Global Alliance For Improved Nutrition Research Articles

Health Promotion in Efforts to Prevent Stunting in the First 1000 Days of Life (HPK) at Puskesmas X Koto 1 Tanah Datar Regency

Stunting, a persistent global nutritional issue from inadequate care and nutritional intake, becomes evident when a child ages two. Tanah Datar recorded a 21.5% stunting rate in 2022, prompting a targeted service to enhance the literacy of pregnant women, mothers of toddlers, and cadres about the critical first 1000 days of life. Utilizing an interactive game, Emotional Demonstration, and drawing on four modules from the Global Alliance for Improved Nutrition (GAIN), the service employed printed modules and game equipment. Held on 10 June 2023 at Wali Nagari Pandai Sikek Hall, the event gathered 20 participants, including pregnant women, mothers, cadres, and X Koto Community Health Center officers. Activities commenced with a pre-test, followed by interactive game-based education, and concluded with a post-test. The community service positively contributed to increased health literacy and awareness in the first 1000 days, validated by significant T-test results (p-value = 0.001), indicating a substantial knowledge improvement post-intervention.

Inclusive diets within planetary boundaries

Inclusive diets within planetary boundaries

Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas.

Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areas.

The Cost-Effectiveness of Existing and Hypothetical Iron Fortification Programs in Haiti

Abstract Objectives Our objectives were to estimate apparent intake of iron in Haiti, to assess the adequacy of iron intake among women of reproductive age (WRA), and to model the cost-effectiveness of fortifying alternative food vehicles for reducing inadequate intake. Methods We analyzed the most recent Haiti household food consumption data (2012 ECVMAS) to estimate adequacy of apparent iron intake from dietary sources (using the adult male equivalent method; assuming 10% absorption) and modeled the impacts of fortifying currently mandated (wheat flour, applying local data on current compliance) and hypothetical (bouillon and rice) food vehicles on reductions in the prevalence of inadequate iron intake (effective coverage). We built activity-based cost models to estimate large scale food fortification (LSFF) program establishment and management costs, based on key informant interviews and on published cost estimates from other settings adapted to fit the Haitian case. Results The prevalence of inadequate dietary intake of iron among WRA was 79% (100% among pregnant women). Iron-fortified wheat flour was the most cost-effective vehicle: $4.32 and $4.75 per WRA-year effectively covered at current (75% of flour fortified to the standard of 30 mg/kg) and target (90% fortified to the standard) fortification levels. Fortified wheat flour effectively covered 11–13% of non-pregnant WRA, but almost no pregnant women. Although bouillon was consumed by > 98% of households, low estimated iron absorption from fortified bouillon (2%) led to low effective coverage. Iron-fortified rice (90% fortified at 120 mg/kg) was predicted to effectively cover the largest number of WRA (reducing inadequate intake to ∼30%), but at a cost of $7.80 per WRA-year effectively covered. Conclusions Of the food vehicles modeled, wheat flour was the most cost-effective for reducing inadequate iron intake. Modeling iron fortification of individual and combinations of food vehicles showed that well-designed LSFF programs can contribute to improving iron status among non-pregnant women, but eliminating inadequate iron intake among all WRA will require complementary iron interventions. Funding Sources This work was supported by grants to UC Davis from the Global Alliance for Improved Nutrition (GAIN) and to Partners of the Americas from the United States Agency for International Development (USAID).

Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification.

