Complementary Food Supplements Research Articles

2020 Social Marketing to Sustainably Influence Nutrition Behavior

Every year, 9 million children worldwide die before the age of five. Directly or indirectly, one out of every two of these deaths is due to malnutrition. Malnutrition is especially devastating during the first 1,000 days of life, from an infant’s conception to its second birthday. Even when it does not kill, malnutrition causes irreversible damage that lasts into adulthood (high morbidity, physical and mental disabilities). This damage is passed on from one generation to the next, and has serious consequences for development. Malnutrition during this period is partly caused by the inadequate intake of nutritionally appropriate foods that are complementary to breast milk, and it can lead to food-borne diseases (diarrhea, parasitic infections) and/or the reduced bioavailability of micronutrients. The timely use of appropriate complementary foods and/or food supplements is generally recognized as a necessary prerequisite for preventing malnutrition. However, encouraging mothers to buy or prepare appropriate food products at the appropriate time is a challenge that has oft en been addressed without major success in developing countries.

National dietary survey on the children population in the Republic of North Macedonia

This National Dietary Survey, first in kind in the Republic of North Macedonia, provided a base for collection of accurate and reliable dietary data on food consumption and other information about eating habits in toddlers and children. Data on 1079 children at the age of one to nine years old were obtained in line with the “Guidance on EU Menu methodology” provided by the European Food Safety Authority and it will be included in the EFSA Comprehensive European Food Consumption Database. The survey was funded through an EFSA procurement contract and included in the EU Menu Project. The pilot study was performed prior to the data collection process. For the purposes of data collection process, three-stage random probability sampling was used according to the latest “Assessment of population” by State Statistical Office. Within the fieldwork data on the foods consumed as well as the food habits was collected for 534 toddlers (1-3 years old) and 545 other children aged 3-9 years old. Overall response rate in the survey was 85%. Data collection period was divided into four quarters (3-monthly samples) with equal distribution of weekdays and weekend days. Two non-consecutive food diaries were implemented to collect the information about the food consumption, as well as the food propensity questionnaire about the habitual food intake. Information about breastfeeding and complementary feeding practices, food allergies, and food supplements consumption was also collected. Food items consumed were coded according to the FoodEx2 classification. Diet Assess & Plan (DAP) software was used for dietary intake data collection and assessment. Anthropometry measurements of body weight and height/length were performed to assess the current anthropometric characteristics on nutritional status and the children’s trends of growth.

Trends in complementary feeding practices and caregivers' feeding knowledge among children aged 6-23 months: Repeated cross-sectional surveys in rural Qinghai China 2012-18.

BackgroundAppropriate infant and young child feeding is the basis for child survival, growth and development. The aim of this study was to investigate trends in complementary feeding practices and caregivers’ feeding knowledge among children from 2012 to 2018 in Huzhu County, Qinghai Province, China.MethodsThis study took place during and after a controlled interventional evaluation trial in Qinghai Province, China, which aimed to evaluate the effectiveness of community-based nutrient-dense complementary food supplements (YingYangBao) combined with dietary counseling on improving 6-23 month-old children's health status. We conducted four representative cross-sectional surveys on caregivers of children aged 6-23 months in Huzhu County, Qinghai Province, China (baseline survey for the trial (N = 1804) in August 2012, end-line survey for the trial (N = 2186) in August 2014, follow-up survey 1 (N = 496) in January 2016, and follow-up survey 2 (N = 754) in July 2018). In all surveys we used the same questionnaire to collect household information, infant feeding practices and caregivers’ feeding knowledge.ResultsDuring the trial period (2012-2014), the proportion of children aged 6-8 months that introduced (semi-) solid food increased from 86.1% to 96.3% (P < 0.0001), however, there was a downward trend from 2014 to 2018 (P = 0.0014 for trend). The prevalence of minimum dietary diversity also increased from 51.4% at 2012 baseline survey to 57.5% at 2014 endline survey (P = 0.0004), but the upward trend did not maintain from 2014 to 2018 (P = 0.7863 for trend). The minimum dietary frequency, the minimum acceptable diet, and continued breastfeeding at one year were nearly unchanged from 2012 to 2018 (P = 0.9529, P = 0.7602 and P = 0.6013 for trend, respectively), remaining around 30%, 10% and 20% respectively in the four surveys. Caregivers’ feeding knowledge on the duration of exclusive breastfeeding and introduction of semi or solid foods at 6-8 months increased from 2012 to 2018 (18.6% to 39.5%, 43.2% to 64.3%, respectively).ConclusionThis study showed that the sustainability of community-based YYB and dietary counseling program was suboptimal. We suggest that multiple information delivery channels such as smartphones and the Internet should be explored as a supplement to existing channels for delivering counseling information.Trial registrationChiCTRPRC12002444.

