Arnaud Laillou

Optimal Screening of Children with Acute Malnutrition Requires a Change in Current WHO Guidelines as MUAC and WHZ Identify Different Patient Groups

Background Timely treatment of acute malnutrition in children <5 years of age could prevent >500,000 deaths annually. Screening at community level is essential to identify children with malnutrition. Current WHO guidelines for community screening for malnutrition recommend a Mid Upper Arm Circumference (MUAC) of <115 mm to identify severe acute malnutrition (SAM). However, it is currently unclear how MUAC relates to the other indicator used to define acute malnutrition: weight-for-height Z-score (WHZ). Methods Secondary data from >11,000 Cambodian children, obtained by different surveys between 2010 and 2012, was used to calculate sensitivity and ROC curves for MUAC and WHZ. Findings The secondary analysis showed that using the current WHO cut-off of 115 mm for screening for severe acute malnutrition over 90% of children with a weight-for-height z-score (WHZ) <−3 would have been missed. Reversely, WHZ<−3 missed 80% of the children with a MUAC<115 mm. Conclusions The current WHO cut-off for screening for SAM should be changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm would allow inclusion of >65% of children with a WHZ<−3. Importantly, MUAC and WHZ identified different sub-groups of children with acute malnutrition, therefore these 2 indicators should be regarded as independent from each other. We suggest a 2-step model with MUAC used a screening at community level, followed by MUAC and WHZ measured at a primary health care unit, with both indicators used independently to diagnose severe acute malnutrition. Current guidelines should be changed to reflect this, with treatment initiated when either MUAC <115 mm or WHZ<−3.

Absorption Studies Show that Phytase from Aspergillus niger Significantly Increases Iron and Zinc Bioavailability from Phytate-Rich Foods

Background Iron and zinc deficiency are major public health problems affecting many parts of the world, including Southeast Asia. Infants, young children, and women of reproductive age are particularly vulnerable due to their high requirements. Even though iron and zinc are present in significant amounts in the plant-based diets typically consumed in developing countries, their bioavailability is low due to high levels of absorption inhibitors such as phytate. Phytase has been used in animal nutrition for decades to improve the bioavailability of certain minerals in feed. Objective To show the effect of phytase in human nutrition based on evidence from human studies. Phytase can be used either during processing or as an active food ingredient degrading dietary phytate during stomach transit time. Methods Evidence from human studies testing the effect of phytase on iron and zinc bioavailability using stable isotopes was reviewed. Results Twelve studies tested the effect of phytase on iron and five tested its effect on zinc bioavailability. Most of these studies used a phytase derived from Aspergillus niger. They found a beneficial effect unless phytate concentrations were too low or levels of inhibitors or enhancers of iron absorption were too high. Twenty to 320 phytase units per 100 g of flour significantly improved iron absorption, even though higher levels might further increase iron bioavailability. For zinc, not enough information is available to determine optimal activities. Conclusions Phytase clearly has a beneficial effect on iron and zinc absorption from phytate-rich foods. It also has the potential to increase the absorption of magnesium, calcium, and phosphorus in areas such as Southeast Asia where mineral deficiencies are widespread.

Vegetable oil of poor quality is limiting the success of fortification with vitamin A in Egypt.

Background Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. Objectives To estimate vitamin A losses in oil with different chemical characteristics. Methods Samples of fortified oils with different chemical characteristics were collected from two Egyp- tian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during stor- age to determine losses over time, and peroxide values were determined. Results Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% (p < .001), respectively. In semidark conditions, the vitamin A losses after 4 weeks in fortified oil B and fortified oil A were significantly different: 26.1% and 0.7% (p < .001), respectively. In an accelerated storage test, the vitamin A loss in 8 days was 48.3% for fortified oil B and 4.2% for fortified oil A (p < .001). Conclusions This study shows a significant effect of peroxide level (one indicator of the quality of oil) on the stability of vitamin A, regardless of storage conditions. To optimize and sustain vitamin A levels in fortified oil, governments and industries should minimize the perox- ide level to less than 2 mEq/kg at production.

The Growing Importance of Staple Foods and Condiments Used as Ingredients in the Food Industry and Implications for Large-Scale Food Fortification Programs in Southeast Asia

