Fortification strategies to meet micronutrient needs: sucesses and failures

Food fortification is likely to have played an important role in the current nutritional health and well-being of populations in industrialized countries. Starting in the early part of the 20th century, fortification was used to target specific health conditions: goitre with iodized salt; rickets with vitamin D-fortified milk; beriberi, pellagra and anaemia with B-vitamins and Fe-enriched cereals; more recently, in the USA, risk of pregnancy affected by neural-tube defects with folic acid-fortified cereals. A relative lack of appropriate centrally-processed food vehicles, less-developed commercial markets and relatively low consumer awareness and demand, means it has taken about another 50 years for fortification to be seen as a viable option for the less-developed countries. The present paper reviews selected fortification initiatives in developing countries to identify different factors that contributed to their successful implementation, as well as the challenges that continually threaten the future of the se programmes. Ultimately, the long-term sustainability of fortification programmes is ensured when consumers are willing and able to bear the additional cost of fortified foods. There has been an enormous increase in fortification programmes over the last couple of decades in developing countries. Considerable progress has been made in reducing vitamin A and I deficiencies, although less so with Fe, even as Zn and folic acid deficiencies are emerging as important public health problems. Food fortification based on sound principles and supported by clear policies and regulations can play an increasingly large role in this progress towards prevention and control of micronutrient malnutritio

Achieving the Millennium Development Goals through mainstreaming nutrition: speaking with one voice.

At the most recent meeting of the Standing Committee on Nutrition of the UN system in Geneva in March of this year (2006) there was a dramatic shift in the tenor of the opening plenary session. Three very high-ranking officials of three of the largest implementing UN agencies (WHO UNICEF World Bank) along with WFP and FAO produced -- independently of one another -- a clear consistent message focusing on the importance of nutrition for development. In each case this was couched within the comparative advantage of each agency. It was also striking that none of the speakers came from a background of nutrition training -- one economist one public health physician one health economist and one development expert. All had been converted by enthusiastic nutrition colleagues within their particular agency and by long experience in many countries and an expanding evidence base. All referred to the same evidence base -- the Bellagio Child Survival Study Group and subsequent papers published not in nutrition or even public health journals but in medical journals (the Lancet and the British Medical Journal in particular) although the significance of this will not be discussed here. But all were somewhat perplexed as to why nutrition issues were not an automatic component of all national health and development programmes including within each agency. They had clearly used their considerable experience in the public sector to think this through especially the importance of having a common and consistent message. (excerpt

Responding to the crisis in sub-Saharan Africa: The role of nutrition

In the chapter dealing with education and health, the report of the influential Commission for Africa prioritises basic health systems, HIV/AIDS, malaria and tuberculosis. In contrast, nutrition is given less than half a page and is reduced to parasite control and micronutrient support. Such neglect of nutrition is hard to understand in the context of increasing hunger and malnutrition across the continent. Sub-Saharan Africa is the only region in the world where the proportion of underweight children has stagnated and the absolute numbers have actually increased in the last decade. It has been pointed out that if current trends continue sub-Saharan Africa will achieve the Millennium Development Goal for child mortality around 2115 – one century after the target date. Quite clearly those concerned with nutrition need to more powerfully advocate the role of nutrition in lifting Africa out of the spiral of poverty. The present paper argues that to achieve this requires an understanding not just of the critical role of nutrition for health and development (both individual and national), but also of how recent global changes are interacting with changes in food production and supply, other determinants of maternal and child health, and the role and capacity of the state to tackle malnutrition in Africa. It concludes by suggesting some responses that nutritionists could now be making

Characterising infant and young child feeding practices and the consumption of poultry products in rural Tanzania: A mixed methods approach

Suboptimal breastfeeding practices, early initiation of complementary feeding, and monotonous cereal‐based diets have been implicated as contributors to continuing high rates of child undernutrition in sub‐Saharan Africa. Nutrition‐sensitive interventions, including agricultural programs that increase access to nutrient‐rich vegetables, legumes, and animal‐source foods, have the potential to achieve sustainable improvements in children's diets. In the quest to evaluate the efficacy of such programs in improving growth and development in the first 2 years of life, there is a role for mixed methods research to better understand existing infant and young child feeding practices. This analysis forms part of a longitudinal study assessing the impact of improvements to poultry health and crop production on diets and growth of 503 randomly selected children from eight rural communities in Manyoni District in central Tanzania. Using an explanatory sequential design, the quantitative phase of data collection was conducted between May 2014 and May 2016, comprising six monthly structured questionnaires, four monthly household‐level documentation of chicken and egg consumption, and fortnightly records of children's breastfeeding status. The subsequent qualitative phase involved in‐depth interviews with a subset of 39 mothers in October 2016. Breastfeeding was almost universal (96.8%) and of long duration (mean = 21.7 months, SD = 3.6), but early initiation of complementary feeding was also common (74.4%; mean = 4.0 months, SD = 1.8), overwhelmingly driven by maternal perceptions of insufficient milk supply (95.0%). Chicken and eggs were infrequently eaten, but close associations between maternal and child consumption patterns (p < .001) suggest the potential for strategies that increase household‐level consumption to bring nutritional benefits to young children

