the rancidity of premixes, new processes of dry mixing have been developed in which no oil is used, This opens a real possibility for the fortification of sugar with other nutrients. Sugar fortified with vitamin A, iron, and zinc, either alone or in any combination, is commercially available in Brazil, where, under the guidance of the Latin American Centre of Nutrition and Metabolic Studies (CELANEM), the procedures have been developed using iron amino acid chelated minerals.
New Issues in Developing Effective Approaches for the Prevention and Control of Vitamin A Deficiency
Authors: Bloem Martin W. , de Pee Saskia , Darnton-Hill Ian
Published: November 2015

Even mild to moderate vitamin A deficiency is now recognized as an important factor in child health and survival. This has given increased emphasis to the goal of virtually eliminating vitamin A deficiency and its consequences, including blindness, by the end of the decade. The implications of vitamin A deficiency, however, vary according to the group at risk, and this needs to be addressed when looking at ways to achieve the goal. In pre-school children, vitamin A deficiency can lead to increased risk of mortality and morbidity and to blindness. In pregnant and lactating women, it can lead to night-blindness and appears to have implications for maternal morbidity and mortality. Although the immediate health consequences for schoolchildren and adolescents are not completely known, they are probably less dramatic. Nevertheless, it is clear that there is a cross-generational cycle leading to and perpetuating vitamin A deficiency in affected communities. This also has implications when addressing prevention and control strategies. The existing, somewhat successful approach has been to target children aged six months to six years; it is implicit that this criterion is used to measure progress towards the end-of-decade goals. A broader, complementary, life-cycle approach to vitamin A deficiency is now appropriate in many countries. There is increasing emphasis on such approaches, i.e., fortifying foods with vitamin A and improving the diet, which address the whole population at risk. A mix of interventions will give governments the chance to shift from a subsidized vitamin A capsule programme to more sustainable, non-subsidized, consumer-funded vitamin A interventions, although in an appreciable number of countries, supplementation with vitamin A will be a necessity for some years to come. Guidelines to assist governments in such transitions are a high priority.
Fortification of Salt with Iodine
Authors: Chen Junshi , Wu Huiyun
Published: November 2015

Iodized salt is the best means of providing iodine to deficient populations, and it has been used successfully and safely for 70 years around the world. In China about 450 million people live in iodine-deficient areas. The prevalence of endemic goitre in 7- to 14-year-old children was estimated to be 20% (7 million cases). The Chinese government has undertaken to eliminate iodine-deficiency disorders by the year 2000, and the manufacture and use of iodized salt throughout China has been compulsory since early 1995. Currently, potassium iodate is used. National regulations require the iodine content of iodized salt to be no less than 30 mg/kg in the salt-processing plant, no less than 25 mg/kg in the market, and no less than 20 mg/kg in the household. According to sporadic sample checking, however, the iodine content of salt in the market and the household is far from satisfactory. The loss of iodine during cooking is as high as 50% to 70%. The major problems in the fortification of salt with iodine in China are the use of uniodized salt in remote areas, an unsatisfactory system for monitoring the quality of iodized salt, the lack of knowledge and skill among marketing staffs, the loss of iodine during storage and cooking, and the lack of nationwide systematic studies to monitor the effectiveness of iodized salt in the control of endemic goitre.
The Iraqi National Nutrition Survey: Correlation between Various Anthropometric Measurements as Indicators of Severity of Malnutrition
Authors: Tawfeek Haifa , Al-Mashikhi Shalan A. , Salom Amer
Published: November 2015

This study is part of a national nutrition survey conducted in Iraq during 1992 and 1993. Anthropometric measurements were obtained in 3,616 children under five years of age. Of those children, 24% were diagnosed as moderately undernourished and 6% as severely undernourished by mid-upper-arm circumference measurements. According to weight-for-height, only 11% were diagnosed as moderately undernourished and 3% as severely undernourished. The discrepancy between the results of these two measurements can be minimized by establishing a new cut-off level for mid-upper-arm circumference for defining malnutrition in our population.
Energy and Protein Intake and Nutritional Status of Primary Schoolchildren 5 to 10 Years of Age in Schools with and without Feeding Programmes in Nyambene District, Kenya
Authors: Meme M. M. , Kogi-Makau W. , Muroki N. M. , Mwadime R. K.
Published: November 2015

The dietary intake and nutritional status of 162 children in a school with a lunch programme (the feedingprogramme group) and 163 children in a school without a lunch programme (the no-feeding-programme group) in Nyambene District, Kenya, were compared. The relationship between such child growth determinants as income sources, per capita weekly food expenditure and consumption frequency, per capita energy and protein intake, and the nutritional status of the children was also compared between the two groups. Daily caloric consumption in the group with a feeding programme was significantly higher than in the group without a feeding programme: 1,590 kcal, or 86% of the recommended daily allowance (RDA), versus 1,457 kcal, or 76% of the RDA ( p < .05). The protein intake was mainly of plant origin. Although not significantly different between the two groups, it was higher for children without a feeding programme (62 g; 238% of the RDA) than for those with a feeding programme (56 g; 216% of the RDA). The prevalence of wasting among children with a feeding programme (9%) was significantly higher than among those without a feeding programme (2%) ( p < .05). The level of stunting was about the same in both groups: 24% in the group with a feeding programme and 25% in the group without a feeding programme. There was no significant difference in the prevalence of underweight between the two groups. Overall, the nutritional status of girls was better than that of boys, although the difference was not statistically significant. It is evident that children participating in the feeding programme did not have a nutritional advantage over non-participants. Thus, there is need to evaluate school feeding programmes in Kenya to identify and address the weaknesses that curtail their impact.