Daily calcium intake is well below current recommendations in most low- and middle-income countries (LMICs). Calcium intake is usually related to bone health, however an adequate calcium intake has also been shown to reduce hypertensive disorders of pregnancy, lower blood pressure and cholesterol values, and to prevent recurrent colorectal adenomas. Fortification of foods has been identified as a cost-effective strategy to overcome micronutrient gaps in public health. This review summarizes regulatory aspects of fortification of commonly consumed foods with micronutrients, with an emphasis on calcium. We selected a convenient sample of 15 countries from different WHO regions and described the regulatory framework related to calcium fortification of staple foods. We assessed the relevant policies in electronic databases including the WHO Global database on the Implementation of Nutrition Action (GINA) for fortification policies and the Global Fortification Data Exchange Database, a fortification database developed and maintained by Food Fortification Initiative (FFI), Global Alliance for Improved Nutrition (GAIN), Iodine Global Network (IGN), and Micronutrient Forum. Food fortification with micronutrients is widely used in many of the selected countries. Most countries had national legislation for the addition of micronutrients to staple foods, especially wheat flour. These national legislations, that includes regulations and standards, can provide the framework to consider the implementation of adding calcium to the fortification strategies, including the selection of the adequate food vehicle to reach the targeted population at risk safely. The strategy to include calcium in the fortification mix in fortified staple foods seems promising in these countries. However, potential undesired changes on the organoleptic characteristics of fortified foods and products thereof, and operational feasibility at the manufacturing site should be evaluated by the stakeholders during the planning stage. Codex Alimentarius standards should be considered by regulators in order to assure adherence to international standards. While the selected countries already have established national regulations and/or standards for fortification of key staple food vehicles, and there are experiences in the implementation of fortification of some staple foods, national food intake surveys can help plan, design, and modify existing fortification programs as well as monitor food and nutrient consumption to assess risk and benefits.

Considerations for Rice (Oryzasativa) Fortification with Essential Micronutrients in Public Health Intervention

Background and Rationale: Fortification of staple foods and commonly used condiments with vitamins and minerals has been considered one of the most cost-effective interventions to prevent and control micronutrient deficiencies. Because of its wide local consumption, acceptability, reach, and quantum of consumption, rice (Oryzasativa) far exceeds the requirements of a staple food vehicle that can be considered for fortification purposes at a population-level intervention. The World Health Organization (WHO) has the mandate to develop evidenceinformed guidelines for the fortification of staple foods as a public health intervention, including rice fortification with micronutrients. The WHO, in collaboration with the Global Alliance for Improved Nutrition (GAIN), convened a consultation on “Technical Considerations for Rice Fortification in Public Health” in Geneva, Switzerland in 2012 to provide technical inputs to the guideline development process, particularly with reference to feasibility and implementability.
 Conclusion: The industrial and regulatory technical considerations in rice fortification, as well as the considerations for implementing it as a public health strategy and assuring equitable access and universal coverage and priority research areas for the forthcoming years were reviewed in this article based on WHO consultation
 Bangladesh Journal of Medical Science Vol.19(2) 2020 p.189-193

Development of a Diet Quality Questionnaire for Improved Measurement of Dietary Diversity and Other Diet Quality Indicators (P13-018-19)

ObjectivesThe objective of this research was to develop and test a low-burden method to gather diet quality data that is comparable across countries, consistently implemented, and easily understood by respondents. A common method for collecting dietary diversity data consists of open-ended food group questions, e.g., Yesterday, did you eat any porridge, bread, rice, pasta or other foods made from grains? Our hypotheses were (1) the majority of consumption of each food group could be represented by a few foods in each country setting (sentinel foods); (2) respondents who did not eat the listed examples might misclassify other foods they ate as belonging to the same food group. We sought to refine the method by modifying each question to be closed-ended. MethodsWe developed a 26-item diet quality questionnaire (DQ-Q), where each yes/no question asks about consumption of a distinct food group in the previous day or night. We tested the first hypothesis using 24-hour nationally representative dietary intake data from Brazil (Individual Food Intake Survey 2008–2009) and the United States (NHANES 2009–2014). We categorized each food and beverage item into the 26 food groups of the DQ-Q, and identified the most commonly consumed foods in each. Individuals were categorized according to whether they had consumed at least one item in each food group (1) or not (0). We tested the second hypothesis through 82 cognitive interviews in five languages São Paulo and New York City, in which we compared responses to closed-ended sentinel food questions to open-ended food group questions. ResultsOn average, 1–7 sentinel foods captured 96–97% of people who consumed each food group (range 85–100%). Respondents in both countries sometimes miscategorized foods when asked open-ended food group questions, and open-ended questions presented an additional cognitive burden. The DQ-Q took 3–5 minutes to administer. ConclusionsThe DQ-Q is a rapid low-burden method to collect diet quality data. Closed-ended questions using sentinel foods capture the vast majority of consumption and are better understood by respondents than open-ended list-based methods, for measuring dietary diversity and other aspects of diet related to NCD risk. Funding SourcesFunding for this work was provided by the Global Alliance for Improved Nutrition (GAIN) and the Swiss Agency for Development and Cooperation (SDC).