Does village chicken-keeping contribute to young children’s diets and growth? A longitudinal observational study in rural Tanzania

There is substantial current interest in linkages between livestock-keeping and human nutrition in resource-poor settings. These may include benefits of improved diet quality, through animal-source food consumption and nutritious food purchases using livestock-derived income, and hazards of infectious disease or environmental enteric dysfunction associated with exposure to livestock feces. Particular concerns center on free-roaming chickens, given their proximity to children in rural settings, but findings to date have been inconclusive. This longitudinal study of 503 households with a child under 24 months at enrolment was conducted in villages of Manyoni District, Tanzania between May 2014, and May 2016. Questionnaires encompassed demographic characteristics, assets, livestock ownership, chicken housing practices, maternal education, water and sanitation, and dietary diversity. Twice-monthly household visits provided information on chicken numbers, breastfeeding and child diarrhea, and anthropometry was collected six-monthly. Multivariable mixed model analyses evaluated associations between demographic, socioeconomic and livestock-associated variables and (a) maternal and child diets, (b) children’s height-for-age and (c) children’s diarrhea frequency. Alongside modest contributions of chicken-keeping to some improved dietary outcomes, this study importantly (and of substantial practical significance if confirmed) found no indication of a heightened risk of stunting or greater frequency of diarrhea being associated with chicken-keeping or the practice of keeping chickens within human dwellings overnight

Food composition tables in resource-poor settings: Exploring current limitations and opportunities, with a focus on animal-source foods in sub-Saharan Africa

Animal-source foods (ASF) have the potential to enhance the nutritional adequacy of cereal-based diets in low- and middle-income countries, through the provision of high-quality protein and bioavailable micronutrients. The development of guidelines for including ASF in local diets requires an understanding of the nutrient content of available resources. This article reviews food composition tables (FCT) used in sub-Saharan Africa, examining the spectrum of ASF reported and exploring data sources for each reference. Compositional data are shown to be derived from a small number of existing data sets from analyses conducted largely in high-income nations, often many decades previously. There are limitations in using such values, which represent the products of intensively raised animals of commercial breeds, as a reference in resource-poor settings where indigenous breed livestock are commonly reared in low-input production systems, on mineral-deficient soils and not receiving nutritionally balanced feed. The FCT examined also revealed a lack of data on the full spectrum of ASF, including offal and wild foods, which correspond to local food preferences and represent valuable dietary resources in food-deficient settings. Using poultry products as an example, comparisons are made between compositional data from three high-income nations, and potential implications of differences in the published values for micronutrients of public health significance, including Fe, folate and vitamin A, are discussed. It is important that those working on nutritional interventions and on developing dietary recommendations for resource-poor settings understand the limitations of current food composition data and that opportunities to improve existing resources are more actively explored and supported

Challenges and Opportunities in Scaling-Up Nutrition in Healthcare

Healthcare continues to be in a state of flux; conventionally, this provides opportunities and challenges. The opportunities include technological breakthroughs, improved economies and increasing availability of healthcare. On the other hand, economic disparities are increasing and leading to differing accessibility to healthcare, including within affluent countries. Nutrition has received an increase in attention and resources in recent decades, a lot of it stimulated by the rise in obesity, type 2 diabetes mellitus and hypertension. An increase in ageing populations also has meant increased interest in nutrition-related chronic diseases. In many middle-income countries, there has been an increase in the double burden of malnutrition with undernourished children and overweight/obese parents and adolescents. In low-income countries, an increased evidence base has allowed scaling-up of interventions to address under-nutrition, both nutrition-specific and nutrition-sensitive interventions. Immediate barriers (institutional, structural and biological) and longer-term barriers (staffing shortages where most needed and environmental impacts on health) are discussed. Significant barriers remain for the near universal access to healthcare, especially for those who are socio-economically disadvantaged, geographically isolated, living in war zones or where environmental damage has taken place. However, these barriers are increasingly being recognized, and efforts are being made to address them. The paper aims to take a broad view that identifies and then comments on the many social, political and scientific factors affecting the achievement of improved nutrition through healthcare