Marieke Vossenaar

Nutrient density in complementary feeding of infants and toddlers

The paradigm of the first 1000 days of life, the period from conception to the second birthday, has been advanced as a critical window of opportunity to save a life and a child’s future. Infancy and toddler life, through the first 24 months after birth, is a unique period during which human milk is recommended as either the exclusive source of nutrition (6 months) or a variable component thereof. After the maternal delivery of milk is accounted for, the remainder of the energy and nutrients needs come from complementary foods. There is an intrinsic gap left by the maternal milk supply in volume and micronutrient content in relation to expanding infant and toddler needs. The nutrient density approach provides us with a mathematical framework to manage the closing of the nutrient gap. The intrinsic nutrient content of the unprocessed foods appropriate for young children is limited. The most problematic nutrients are calcium, iron and zinc. Some manner to enhance the nutrient density of the complementary foods is an incontestable necessity. The nutrient density consideration, which identifies for us the nature of the problem, offers a tool for the titrating of the fortification to an adequate—but safe—addition.

Distribution of macro- and micronutrient intakes in relation to the meal pattern of third- and fourth-grade schoolchildren in the city of Quetzaltenango, Guatemala.

OBJECTIVE Our objective was to assess the distribution of energy, macro- and micronutrient intakes by meal (breakfast, lunch, dinner and combined snacks) in a cross-sectional sample of schoolchildren. DESIGN Cross-sectional dietary survey in schoolchildren. SETTING Twelve private and public schools in the urban setting of Quetzaltenango, Guatemala. SUBJECTS A total of 449 schoolchildren (from higher and lower socio-economic strata) were enrolled in the study. METHODS Each child completed a single, pictorial 24 h prospective diary and a face-to-face interview to check completeness and estimate portion sizes. Estimated daily intakes were examined by mealtime as: (i) absolute intakes; (ii) relative nutrient distribution; and (iii) critical micronutrient density (i.e. nutrient density in relation to the WHO Recommended Nutrient Intakes/median age-specific Guatemalan energy requirements). RESULTS The daily distribution of energy intake was 24% at breakfast, 30% at lunch, 23% at dinner and 23% among snacks. Lunch was also the leading meal for macronutrients, providing 35% of proteins, 27% of fat and 30% of carbohydrate. The distribution of selected micronutrients did not follow the pattern of energy, insofar as lunch provided relatively more vitamin C and Zn, whereas breakfast led in terms of vitamins A and D, thiamin, riboflavin, folate, Ca and Fe. CONCLUSIONS Meal-specific distribution of energy, macro- and micronutrients provides a unique and little used perspective for evaluation of childrens habitual intake, and may provide guidance to strategies to improve dietary balance in an era of coexisting energy overnutrition and micronutrient inadequacy.

Regulatory Monitoring of Fortified Foods: Identifying Barriers and Good Practices

Food fortification with micronutrients often is not compliant with relevant standards, in large part because poor regulatory monitoring does not sufficiently identify and hold producers accountable for underfortified products. We propose these reinforcing approaches: clear legislation, government leadership, strong enforcement of regulations, improved financial and human capacity at the regulatory agency and industry levels, civil society engagement, simplified monitoring processes, and relationship building between industry and government. Food fortification with micronutrients often is not compliant with relevant standards, in large part because poor regulatory monitoring does not sufficiently identify and hold producers accountable for underfortified products. We propose these reinforcing approaches: clear legislation, government leadership, strong enforcement of regulations, improved financial and human capacity at the regulatory agency and industry levels, civil society engagement, simplified monitoring processes, and relationship building between industry and government. While fortification of staple foods and condiments has gained enormous global traction, poor performance persists throughout many aspects of implementation, most notably around the critical element of regulatory monitoring, which is essential for ensuring foods meet national fortification standards. Where coverage of fortified foods is high, limited nutritional impact of fortification programs largely exists due to regulatory monitoring that insufficiently identifies and holds producers accountable for underfortified products. Based on quality assurance data from 20 national fortification programs in 12 countries, we estimate that less than half of the samples are adequately fortified against relevant national standards. In this paper, we outline key findings from a literature review, key informant interviews with 11 fortification experts, and semi-quantitative surveys with 39 individuals from regulatory agencies and the food fortification industry in 17 countries on the perceived effectiveness of regulatory monitoring systems and barriers to compliance against national fortification standards. Findings highlight that regulatory agencies and industry disagree on the value that enforcement mechanisms have in ensuring compliance against standards. Perceived political risk of enforcement and poorly resourced inspectorate capacity appear to adversely reinforce each other within an environment of unclear legislation to create a major hurdle for improving overall compliance of fortification programs against national standards. Budget constraints affect the ability of regulatory agencies to create a well-trained inspector cadre and improve the detection and enforcement of non-compliant and underfortified products. Recommendations to improve fortification compliance include improving technical capacity; ensuring sustained leadership, accountability, and funding in both the private and the public sectors; and removing political barriers to ensure consistent detection of underfortified products and enforcement of applicable fortification standards. Only by taking concrete steps to improve the entire regulatory system that is built on a cooperative working relationship between regulatory agencies and food producers will a nutrition strategy that uses fortification see its intended health effects.