A Delivery Model for Home Fortification of Complementary Foods with Micronutrient Powders: Innovation in the Context of Vietnamese Health System Strengthening.

Adding micronutrient powders (MNP) to complementary foods at the point of preparation (home fortification) can improve micronutrient status of young children. Ensuring sustained access to MNPs at scale, however, remains challenging in many countries. The Global Alliance for Improved Nutrition (GAIN) partnered with the National Institute of Nutrition (NIN) in Vietnam to pioneer the distribution of a locally-produced MNP, provided for sale through the public health system with counseling on optimal infant and young child feeding practices by trained health workers. Different packaging options were available to adapt to caregivers’ disposable income. During the six-month pilot, 1.5 million sachets were sold through 337 health centers across four provinces, targeting children 6–59 months of age. Sales were routinely monitored, and a cross-sectional survey in 32 communes for caregivers (n = 962) and health staff (n = 120) assessed MNP coverage and compliance, five months after the start of distribution. A total of 404 caregivers among the 962 caregivers surveyed (i.e., 42%) had visited the health center in the past year. Among them, 290 caregivers had heard about the product and a total of 217caregivers had given the MNP to their child at least once, representing a conversion rate from product awareness to product trial of 74.8%. The effective coverage (i.e., consumption of ≥3 sachets/child/week) was 11.5% among the total surveyed caregivers and reached 27.3% amongst caregivers who visited health centers in the previous month. The MNP purchase trends showed that the number of sachets bought by caregivers was positively correlated with the wealth index. The pilot showed that providing MNPs for sale in packs of various quantities, combined with infant and young child feeding (IYCF) counseling at the health center, is effective for groups accessing the health system.

Quality-driven programming in global surgery: A 30-Year institutional experience delivering safe, timely and effective surgical care

databases. Grey literature documents were provided by the Global Alliance for Improved Nutrition (GAIN) and retrieved from nonindexed sources such as the websites of non-governmental organizations (NGOs) and fortified food manufacturers . Outcomes included both quantitative (effectiveness) and qualitative (analysis of programs/ barriers/lessons) measures. As such, our search was not restricted by study design. Inclusion criteriacapturedstudies that evaluate large scale, typically country-wide, fortification efforts in LMICs. Full text retrieval, data abstraction, and quality assessment were completed in duplicate for all studies that passed the screening process. Analysis Statistical analyses were performed using Review Manager Software version 5.3. Meta-analyses were conducted where possible. Findings: A total of 140 quantitative studies were identified as ‘included’, of which 25 pertained to mass fortification with folic acid. Of these 25 studies,14 reported aperinatal/neonatal outcome. In all cases, this referred to one or more type of NTD (spina bifida, anencephaly, or cephalocele). A meta-analysis for each outcomewas conducted in order to determine to risk ratio (RR) ofNTDs after folic acid fortification.When looking at totalNTD rates, the combined RR was 0.65 [95% confidence intervals (CI) 0.530.79], demonstrating a positive association between fortification with folic acid and reduction in NTD prevalence. When examining NTD by type, this reduction in prevalence was also present. The overall RR was 0.53 [95% CI 0.42-0.66] for anencephaly, 0.67 [95% CI 0.48-0.92] for spina bifida, and 0.68 [95% CI 0.48-0.97] for cephalocele. Interpretation: While there were some country-specific variations, the overall impact of mass food fortification led to a significant reduction in risk of NTDs when comparing preand post-fortification periods. Funding: No funding listed. Abstract #: 02ITIS005

Considerations for rice fortification in public health: conclusions of a technical consultation.

