Elizabeth Zehner

The Case for Promoting Multiple Vitamin and Mineral Supplements for Women of Reproductive Age in Developing Countries

Women in developing countries often consume inadequate amounts of micronutrients because of their limited intake of animal products, fruits, vegetables, and fortified foods. Intakes of micronutrients less than the recommended values increase a womans risk of having micronutrient deficiencies. the adverse effects of deficiencies in vitamin A, iron, and folic acid, including night-blindness in pregnant and lactating women and iron-deficiency anaemia, are well known. Low intakes of these and other nutrients, including zinc, calcium, riboflavin, vitamin B6, and vitamin B12, also have consequences for womens health, pregnancy outcome, and the health and nutritional status of breastfed children. Multiple deficiencies coexist, so the benefit of multiple micronutrient supplements is becoming increasingly apparent. Supplementation of women with multiple vitamins and minerals should be one component of a strategy to improve micronutrient status among women in developing countries. However, there are several issues for programme managers to consider before implementing programmes. Which reference standards will be used to determine nutrient levels to include in the supplements? Which nutrients will be included and in what quantities? Which factors need to be considered in purchasing supplements? These issues are discussed, and guidance is provided on the selection of appropriate supplements for pregnant women and women of reproductive age in developing countries.

Multiple micronutrient supplementation during pregnancy in developing-country settings: Policy and program implications of the results of a meta-analysis

Background An independent Systematic Review Team performed a meta-analysis of 12 randomized, controlled trials comparing multiple micronutrients with daily iron–folic acid supplementation during pregnancy. Objective To provide an independent interpretation of the policy and program implications of the results of the meta-analysis. Methods A group of policy and program experts performed an independent review of the meta-analysis results, analyzing internal and external validity and drawing conclusions on the program implications. Results Although iron content was often lower in the multiple micronutrient supplement than in the iron–folic acid supplement, both supplements were equally effective in tackling anemia. Community-based supplementation ensured high adherence, but some mothers still remained anemic, indicating the need to concomitantly treat infections. The small, significant increase in mean birthweight among infants of mothers receiving multiple micronutrients compared with infants of mothers receiving iron-folic acid is of similar magnitude to that produced by food supplementation during pregnancy. Larger micronutrient doses seem to produce greater impact. Meaningful improvements have also been observed in height and cognitive development of the children by 2 years of age. There were no significant differences in the rates of stillbirth, early neonatal death, or neonatal death between the supplemented groups. The nonsignificant trend toward increased early neonatal mortality observed in the groups receiving multiple micronutrients may be related to differences across trials in the rate of adolescent pregnancies, continuing iron deficiency, and/or adequacy of postpartum health care and merits further investigation. Conclusions Replacing iron–folic acid supplements with multiple micronutrient supplements in the package of health and nutrition interventions delivered to mothers during pregnancy will improve the impact of supplementation on birthweight and on child growth and development.

Legislation should support optimal breastfeeding practices and access to low-cost, high-quality complementary foods: Indonesia provides a case study.

It is important to support women to exclusively breastfeed for 6 months and continue breastfeeding for 24 months and beyond. It is also necessary to provide the poor with access to affordable ways to improve the quality of complementary foods. Currently, many countries do not have the legal and policy environment necessary to support exclusive and continued breastfeeding. Legislative and policy changes are also necessary for introducing complementary food supplements, allowing them to be marketed to those who need them, and ensuring that marketing remains appropriate and in full compliance with the International Code of Marketing of Breastmilk Substitutes. This paper aims to illustrate the above with examples from Indonesia and to identify legislative requirements for supporting breastfeeding and enabling appropriate access to high-quality complementary food supplements for children 6-24 months of age. Requirements include improved information, training, monitoring and enforcement systems for the International Code of Marketing of Breastmilk Substitutes; implementation and monitoring of the Baby-Friendly Hospital Initiative; establishment of a registration category for complementary food supplements to enhance availability of high-quality, low-cost fortified products to help improve young child feeding; clear identification and marketing of these products as complementary food supplements for 6-24-month-olds so as to promote proper use and not interfere with breastfeeding.

Spotlight on infant formula: coordinated global action needed

www.thelancet.com Vol 387 January 30, 2016 413 support as part of national tobacco control programmes, addressing tobacco use by health-care workers and helping them stop, ensuring that tobacco use is recorded in all medical notes, integrating brief advice into existing health-care systems, establishing a text messaging support programme, making aff ordable drugs available, and using the media to promote cessation. Implementation of these core recommendations will save many lives and health-care resources. We believe that the availability of new low-cost interventions and methods to help countries select aff ordable treatments will remove large barriers in development of tobacco dependence treatment. It is time that the FCTC article 14 and its guidelines are taken seriously.

Promotion and consumption of commercially produced foods among children: situation analysis in an urban setting in Senegal.