Dietary characteristics of complementary foods offered to Guatemalan infants vary between urban and rural settings

The objective of this study was to describe and compare the dietary variety, diversity, and origins of complementary foods given to urban and rural Guatemalan infants in the second semester of life. Dietary intake from a total of 128 infants of both sexes, aged 6.0 to 12.0 months on admission, from a low-income district of Guatemala City and a rural Mayan village was collected by means of 3 nonconsecutive 24-hour quantitative intake recalls and breast-feeding histories. We hypothesized that rural/urban, age, and sex differences would occur with respect to dietary variety and diversity scores and descriptive features at 7 levels, that is, animal or plant origin (animal, plant, both, or water); solids or semisolids vs soups and stews vs liquids; infant vs family foods; modern vs traditional foods; processed vs nonprocessed foods; commercial vs noncommercial foods; and fortified vs nonfortified foods. Overall dietary variety and diversity scores did not differ significantly between sampling areas or between sexes. Infants aged 9 to 12 months had a higher dietary variety and diversity than infants aged 6 to 9 months. Plant sources constituted a large part of the diet in both areas. Foods prepared specifically for infants, rather than for the household, were not common, although more common in the urban area than in the rural area. Commercial, processed, and fortified foods were commonly consumed in both settings. It can be concluded that although no geographical differences were seen in dietary variety or diversity, distinctions between types of selected and consumed foods were observed.

Ready-to-eat cereals are key sources of selected micronutrients among schoolchildren from public and private elementary schools in Quetzaltenango, Guatemala.

This cross-sectional dietary survey aimed to assess the consumption and relative nutrient contribution of ready-to-eat cereals (RTEC) among schoolchildren from 2 social classes in an urban center in the Guatemalan province of Quetzaltenango. A total of 449 24-hour dietary records were collected using a pictorial workbook registry method among third- and fourth-grade schoolchildren. The sample population was divided between low-income, public school attendants (n = 219) and students from higher-income private institutions (n = 230). We described the contribution of RTEC to estimated total energy; carbohydrates; protein; fat; vitamins A, C, and D; thiamin; riboflavin; folate; calcium; iron; and zinc over the 24-hour interval of registry. Approximately 41% of the subjects mentioned RTEC at least once in their 24-hour record; 93% of these at breakfast time. From the 7 RTEC varieties reported, 4 were presweetened. Estimated cereal consumption was significantly higher among private school participants (P < .001). The RTEC contributed 2.4% of estimated total energy across the whole sample and 3.6% of total carbohydrate; iron intake from RTEC was 21% of total, whereas less than 1% of calcium intake came from this source. Among the subgroup of cereal consumers, RTEC accounted for more than 40% of their daily recommendation intake for iron, vitamin C, thiamin, and riboflavin. The RTEC consumers had significantly higher intakes for all nutrients except carbohydrate and riboflavin as compared with nonconsumers. This study demonstrates the importance of RTEC as a key source of several selected micronutrients to schoolchildrens diet in this setting.