Supplementation with Fortified Lipid-Based and Blended Complementary Foods has Variable Impact on Body Composition Among Rural Bangladeshi Children: A Cluster-Randomized Controlled Trial

ABSTRACTBackgroundComplementary food supplementation enhances linear growth and may affect body composition in children.ObjectiveWe aimed to determine the effect of complementary food supplements provided from the age of 6 to 18 mo on fat-free mass (FFM) and fat mass (FM) gain among children in rural Bangladesh.MethodsIn an unblinded, cluster-randomized, controlled trial we tested the effects of 4 complementary food supplements for 1 y [chickpea, rice lentil, Plumpy'doz, and wheat-soy-blend++ (WSB++)] compared with no supplements on linear growth. Body composition was estimated using weight-length-based, age- and sex-specific equations at 6, 9, 12, 15, and 18 mo and postintervention aged 24 mo. Generalized estimating equations (GEEs) were applied to estimate the effect of each complementary food on mean FFM and FM from 9 to 18 and 24 mo compared with the control, adjusting for baseline measures. Sex interactions were also explored.ResultsIn total, 3592 (65.9% of enrolled) children completed all anthropometric assessments. Estimated FFM and FM (mean ± SD) were 5.3 ± 0.6 kg and 1.4 ± 0.4 kg, respectively, at the age of 6 mo. Mean ± SE FFM and FM from 9 to 18 mo were 75.4 ± 14.0 g and 32.9 ± 7.1 g, and 61.0 ± 16.6 g and 30.0 ± 8.4 g, higher with Plumpy'doz and chickpea foods, respectively, than the control (P < 0.001). Estimated FFM was 41.5 ± 16.6 g higher in rice-lentil-fed versus control (P < 0.05) children. WSB++ had no impact on FFM or FM. A group-sex interaction (P < 0.1) was apparent with Plumpy'doz and rice-lentil foods, with girls involved in the intervention having higher estimated FFM and FM than control girls compared with no significant effect in boys. At 24 mo, FFM and FM remained higher only in girls eating Plumpy'doz compared with the controls (P < 0.01).ConclusionsIn this randomized trial, supplementation effected small shifts in apparent body composition in rural Bangladeshi children. Where seen, FFM increments were twice that of FM, in proportion to these compartments, and more pronounced in girls. FFM increased in line with reported improvements in length. This trial was registered at clinicaltrials.gov as NCT01562379.

Micronutrient and Inflammation Status Following One Year of Complementary Food Supplementation in 18-Month-Old Rural Bangladeshi Children: A Randomized Controlled Trial

Background: Four fortified complementary food supplements (CFSs) in a randomized controlled trial (RCT) were found to improve childhood linear growth in rural Bangladesh. We hypothesized children receiving these supplements would have improved micronutrient status. Methods: In the RCT, we assessed hemoglobin and serum ferritin, retinol, zinc, C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) at endline (18 mo) in a subsample of children (n = 752). The impact of supplementation on mean concentrations and the prevalence of nutrient deficiency and inflammation were evaluated using adjusted generalized estimating equation (GEE) linear and log-binomial regression models. Results: In the control arm at age 18 months, 13% of children were anemic (hemoglobin < 110 g/L), and 6% were iron (inflammation-adjusted ferritin < 12 μg/L), 8% vitamin A (inflammation-adjusted retinol < 0.70 μmol/L), and 5% zinc (zinc < 9.9 μmol/L) deficient. The prevalence of inflammation by CRP (>5 mg/L) and AGP (>1 g/L) was 23% and 66%, respectively, in the control group. AGP trended lower in CFS groups (p = 0.04), while CRP did not. Mean ferritin (p < 0.001) and retinol (p = 0.007) were higher in all supplemented groups relative to control, whereas hemoglobin improved with two of the four CFSs (p = 0.001), and zinc was equal or lower in supplemented groups relative to control (p = 0.017). Conclusions: CFSs improved iron status and vitamin A concentrations and lowered inflammation in a context of low underlying nutrient deficiency but high inflammation.