Abstract This study assessed the promotion of commercially produced foods and consumption of these products by children less than 24 months of age in Dakar Department, Senegal. Interviews with 293 mothers of children attending child health clinics assessed maternal exposure to promotion and maternal recall of foods consumed by the child on the preceding day. Promotion of breastmilk substitutes and commercially produced complementary foods outside health facilities was common with 41.0% and 37.2% of mothers, respectively, reporting product promotions since the birth of their youngest child. Promotion of commercially produced snack food products was more prevalent, observed by 93.5% of mothers. While all mothers reported having breastfed their child, only 20.8% of mothers breastfed their newborn within the first hour after delivery, and 44.7% fed pre‐lacteal feeds in the first 3 days after delivery. Of children 6–23 months of age, 20.2% had consumed a breastmilk substitute; 49.1% ate a commercially produced complementary food, and 58.7% ate a commercially produced snack food product on the previous day. There is a need to stop the promotion of breastmilk substitutes, including infant formula, follow‐up formula, and growing‐up milks. More stringent regulations and enforcement could help to eliminate such promotion to the public through the media and in stores. Promotion of commercial snack foods is concerning, given the high rates of consumption of such foods by children under the age of 2 years. Efforts are needed to determine how best to reduce such promotion and encourage replacement of these products with more nutritious foods.

Infant and young child feeding practices among children under 2 years of age and maternal exposure to infant and young child feeding messages and promotions in Dar es Salaam, Tanzania.

Abstract There are limited data describing infant and young child feeding practices (IYCF) in urban Tanzania. This study assessed the types of foods consumed by children under 2 years of age and maternal exposure to promotions of these foods in Dar es Salaam, Tanzania. A cross‐sectional survey was conducted among 305 mothers of children less than 24 months of age who attended child health services in October and November, 2014. Among infants less than 6 months of age, rates of exclusive breastfeeding were low (40.8%) and a high proportion (38.2%) received semi‐solid foods. Continued breastfeeding among 20–23‐month‐olds was only 33.3%. Consumption of breastmilk substitutes was not prevalent, and only 3.9% of infants less than 6 months of age and 4.8% of 6–23 month‐olds were fed formula. Among 6–23‐month‐olds, only 38.4% consumed a minimum acceptable diet (using a modified definition). The homemade complementary foods consumed by the majority of 6‐23‐month‐olds (85.2%) were cereal‐dominated and infrequently contained micronutrient‐rich ingredients. Only 3.1% of 6–23‐month‐olds consumed commercially produced infant cereal on the day preceding the interview. In contrast, commercially produced snack foods were consumed by 23.1% of 6–23‐month‐olds. Maternal exposure to commercial promotions of breastmilk substitutes and commercially produced complementary foods was low (10.5% and 1.0%, respectively), while exposure to promotions of commercially produced snack foods was high (45.9%). Strategies are needed to improve IYCF practices, particularly with regard to exclusive and continued breastfeeding, increased dietary diversity and consumption of micronutrient‐rich foods, and avoidance of feeding commercially produced snack foods.

Cross-sectional survey shows that follow-up formula and growing-up milks are labelled similarly to infant formula in four low and middle income countries.

Abstract This cross‐sectional survey assessed the characteristics of labels of follow‐up formula (FUF) and growing‐up milk (GUM) compared with infant formula (IF), including cross‐promotion practices between FUF/GUM and IF manufactured by the same company, sold in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania. All products were imported. A wide recommended age/age range for introduction was provided by manufacturers across all sites, with products with an age recommendation of 0–6 months being most prevalent in three sites, representing over a third of all products. Various age categories (e.g. 1, 1+ and Stage 1) commonly appeared on labels. A number of descriptive names (e.g. infant formula and milk formula) per category of age of introduction were used with some appearing across more than one category. Images of feeding bottles were found on most labels across all age categories, but prevalence decreased with older age categories. The majority of FUF/GUM manufactured by IF companies across all sites displayed at least one example of cross‐promotion with one or more of the companys IF: two‐thirds or more contained similar colour schemes/designs and similar brand names; 20–85% had similar slogans/mascots/symbols. A wide and potentially confusing range of ages/categories of introduction and descriptive names were found, and cross‐promotion with IF was common on FUF/GUM labels. Global guidance from normative bodies forms the basis of most low and middle income countries policies and should provide specific guidance to prohibit cross‐promotion between FUF/GUM and IF, and all three categories should be classified as breastmilk substitutes.

Assessment of corporate compliance with guidance and regulations on labels of commercially produced complementary foods sold in Cambodia, Nepal, Senegal and Tanzania

Abstract National legislation and global guidance address labelling of complementary foods to ensure that labels support optimal infant and young child feeding practices. This cross‐sectional study assessed the labels of commercially produced complementary foods (CPCF) sold in Phnom Penh (n = 70), Cambodia; Kathmandu Valley (n = 22), Nepal; Dakar Department (n = 84), Senegal; and Dar es Salaam (n = 26), Tanzania. Between 3.6% and 30% of products did not provide any age recommendation and 8.6−20.2% of products, from all sites, recommended an age of introduction of <6 months. Few CPCF products provided a daily ration (0.0−8.6%) and 14.5−55.6% of those that did exceeded the daily energy recommendation for complementary foods for a breastfed child from 6 to 8.9 months of age. Only 3.6−27.3% of labels provided accurate and complete messages in the required language encouraging exclusive breastfeeding, and almost none (0.0−2.9%) provided accurate and complete messages regarding the appropriate introduction of complementary foods together with continued breastfeeding. Between 34.3% and 70.2% of CPCF manufacturers also produced breastmilk substitutes and 41.7−78.0% of relevant CPCF products cross‐promoted their breastmilk substitutes products. Labelling practices of CPCF included in this study do not fully comply with international guidance on their promotion and selected aspects of national legislation, and there is a need for more detailed normative guidance on certain promotion practices in order to protect and promote optimal infant and young child feeding.