Contribution of beverages to energy, macronutrient and micronutrient intake of third‐ and fourth‐grade schoolchildren in Quetzaltenango, Guatemala

Beverages are selected based on availability, culture, taste preference, health, safety and social context. Beverages may be important to energy and to the macronutrient and micronutrient quality of overall intake. The aim of this study was to determine the contribution of beverages to the dietary energy and estimated macro- and micronutrient intake to the diet of young schoolchildren. We analyzed data from third- and fourth-grade urban Guatemalan school-children aged predominantly 8-10 years old. One-day pictorial registries of all beverages, foods and snacks consumed over a 24-h period were collected from children from private (n = 219) and public (n = 230) schools. Food composition nutrient values were assigned to the items consumed. Eleven main categories of beverages were identified. The contribution of each of the 11 beverage categories to energy, macro- and micronutrients was evaluated. The estimated intake of beverages was 475,300 mL, as reported by the 449 children. As a group, the beverage consumed in the greatest quantity was coffee (126,500 mL), followed by plain water (62,000 mL). Beverages represented a mean energy contribution of 418 +/- 26 kcal (21.5% of total dietary energy). The beverages varied in energy density from 0 (water) to 1.5 kcal mL(-1) (thin gruels). Beverages contributed one-third of the dietary carbohydrate. Through the contribution of fortified drinks, beverages were important sources of vitamin A (55%), vitamin C (38%), zinc (21%) and calcium (19%). Milk was an important source for vitamin D (10%). These results show the importance of drinks to nutrition and the balance of concerns of overweight/obesity with micronutrient quality.

Evaluating concordance with the 1997 World Cancer Research Fund/American Institute of Cancer Research cancer prevention guidelines: challenges for the research community

Diet, nutritional status and lifestyle practices are significant determinants of the risk of certain cancers. In 1997 The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) developed a series of evidence-based recommendations to help reduce the population and individual risk of cancer. However, guidance for evaluating concordance or compliance with these recommendations is limited. To illustrate the challenges in evaluation, four publications were reviewed that explored the task of creating operative criteria from which to assess concordance with the tenets of the WCRF/AICR recommendations. Three documents dealt with secondary analysis, whereas one was a prospective inquiry, with procedures and instruments designed to obtain responses to WCRF/AICR cancer-prevention specification. One considered only population-goal criteria, and two dealt implicitly or explicitly with criteria at both population and individual levels. The assessment approaches used by the authors were compared with alternative semantic and conceptual interpretations of the WCRF/AICR population goals and individual guidelines. Attempts to develop operative criteria for assessment of concordance (reflecting either a more superficial or more in-depth parsing of recommendations) have been inconsistent. The results indicate that the language of the WCRF/AICR leaves a certain degree of semantic ambiguity for evaluation purposes. Future design of prospective studies for analyses of behaviours and relevant exposures (including those reported in the 2007 WCRF/AICR report) should carefully consider evaluation criteria and fully document detailed methodology.

Day-to-Day Variations in Iron, Zinc and Copper in Breast Milk of Guatemalan Mothers

Objective: To assess the within-subject and between-subject coefficients of variation (CV) of iron, zinc and copper concentrations in the milk of Guatemalan mothers. Methods: We performed a cross-sectional study in lactating women who had delivered a healthy infant 1 to 6 months previously in two low-income peri-urban areas (San Bartolomé Milpas Altas and Ciudad Peronia) and a low-income rural area (San Juan Chamelco) in Guatemala. Women infested with Ascaris lumbricoides or Trichuris trichiura received a single dose of albendazole (400 mg) or placebo. Two weeks after treatment, milk samples were collected on 3 or 4 consecutive days. Trace element concentrations in milk were measured by inductively coupled plasma/atomic emission spectrometry. Results: The instrumental error of the inductively coupled plasma/atomic emission spectrometry method, expressed as SD, was 0.04, 0.27 and 0.02 mg/L for iron, zinc and copper, respectively. Concentrations in milk samples collected from 47 mothers on 3 or 4 consecutive days, expressed as mean ± SD, were 0.28 ± 0.13, 2.03 ± 0.37 and 0.29 ± 0.07 mg/L for iron, zinc and copper, respectively. The within-subject CV was 46.1%, 18.2%, and 22.8% and the between-subject CV was 61.2%, 48.3% and 31.7% for iron, zinc and copper, respectively. Stage of lactation, infestation with intestinal parasites and residential area had a significant influence on milk zinc, copper and iron concentrations. Conclusions: One sample of milk is sufficient to give a reliable estimate of the zinc concentration in milk. Two samples taken on consecutive days are required for a reliable estimate of iron and copper concentrations.