Complementary and alternative medicine use in glioma patients in France.

Complementary and alternative medicine (CAM) use increases in cancer patients, including adult patients with diffuse gliomas. Questionnaires addressing CAM use were distributed to adult patients with gliomas of WHO grades II-IV and ECOG performance score of 0-2 during hospital visits and filled in anonymously. The study was conducted in nine centers in France from May 2017 to May 2018. Descriptive cohort analyses and comparative analyses according to gender, age, WHO grade, and recurrent versus newly diagnosed disease were conducted. Two hundred twenty-seven questionnaires were collected; 135 patients (59%) were male. Median age was 48 years, 105 patients (46%) declared having glioblastoma, 99 patients (43%) declared having recurrent disease. Hundred-three patients (45%) had modified their alimentary habits after the glioma diagnosis. At the time of the questionnaire, 100 patients (44%) were on complementary treatment, mainly vitamins and food supplements, and 73 patients (32%) used alternative medicine approaches, mainly magnetism and acupuncture. In total, 154 patients (68%) declared using at least one of these approaches. Expenditures exceeding 100 € per month were reported by users in 14% for modification of alimentary habits, in 25% for complementary treatment, and in 18% for alternative medicines. All approaches were commonly considered as improving quality of life and experienced as efficient, notably those associated with more expenditures. CAM are frequently used by glioma patients in France. Underlying needs and expectations, as well as potential interactions with tumor-specific treatments, and financial and quality of life burden, should be discussed with patients and caregivers.

Complementary Food Supplements Increase Dietary Nutrient Adequacy and Do Not Replace Home Food Consumption in Children 6–18 Months Old in a Randomized Controlled Trial in Rural Bangladesh

Inadequate complementary feeding is common in low- and middle-income countries, contributing to growth deficits. Complementary food supplements (CFSs) aim to fill dietary gaps, but few CFS studies have measured nutrient intake. In a community-based, randomized CFS trial in Bangladesh, we previously reported poor dietary diversity in 6-18-mo-old participants. We investigated, in a secondary analysis in the same trial, micronutrient intake adequacy in supplemented compared with control-arm children. At age 6 mo, children were assigned to 1 y of child-feeding counseling for mothers (control) or counseling plus 1 of 4 CFS formulations. Mothers were administered quantitative past 24-h diet questionnaires for their children at ages 6, 9, 12, 15, and 18 mo. Nutrient intakes were estimated with local recipes and food composition tables assuming average age-specific breastmilk intake. Adequacy was evaluated relative to estimated average requirements or adequate intakes. Multivariate analysis of variance and generalized estimating equation (GEE) regression models estimated the effect of each CFS on nutrient adequacy. GEE models tested dietary predictors of nutrient adequacy in the control arm. A total of 25,964 dietary modules across 5 interviews were completed. Nutrient adequacy from home foods combined with assumed breastmilk intake was low. Only 5 of 16 micronutrients were adequately consumed by >60% of children at 18 mo of age. Daily CFSs did not affect energy-adjusted micronutrient intake from home foods at any follow-up age (P>0.05). CFSs increased the mean adequacy ratio for all micronutrients (P<0.001 at all ages), to ≥1 for 14 of 16 micronutrients at 18 mo. Dietary diversity predicted adequate iron, zinc and calcium intake at 15 mo in unsupplemented controls. Home foods did not meet the estimated micronutrient needs of 9-18-mo-old children in rural Bangladesh. Daily supplementation with fortified complementary foods filled many micronutrient intake gaps and did not displace home foods. Previously, CFSs were shown to also improve linear growth and reduce stunting in this cohort. Findings support the need for CFSs in similar settings to promote nutritional well being and growth. This trial was registered at clinicaltrials.gov as NCT01562379.