Point-of-sale promotion of breastmilk substitutes and commercially produced complementary foods in Cambodia Nepal Senegal and Tanzania.

Abstract In order to assess the prevalence of point‐of‐sale promotions of infant and young child feeding products in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania, approximately 30 retail stores per site, 121 in total, were visited. Promotional activity for breastmilk substitutes (BMS) and commercially produced complementary foods in each site were recorded. Point‐of‐sale promotion of BMS occurred in approximately one‐third of sampled stores in Phnom Penh and Dakar Department but in 3.2% and 6.7% of stores in Kathmandu Valley and Dar es Salaam, respectively. Promotion of commercially produced complementary foods was highly prevalent in Dakar Department with half of stores having at least one promotion, while promotions for these products occurred in 10% or less of stores in the other three sites. While promotion of BMS in stores is legal in Senegal, it is prohibited in Cambodia without prior permission of the Ministry of Health/Ministry of Information and prohibited in both Nepal and Tanzania. Strengthening legislation in Senegal and enforcing regulations in Cambodia could help to prevent such promotion that can negatively affect breastfeeding practices. Key messages Even in countries such as Cambodia, Nepal and Tanzania where point‐of‐sale promotion is restricted, promotions of BMS were observed (in nearly one‐third of stores in Phnom Penh and less than 10% in Dar es Salaam and Kathmandu). Limited promotion of commercially produced complementary foods was evident (less than 10% of stores had a promotion for such foods), except in Dakar Department, where promotions were found in half of stores. Efforts are needed to strengthen monitoring, regulation and enforcement of restrictions on the promotion of BMS. Manufacturers and distributors should take responsibility for compliance with national regulations and global policies pertaining to the promotion of breastmilk substitutes.

Promotion and consumption of breastmilk substitutes and infant foods in Cambodia, Nepal, Senegal and Tanzania.

The World Health Organization (WHO) and UNICEF define optimal infant and young child feeding as practising exclusive breastfeeding from birth through the first 6 months of life and feeding with safe and appropriate complementary foods starting from 6months of age together with continued breastfeeding for up to 2 years and beyond (WHO & UNICEF 2003). Meeting the nutritional requirements of children from the age of 6months is challenging when foods fed to children are low in essential micronutrients, low in high quality fats, high in factors that inhibit absorption of nutrients and not adequately dense in calories. To meet the specific nutrient requirements of this vulnerable group, WHO guidelines (Pan American Health Organization & WHO 2003) recommend the use of low-cost fortified products as needed, along with continued breastfeeding; however, these products need to be promoted in a way that protects both breastfeeding and the consumption of high-quality local foods. The International Code of Marketing of Breast-milk Substitutes (WHO 1981) was adopted by the World Health Assembly (WHA) in 1981 to stop the promotion of breastmilk substitutes, which has been shown to be detrimental to breastfeeding practices. In May 2010, the 63rd World Health Assembly recognized that the promotion of some commercial foods for infants and young children also undermines progress in optimal infant and young child feeding (WHA 2010), and in May 2012, the Assembly requested the director general to provide clarification and guidance on the issue of inappropriate promotion of foods for infants and young children (WHA 2012). Information on promotion and consumption of foods for infants and young children in countries around the world is limited. Policy makers at both the global and national levels seeking to improve infant feeding practices and specifically those tasked with providing guidance on promotion of commercially produced complementary foods could benefit from more detailed information on the rates of consumption of foods by infants and young children as well as the prevalence and nature of the promotion of these foods. In response to the call in 2012 by global policymakers for guidance, Helen Keller International, through the Assessment and Research on Child Feeding (ARCH) Project, has conducted research on the promotion of commercially produced foods and their consumption by infants and young children in the largest urban areas of four countries: Cambodia, Nepal, Senegal and Tanzania. TheARCHProject also gathered data on the labelling of commercially produced foods consumed by infants and young children in these four sites. This supplement describes the results from this research. The four study sites are not only geographically diverse but also vary in legislation governing the promotion of infant foods. Strong laws governing the promotion of breastmilk substitutes and commercially produced complementary foods exist in Nepal and Tanzania, covering products for children up to 12months and 5years of age, respectively. Promotion is less strictly regulated inCambodia (where promotions are permitted with government approval) and in Senegal (where promotion is only prohibited within health facilities). The first six articles in this supplement describe information collected from mothers of children under the age of 2 years on exposure to promotional practices