Dietary intakes and food sources of fat and fatty acids in Guatemalan schoolchildren: A cross-sectional study

BackgroundConsumption of healthy diets that contribute with adequate amounts of fat and fatty acids is needed for children. Among Guatemalan children, there is little information about fat intakes. Therefore, the present study sought to assess intakes of dietary fats and examine food sources of those fats in Guatemalan children.MethodsThe study subjects consisted of a convenience sample of 449 third- and fourth-grade schoolchildren (8-10 y), attending public or private schools in Quetzaltenango City, Guatemala. Dietary data was obtained by means of a single pictorial 24-h record.ResultsThe percentages of total energy (%E) from total fat, saturated fat (SFA) and monounsaturated fat (MUFA) reached 29%E for total fat and 10%E for each SFA and MUFA, without gender differences. %E from fats in high vs. low-socio economic status (SES) children were significantly higher for boys, but not for girls, for total fat (p = 0.002) and SFA (p < 0.001). Large proportions of the children had low levels of intakes of some fatty acids (FA), particularly for n-3 FA, with >97% of all groups consuming less than 1%E from this fats. Fried eggs, sweet rolls, whole milk and cheese were main sources of total fat and, SFA. Whole milk and sweet bread were important sources of n-3 FA for high- and low-SES boys and girls, respectively. Fried plantain was the main source of n-3 FA for girls in the high-SES group. Fried fish, seafood soup, and shrimp, consumed only by boys in low amounts, were sources of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, which may explain the low intakes of these nutrients.Conclusionsα-linolenic acid, EPA and DHA were the most limiting fatty acids in diets of Guatemalan schoolchildren, which could be partially explained by the low consumption of sources of these nutrients, particularly fish and seafood (for EPA and DHA). This population will benefit from a higher consumption of culturally acceptable foods that are rich in these limiting nutrients.

Earlier introduction of agüitas is associated with higher risk of stunting in infants and toddlers in the Western Highlands of Guatemala

BACKGROUND In many cultures, simple herbal infusions, thin gruels, or sweetened water (agüitas in Guatemalan parlance) are given to infants and toddlers. Formative research has shown that the use of agüitas in early child feeding is deeply embedded in Guatemalan culture. OBJECTIVE We examined the prevalence and timing of the introduction of agüitas during early life in a low-income population of metropolitan Quetzaltenango in relation to stunting in children. DESIGN Responses from 456 mothers of children aged 5-23 mo were analyzed by using logistic regression to explore relations between linear growth (stunting), diarrhea, and age at the first introduction of agüitas. RESULTS A total of 358 of 456 infants (79%) were agüita users independent of sex or ethnicity. Of infants given agüitas, one-fourth of subjects were introduced to agüitas within the first 2.9 wk of age, and one-half of subjects were introduced to agüitas within the first 9 wk of age. Subjects introduced to agüitas before 2.9 wk of age were 1.8 times more likely to be stunted (95% CI: 1.1, 2.8; P = 0.03) irrespective of ethnicity. Children who had ever been given agüitas were twice as likely to have also had diarrhea (OR: 2.1; 95% CI: 1.3, 3.3) and more likely to have needed medical attention for diarrhea (OR: 2.1; 95% CI: 1.1, 4.2), but diarrheal experience was independent of stunting. CONCLUSION Because of the early introduction of agüitas and the high prevalence of stunting in Guatemala, longitudinal studies are urgently needed to clarify the causal relations. This trial was registered at Nederlands Trial register as NTR3273 for 5-mo-olds and Nederlands Trial register as NTR3292 for infants ≥6 mo.