Scaling-up interventions to improve infant and young child feeding in India: What will it take?

We assessed India's readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF program models implemented between 2007 and 2012. We find that Indian policies are well aligned with global technical guidance on counselling interventions. However, guidelines for complementary food supplements (CFS) need to be reexamined. Two national programs with the operational infrastructure to deliver IYCF interventions offer great potential for scale, but more operational guidance, capacity, and monitoring are needed to actively support delivery of IYCF counselling at scale by available frontline workers. Many IYCF implementation efforts to date have experimented with approaches to improve breastfeeding and initiation of complementary feeding but not with improving diet diversity or the quality of food supplements. Financing is currently inadequate to deliver CFS at scale, and governance issues affect the quality and reach of CFS. Available evidence from Indian studies supports the use of counselling strategies to improve breastfeeding practices and initiation of complementary feeding, but limited evidence exists on improving full spectrum of IYCF practices and the impact and operational aspects of CFS in India. We conclude that India is well positioned to support the full spectrum of IYCF using existing policies and delivery platforms, but capacity, financing, and evidence gaps on critical areas of programming can limit impact at scale.

Ying Yang Bao: Improving Complementary Feeding for Chinese Infants in Poor Regions.

Ying Yang Bao (YYB), a complementary food supplement, has helped to rapidly improve the nutrition status of infants and young children in poor rural regions in China. The first YYB study was performed in 2001 by the International Life Sciences Institute, the Chinese Centers for Disease Control and Prevention, and Nestlé. In 2008, the establishment of national standards for complementary food supplements stimulated implementation of about 15 nutrition intervention projects in poor rural counties in which YYB was applied to infants and young children as home fortification for complementary feeding. Data were accumulated in different studies and showed that YYB enhanced the growth of infants with respect to both anthropometry and cognition, and decreased anemia prevalence significantly in infants aged 6-24 months. The Chinese government has launched a project named Improving Children's Nutrition in Poor Rural Regions in 2012. The project has covered more than 4 million infants aged 6-24 months in 341 counties in 21 provinces in western and middle regions by the end of 2015. This nutrition intervention in early life is rather an opportunity for a better later life. The YYB program in China might present an example for developing countries aiming to improve nutrition in early life.

Effect of complementary food supplementation on breastfeeding and home diet in rural Bangladeshi children

Background: Complementary food supplements (CFSs) can enhance growth where stunting is common, but substitution for the usual diet may reduce observed benefits.Objective: We aimed to characterize dietary diversity from home foods in a CFS efficacy trial and determine whether supplementation reduced breastfeeding frequency or displaced home foods.Design: In a cluster-randomized controlled trial in rural Bangladesh, children (n = 5499) received, for 1 y starting at age 6 mo, periodic child feeding counseling for mothers (control) or counseling plus 1 of 4 CFSs fed as a daily snack. Breastfeeding status and past 24-h diet were assessed at enrollment and every 3 mo thereafter until 18 mo of age. A 7–food group dietary diversity score (DDS) was calculated from home foods only, and a DDS ≥4 constituted minimum dietary diversity (MDD).Results: Most children (97%) were breastfed through 18 mo of age, and 24-h breastfeeding frequency did not differ by supplementation group. Child dietary diversity was low; only 51% of children met the MDD by 18 mo. Rice, potatoes, and biscuits (cookies) were the most frequently consumed foods, whereas the legumes, dairy, eggs, and vitamin A–rich fruit and vegetable food groups were each consumed by <50% of children. The odds of meeting the MDD through the consumption of home foods were equal or greater in the supplemented groups compared with the control group at all ages. High socioeconomic status and any maternal education were associated with increased odds of MDD at age 18 mo, whereas child sex and household food security were not associated with MDD.Conclusions: In a setting where daily complementary food supplementation improved linear growth, there was no evidence that supplementation displaced breastfeeding or home foods, and the supplementation may have improved dietary diversity. Pathways by which supplementation with fortified foods may enhance dietary diversity, such as an improved appetite and increased body size, need elucidation. This trial was registered at clinicaltrials.gov as NCT01562379.