Background Food fortification is a viable strategy to improve the nutritional status of populations. In South-east Asia, recent growth and consolidation of the food industry provides an opportunity to explore whether certain widely consumed processed foods could contribute to micronutrient status if they are made with adequately fortified staples and condiments. Objective To estimate the potential contribution certain processed foods can make to micronutrient intake in Southeast Asia if they are made with fortified staples and condiments; e.g., via the inclusion of iodized salt in various processed foods in the Philippines, fortified wheat flour in instant noodles in Indonesia, and fortified vegetable oil in biscuits in Vietnam. Methods For Indonesia, the Philippines, and Vietnam, a review of consumption trends, relevant policies, and industry practices was conducted using publicly available sources, food industry market data and research reports, and oral communication. These informed the estimates of the proportion of the Recommended Nutrient Intake (RNI) that could be delivered via select processed foods. Results In the Philippines, Indonesia, and Vietnam, the processed food industry is not always required to use fortified staples and condiments. In the Philippines, dried salted fish with iodized salt would provide 64% to 85% of the iodine RNI for women of reproductive age and 107% to 141% of the iodine RNI for children 1 to 6 years of age. In Indonesia, a 75-g pack of instant noodles (a highly consumed product) with fortified wheat flour would provide 45% to 51% of the iron RNI for children 4 to 6 years of age and 10% to 11% of the iron RNI for women of reproductive age. In Vietnam, biscuits containing vegetable oil are increasingly popular. One 35-g biscuit serving with fortified vegetable oil would provide 13% to 18% of the vitamin A RNI for children 4 to 6 years of age and 12% to 17% of the vitamin A RNI for women of reproductive age. Conclusions Ensuring that fortified staples and condiments such as flour, salt, and vegetable oil are used in widely consumed processed foods would ensure that these foods contribute to improvement in micronutrient intake among populations in Southeast Asia, particularly as the consumption of these foods is increasing. Policymakers and nutrition program managers should consider the contribution to nutritional intake that fortified staples and condiments can provide through processed foods, in addition to being used for cooking in the home, and ensure that the food industry is required to use these fortified staples and condiments rather than nonfortified foods.

Key strategies to further reduce stunting in Southeast Asia: Lessons from the ASEAN countries workshop

Background To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified. Objective Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia. Methods Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries. Results Between 1990–2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation. Conclusions In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.

A review of vitamin D fortification: implications for nutrition programming in Southeast Asia.

Background Vitamin D is vital for bone health and has important roles in nonskeletal health and organ function. Most vitamin D is generated in the body by exposure to sunlight, with limited amounts added by the diet. Despite the presence of regular sunshine in Southeast Asia, vitamin D deficiency or insufficiency is being found there more commonly, primarily due to reduction of sunlight exposure as a result of lifestyle changes. Some of these lifestyle changes are unlikely to be reversed, and foods naturally containing vitamin D are not widely consumed, so fortification of foods with vitamin D may raise vitamin D status. Methods The literature database was searched for studies of vitamin D fortification, and we estimated potential vitamin D intakes from fortified vegetable oil. Results Almost all of the studies showed that circulating vitamin D (25-hydroxyvitamin D [(25OHD]) increased in a dose-dependent manner with increased intake of vitamin D–fortified foods. However, in a number of studies the additional intake was insufficient to increase vitamin D levels to 50 nmol/L. Vegetable oil fortified with vitamin D at a level of 10 μg/100 g could provide 3.9% to 21% of the Institute of Medicine Estimated Average Requirement (EAR) of vitamin D for adults in Southeast Asia. Conclusions Fortification of widely consumed foods, such as edible oil, with vitamin D could contribute to improved vitamin D status in Southeast Asian countries. Intake modeling studies should be conducted to calculate the resulting additional intakes, and fortification of additional foods should be considered. More nationally representative studies of vitamin D status in the region are urgently needed.

An Assessment of the Impact of Fortification of Staples and Condiments on Micronutrient Intake in Young Vietnamese Children

Targeted fortification programs for infants and young children are an effective strategy to prevent micronutrient deficiencies in developing countries, but the role of large-scale fortification of staple foods and condiments is less clear. Dietary modeling in children aged 6–60 months was undertaken, based on food consumption patterns described in the 2009 national food consumption survey, using a 24-h recall method. Consumption data showed that the median intake of a child for iron, vitamin A and zinc, as a proportion of the Vietnamese Recommended Dietary Allowance (VRDA), is respectively 16%–48%, 14%–49% and 36%–46%, (depending on the age group). Potential fortification vehicles, such as rice, fish/soy sauces and vegetable oil are consumed daily in significant amounts (median: 170 g/capita/day, 4 g/capita/day and 6 g/capita/day, respectively) by over 40% of the children. Vegetable oil fortification could contribute to an additional vitamin A intake of 21%–24% of VRDA recommended nutrient intake, while fortified rice could support the intakes of all the other micronutrients (14%–61% for iron, 4%–11% for zinc and 33%–49% of folate requirements). Other food vehicles, such as wheat flour, which is consumed by 16% of children, could also contribute to efforts to increase micronutrient intakes, although little impact on the prevalence of micronutrient deficiencies can be expected if used alone. The modeling suggests that fortification of vegetable oil, rice and sauces would be an effective strategy to address micronutrient gaps and deficiencies in young children.

Fish sauce, soy sauce, and vegetable oil fortification in Cambodia: Where do we stand to date?