Fortification of staple foods and commonly used condiments with vitamins and minerals has been considered one of the most cost-effective interventions to prevent and control micronutrient deficiencies. Because of its wide local consumption, acceptability, reach, and quantum of consumption, rice (Oryza sativa) far exceeds the requirements of a staple food vehicle that can be considered for fortification purposes at a population-level intervention. The World Health Organization (WHO) has the mandate to develop evidence-informed guidelines for the fortification of staple foods as a public health intervention, including rice fortification with micronutrients. The WHO, in collaboration with the Global Alliance for Improved Nutrition (GAIN), convened a consultation on "Technical Considerations for Rice Fortification in Public Health" in Geneva, Switzerland on October 9-10, 2012 to provide technical inputs to the guideline development process, particularly with reference to feasibility and implementability. The industrial and regulatory technical considerations in rice fortification, as well as the considerations for implementing it as a public health strategy and assuring equitable access and universal coverage, were reviewed in this consultation. This paper summarizes the discussions and priority research areas for the forthcoming years.

BRAC's experience in scaling-up MNP in Bangladesh.

Despite progress in health status and achievements in Millennium Development Indicators, Bangladesh presents a gloomy scenario for nutrition. In 2009, BRAC (formerly known as Bangladesh Rural Advancement Committee) has begun to implement a community-based approach of Alive & Thrive with Family Health International 360, aiming to reduce undernutrition among children under two by promoting exclusive breastfeeding and appropriate complementary feeding practices. To address anemia and other micronutrient deficiencies, home-fortification with micronutrient powders (MNP) has been promoted among under-fives across Bangladesh along with the Global Alliance for Improved Nutrition (GAIN). BRAC's frontline community health workers play a critical role in promoting micronutrient powders with better feeding practices. Over the years, improvements have been observed in the intervention areas: exclusive breastfeeding rose from 49% to 83% of children (0-6 months), 86% of children received complementary feeding at 6-8 months with about two/thirds being fed the recommended number of times; and 70% of children (6-59 months) adhered to MNP use, ie consumption of 1 sachet per day in the past 60 days. However, many challenges are still observed in traditional feeding practices, along with limited skills of community health workers and households' poor access to quality food, necessitating constant interactions between caregivers, mothers-in-law and fathers with the frontline workers. Maintaining the supply chain of micronutrient powders and a visible and convincing change in nutritional status of children are key success factors. The partnerships between BRAC, GAIN and Renata, the producer of MNP in Bangladesh, have given birth to a home-fortification model that can deliver impact at scale.

Prospects for better nutrition in India.

Being home to 31% of the world's children who are stunted and 42% of those who are underweight, and with many children and adults affected by micronutrient deficiencies, India is facing huge challenges in the field of nutrition. Even though the Indian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the Integrated Child Development Services program alone costs 3 billion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons for this reduction are not unambiguous and appear to include state government commitment, focus on the 'window of opportunity', improved status and education of women, a lowered fertility rate, and combinations of nutrition- specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked with a range of partners to improve access to nutritious foods for large parts of the population, through public and private delivery channels. This supplement presents a selection of these activities, ranging from a capacityassessment of frontline workers in the ICDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.

The Global, Centralized Approach of the GAIN Premix Facility Has Made Oil Fortification in Indonesia More Affordable

Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs. To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia. A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time. The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fortification went down significantly compared with prices they would have been offered had they ordered vitamin A individually. In Indonesia, this consolidated procurement approach has allowed a 14.5% decrease in the unit price of vitamin A. The GAIN Premix Facility demonstrated its effectiveness in acting as a global procurement platform by aggregating demand across different customers and leveraging improved prices through increased volumes. Building on the success of this effort, the GAIN Premix Facility is replicating this global approach for procurement of other standard items being procured across fortification programs worldwide.