Effectiveness of complementary food supplements and dietary counselling on anaemia and stunting in children aged 6–23 months in poor areas of Qinghai Province, China: a controlled interventional study

ObjectiveTo assess the effectiveness of dietary counselling and complementary food supplements on anaemia and stunting prevalence in children aged 6–23 months.DesignA controlled intervention study with measurements of height and haemoglobin...

An enteropathy score predicts subsequent length better than lactulose mannitol (L:M) ratio alone in children enrolled in a community‐based randomized trial of complementary food supplements in rural Bangladesh

Childhood stunting rate in South Asia, including Bangladesh, continues to be high. Subclinical enteropathy may exacerbate stunting though nutrient malabsorption and sequestration, but the magnitude of its effect is unknown, in part due to limited methods for characterizing enteropathy in field‐based studies. Our objective was to derive a composite enteropathy score using a comprehensive set of biomarkers measuring aspects of gut integrity and systemic inflammation, and to determine the extent to which it, relative to the lactulose:mannitol (L:M) test alone, explained attained length. This was done in the context of a randomized controlled trial of complementary food supplements (CFS) for 6–18 mo old children in rural Bangladesh. In a 10% subsample (n=516), stool, serum and urine (2h post lactulose mannitol solution dosing) were collected at age 18 mo. The L:M recovery ratio, a measure of gut permeability and absorptive capacity, was assessed in urine. Stool markers of inflammation (myeloperoxidase and neopterin) and permeability (α−1 antitrypsin) and serum markers of pathogen translocation (endotoxin core antibody immunoglobulin G) and enterocyte repair (glucagon‐like peptide‐1) were measured. A composite enteropathy score (ES) was developed using partial least squares regression with insulin‐like growth factor‐1 (IGF‐1) as the dependent variable. The score was standardized and assessed as an independent variable in regression models with outcome attained length, alone and adjusted for potential confounders. Stunting prevalence among participants was 27.6%, 45.1% and 40.9% at ages 6, 18 and 24 mo, respectively. L:M was elevated (≥0.07) in 42.4% of participants, suggesting prevalent enteropathy, but was not associated with length at 18 or 24 mo. Enteropathy scores ranged from 2.9 to 5.5, with higher scores indicative of poorer intestinal health. In adjusted models, every SD increase in ES was associated with 0.32 (0.06, 0.59) cm lower length at 24 mo. ES trended toward a negative association with length at 18 mo, but confidence intervals included 0 in adjusted models. An enteropathy score inclusive of biomarkers of intestinal permeability, inflammation, absorptive capacity, and repair predicted subsequent length in a setting of prevalent stunting, but its contribution was small (univariate model R2=0.02). A comprehensive index of enteropathy, developed with an analytic approach that accounts for overlapping information from multiple interrelated biomarkers, may be more informative than the L:M test alone; however, our findings suggest compromised gut health has a smaller than expected role in explaining variability in early childhood growth in the rural Bangladesh context, consistent with findings that other growth‐inhibiting mechanisms need to be explored.Support or Funding InformationUSDA NIFA/FANEP [Award # 2010‐38418‐21732], National Institutes of Health [Award # R21HD081503], Bill and Melinda Gates Foundation (GH614) and the Johns Hopkins Sight and Life Global Nutrition Research Institute.

Acceptability of Two Lipid-based Complementary Food Supplements in a Peri-urban South African Community

Acceptability of Two Lipid-based Complementary Food Supplements in a Peri-urban South African Community

UNICEF—CDC Global Assessment of Home Fortification Interventions 2011: Current Status, New Directions, and Implications for Policy and Programmatic Guidance