Background The prevalence of micronutrient deficiencies in Cambodia is among the highest in Southeast Asia. Fortification of staple foods and condiments is considered to be one of the most cost-effective strategies for addressing micronutrient deficiencies at the population level. The Government of Cambodia has recognized the importance of food fortification as one strategy for improving the nutrition security of its population. Objective This paper describes efforts under way in Cambodia for the fortification of fish sauce, soy sauce, and vegetable oil. Methods Data were compiled from a stability test of Cambodian fish sauces fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA); analysis of fortified vegetable oils in the Cambodian market; a Knowledge, Attitudes, and Practices (KAP) study of fortified products; and food fortification program monitoring documents. Results At different levels of fortification of fish sauce with NaFeEDTA, sedimentation and precipitation were observed. This was taken into consideration in the government-issued standards for the fortification of fish sauce. All major brands of vegetable oil found in markets at the village and provincial levels are imported, and most are nonfortified. Conclusions Fish sauce, soy sauce, and vegetable oil are widely consumed throughout Cambodia and are readily available in provincial and village markets. Together with an effective regulatory monitoring system, the government can guarantee that these commodities, whether locally produced or imported, are adequately fortified. A communications campaign would be worth-while, once fortified commodities are available, as the KAP study found that Cambodians had a positive perception of fortified sauces.

The High Prevalence of Anemia in Cambodian Children and Women Cannot Be Satisfactorily Explained by Nutritional Deficiencies or Hemoglobin Disorders

Background: Anemia is highly prevalent in Cambodian women and children, but data on causes of anemia are scarce. We performed a national micronutrient survey in children and women that was linked to the Cambodian Demographic Health Survey 2014 (CDHS-2014) to assess the prevalence of micronutrient deficiency, hemoglobin disorders and intestinal parasite infection. Methods: One-sixth of households from the CDHS-2014 were selected for a follow-up visit for the micronutrient survey. Households were visited from two weeks to two months after the CDHS-2014 visit. Data on micronutrient status were available for 1512 subjects (792 children and 720 women). Results: Anemia was found in 43% of the women and 53% of the children. Hemoglobin disorders affected >50% of the population, with Hemoglobin-E the most prevalent disorder. Deficiencies of iron (ferritin < 15 g/L), vitamin A (retinol-binding-protein (RBP) < 0.70 mol/L) or vitamin B12 (<150 pmol/L) were not prevalent in the women (<5% for all), whereas 17.8% of the women had low concentrations of folic acid (<10 nmol/L). In the children, the prevalence of iron, vitamin A, vitamin B12 or folic acid deficiency was <10%. Zinc deficiency, hookworm infection and hemoglobinopathy were significantly associated with anemia in children, whereas in the women none of the factors was significantly associated with anemia. Iron deficiency anemia (IDA) was more prevalent in children <2 years, but in older children and women, the prevalence of IDA was <5%. The most prevalent, preventable causes of anemia were hookworm infection and zinc and folic acid deficiency. Over 40% of the anemia was not caused by nutritional factors. Conclusion: The very high prevalence of anemia in Cambodian women and children cannot be explained solely by micronutrient deficiencies and hemoglobin disorders. Micronutrient interventions to improve anemia prevalence are likely to have limited impact in the Cambodian setting. The focus of current interventions to reduce the high prevalence of anemia in children and women should be broadened to include zinc and folic acid as well as effective anti-hookworm measures.

Stability and retention of micronutrients in fortified rice prepared using different cooking methods

Fortified rice holds great potential for bringing essential micronutrients to a large part of the world population. However, it is unknown whether differences in cooking methods or in production of rice premix affect the final amount of micronutrient consumed. This paper presents a study that quantified the losses of five different micronutrients (vitamin A, iron, zinc, folic acid, and vitamin B12) in fortified rice that was produced using three different techniques (hot extrusion, cold extrusion, and coating) during cooking and five different cooking methods (absorption method with or without soaking, washing before cooking, cooking in excess water, and frying rice before cooking). Fortified rice premix from six different producers (two for each technique) was mixed with normal rice in a 1:100 ratio. Each sample was prepared in triplicate, using the five different cooking methods, and retention of iron, zinc, vitamin A, vitamin B12, and folic acid was determined. It was found that the overall retention of iron, zinc, vitamin B12, and folic acid was between 75% and 100% and was unaffected by cooking method, while the retention of vitamin A was significantly affected by cooking method, with retention ranging from 0% (excess water) to 80% (soaking), depending on the cooking method and producer of the rice premix. No systematic differences between the different production methods were observed. We conclude that different cooking methods of rice as used in different regions of the world do not lead to a major loss of most micronutrients, with the exception of vitamin A. The factors involved in protecting vitamin A against losses during cooking need to be identified. All production techniques of rice premix yielded similar results, showing that coating is not inferior to extrusion techniques. Standard overages (50%) for vitamin B12 and folic acid are too high.