Micronutrient powders (MNP) reduce anemia and improve iron status in children aged 6 to 23 months. Little is known about home fortification interventions in low-income and middle-income countries. To describe highlights of the Global Assessment of Home Fortification Interventions 2011, new directions, and needed policy and programmatic guidance. A cross-sectional survey ofhomefortification interventions was conducted. Staff at UNICEF and regional focal points at Home Fortification Technical Advisory Group partner agencies sent questionnaires to representatives in 152 low-income and middle-income countries. Included interventions met the following criteria: they were for prevention and used MNP lipid-based nutrient supplements (LNS), or complementary food supplements (CFS); one recommended mode of use was mixing into food; they were implemented or planning to start within 12 months; and research interventions were directly linked to programs. This study identified 63 implemented interventions (36 countries) and 28 planned interventions (21 countries), including 34 implemented interventions (22 countries) and 25 planned interventions (20 countries) that used MNP These interventions were expected to reach 17.2 million people in 2011, including 14.1 million participants in MNP interventions. Among implemented interventions, 16% distributed nationally. Most interventions used integrated approaches targeting young children. Recently, there was increasing expansion of interventions in Africa. The main challenges identified were monitoring and evaluation, adherence, product funding, and procurement. Home fortification interventions, especially those that use MNP, are increasing and scaling up rapidly in regions with widespread problems of micronutrient deficiencies and stunting. Home fortification interventions contribute to global initiatives to reduce undernutrition.

Prospective Study on the Effectiveness of Complementary Food Supplements on Improving Status of Elder Infants and Young Children in the Areas Affected by Wenchuan Earthquake

ObjectiveTo prospectively evaluate the efficiency of daily providing complementary food supplements decreasing malnutrition and anemia prevalence in elder infants and young children living in areas affected by Wenchuan Earthquake.DesignUsing promotional probability sampling method, 250 to 300 children from six-randomized townships (30 to 50 children in each township) in Kang County affected by the Earthquake were randomly chosen for follow up to evaluate intervention effectiveness using anthropometric measurement and hemoglobin level at six, twelve and eighteen months after start of intervention.Setting and SubjectsAll children from 6 to 18 months of age in Kang County (in North Western China) were daily provided with complementary food supplements containing multiple vitamins and minerals for up to 24 months of age. The intervention period lasted for one and half year.ResultsAt beginning of intervention, malnutrition prevalence, including underweight, stunting and wasting were respectively 4.5%, 8.9% and 3.5%; anemia prevalence was 74.3%. After one and half year intervention, the growth and anemia status were significantly improved; the percentages of wasting, stunting underweight prevalence were decreased from 3.5%, 8.9% and 4.5% to 1.7%, 5.0% and 3.3% respectively, and the anemia rates were significantly decreased.ConclusionsOur results indicated that an intervention using complementary food supplements could improve nutritional status and elevate hemoglobin level in elder infants and young children, which would significantly decrease the prevalence of malnutrition and anemia.

GAIN Premix Facility: An Innovative Approach for Improving Access to Quality Vitamin and Mineral Premix in Fortification Initiatives

Vitamin and mineral premix is one of the most significant recurring input costs for large-scale food fortification programs. A number of barriers exist to procuring adequate quality premix, including accessing suppliers, volatile prices for premix, lack of quality assurance and monitoring of delivered products, and lack of funds to purchase premix. To develop and test a model to procure premix through a transparent and efficient process in which an adequate level of quality is guaranteed and a financial mechanism is in place to support countries or specific target groups when there are insufficient resources to cover the cost of premix. Efforts focused on premixes used to fortify flour, such as wheat or maize (iron, zinc, B vitamins, and vitamin A), edible oils (vitamins A and D), and other food vehicles, such as fortified complementary foods, complementary food supplements, and condiments. A premix procurement model was set up with three distinct components: a certification process that establishes industry-wide standards and guidelines for premix, a procurement facility that makes premix more accessible to countries and private industry engaged in fortification, and a credit facility mechanism that helps projects finance premix purchases. After three years of operation, 15 premix suppliers and 29 micronutrient manufacturers have been certified, and more than US$23 million worth of premix that met quality standards has been supplied in 34 countries in Africa, Central and Southern Asia, and Eastern Europe, reaching an estimated 242 million consumers. The Premix Facility demonstrated its effectiveness in ensuring access to high-quality premixes, therefore enabling the success of various fortification programs.

Ensuring optimal breastfeeding and improvements in complementary feeding to improve infant and young child nutrition in developing countries

Ensuring optimal breastfeeding and improvements in complementary feeding to improve infant and young child nutrition in developing countries

Consequences of malnutrition in early life and strategies to improve maternal and child diets through targeted fortified products

This supplement brings together papers focusing onthe critical 1000 days of human development frompregnancy until 2 years of age. It is the third in anannual series first published as a Special SupplementoftheFoodandNutritionBulletininJune2009.Dietsof poor nutritional quality during pregnancy, infancyandearlychildhoodleadtonutrientintakes,whichdonot meet requirements.This, combined with frequentinfections during early childhood,results in deficits ingrowth (stunting),limited psychosocial development,increased risk of mortality, and reduced learningcapacity and productivity later in life among thosethat survive. Programmes need to prevent these defi-cits by improving maternal and child nutrient intakein addition to preventing and treating infections.Over the past 3 years, the community of nutritionscientists and researchers, activists and developmentpractitioners committed to an integrated approach tonutrition programming has grown. This communityadvocates for a greater focus on maternal, infant andyoung child nutrition (MIYCN), the application of alifecycle approach to programming and the breakingdown of the barriers between expertise and sectorsthat limit the scale-up of cost-effective programmesthat meet the needs of vulnerable populations on asustainedbasis.ThisMIYCNsupplementcontinuestoreflect and contribute to this movement by providingthe results of leading-edge research to inform techni-cal consensus, programme design, policy and furtherresearch. It discusses the consequences of malnutri-tion in early life and focuses on programme-relatedresearch to improve nutrient intake through breast-feeding, promoting consumption of special formu-lated fortified foods that fill nutrient gaps or enhancethe diets of women and children. It also presentsresearch assessing feeding practices and preferencesof caregivers in relation to child feeding and formu-lated products. An operations research project inChina is described that illustrates how these activitieswerebroughttogetherinanintegratedprogrammetoimprove nutrient intake in young children.Dewey and Begum (2011) set the stage by summa-rizing the prevalence, causes and consequences ofstunting.One-third of children under 5 years of age indeveloping countries are stunted,with many childrenin several regions already stunted at birth. Stuntingrates increase during the first 24 months of life withlittle change thereafter until adolescence, whendelayed maturation and an extended growth periodresult in some compensatory growth (Bosch

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.

Fortifying complementary foods with NaFeEDTA – considerations for developing countries

As a highly bioavailable iron compound, sodium iron (iii) ethylenediaminetetraacetate (NaFeEDTA) has been recommended as a food additive for fortification. The amount of a food additive that can be ingested daily over a lifetime without appreciable health risk is termed the acceptable daily intake (ADI). The ADI for NaFeEDTA is based on body weight. For complementary foods and food supplements for infants and young children in low-income countries, where prevalence of underweight is high yet nutrient needs are also high, it is not clear which doses might be appropriate. The objective is to calculate the dosage of NaFeEDTA for fortifying complementary foods assuming different population prevalences of underweight. Mathematical models were used to simulate the dosage of NaFeEDTA for 6- to 8-month-old infants under different prevalences of underweight ranging from 5% to 40%. In order to keep NaFeEDTA intake below the ADI for ethylenediaminetetraacetate (EDTA) recommended by the Joint Food and Agriculture Organization (FAO)/World Health Organization (WHO) Expert Committee on Food Additives for 95% of 6- to 8-month-old infants, the daily iron dose from NaFeEDTA in fortified complementary foods should be set between 2.2 mg and 1.8 mg in countries with a prevalence of underweight among 6- to 8-month-old infants between 5% and 40%, respectively. If 2 mg of iron is given to all 6- to 8-month-old infants, the percentage exceeding the ADI for EDTA would be <10% for populations with <30% of children who are underweight, which is the case for many countries. In conclusion, 2 mg of iron from NaFeEDTA could be used for fortifying one daily serving of complementary food to ensure EDTA levels are below the ADI for infants 6-8 months of age. An additional source of iron (such as ferrous sulfate) should be included to increase the iron dose to desired fortification levels.