ASEAN: Insights and Considerations toward Nutrition Programs

In July 2011 the Global Alliance for Improved Nutrition (GAIN) and the World Food Programme (WFP) held a symposium to discuss important nutrition issues in the Association of Southeast Asian Nations (ASEAN) countries. With a focus on micronutrient deficiencies and stunting stakeholders ranging from Ministry of Health participants to leaders of local nongovernmental organization elaborated on pressing nutrition issues in the region and debated strategies to tackle the prevalence of malnutrition. The region still faces high prevalence rates of micronutrient deficiencies and stunting despite Southeast Asia’s progress in reducing mortality rates and its economic growth over the past few decades. Failure to achieve recommended daily intakes of at least some micronutrients (most commonly vitamin A iron calcium riboflavin and iodine) is documented by survey data from almost every part of the region. Stunting and micronutrient deficiencies have detrimental impacts on childhood development and morbidity and according to experts the situation is unlikely to drastically improve in the long term due to food supply shortages. In this context health and nutrition interventions need to synchronize with national government policies to reduce malnutrition as well as obesity. The 1000 Day Window of Opportunity Initiative and the Scaling up Nutrition (SUN) movement provide important strategic framework for these kinds of interventions. The role of the private sector is an integral part of the SUN movement to which some ASEAN countries have already signed up. This supplement highlights some of the pressing issues important for nutrition programming and shares highlights and experiences from ongoing programs addressing malnutrition and micronutrient deficiencies. In mirroring the diverse and rapidly changing ASEAN region the topics of the papers range widely from highlighting the problem of stunting to presenting models of more effective food fortification.

The Global Alliance for Improved Nutrition (GAIN): A Decade of Partnerships to Increase Access to and Affordability of Nutritious Foods for the Poor

The Global Alliance for Improved Nutrition (GAIN) was established in 2002 with a mandate to galvanize efforts by the public and private sectors to end malnutrition. GAIN launched its first large-scale fortification program in 2003, and in less than a decade has scaled its operations to reach more than 600 million people with nutritionally enhanced food. GAIN has evolved considerably as an organization, expanding beyond large-scale food fortification into new program areas, focusing on maternal, infant, and young child nutrition and improvements in agricultural practices to enhance nutrition. This paper describes GAIN's evolution from a large-scale food fortification program focus to a broader nutrition program portfolio directed toward improving access and affordability of nutritious foods for the poor. As GAIN enters its second decade, it continues to respond to the challenges of a changing nutrition landscape by introducing new programs and novel partnerships and by refining its innovative program delivery models.

Lessons Learned from National Food Fortification Projects: Experiences from Morocco, Uzbekistan, and Vietnam

Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. To document the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam. Independent end-of-project evaluations conducted for each project served as the primary data source and contain the history of and project activities undertaken for, each fortification project. Other sources, including national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer-reviewed articles, were used to document the current responses to challenges and future project plans. All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects' design to address the challenges faced. National fortification projects are dynamic and must be continually modified in response to specific performance issues and broader shifts in market structure and consumption patterns.

Our Children Need to be Saved from HUNGER!!

What can I say? This is a special issue, dedicated to the nutritional needs of mothers and children, one of two, sponsored by GAIN (Global Alliance for Improved Nutrition) under their Programme on Infant and Young Child Nutrition. The pictures below tell only a small bit of the story, but quite a bit. The Horn of Africa (Kenya, Ethiopia and Somalia), and beyond (countries in yellow) is facing its worst famine in 60 years, with over 10.5 million people facing starvation. From information available to us locally, there already have been deaths of vulnerable groups (children and old people). It is difficult to get accurate data as officials are too embarrassed to admit that millions of their citizens are actually facing starvation, and that millions of children are going hungry, as many die.

EHPnet: Global Alliance for Improved Nutrition

A third of the world’s population lacks sufficient vitamins and minerals in their diet. Each year nutritional deficiencies contribute to the deaths of 1 million children under the age of 5 years and 50,000 women during or just after childbirth. Such conditions also commonly cause mental and physical health problems such as learning disabilities, birth defects, and blindness. In addition, $6 billion dollars in lost adult work performance will add up annually due to malnutrition, significantly impacting the economies of developing countries. At a special 2002 UN session on child health, the Global Alliance for Improved Nutrition (GAIN) was formed to address the problems of inadequate diet in at-risk populations using food fortification, as described at http://www.gainhealth.org/. To date GAIN has had three rounds of grant funding, with 18 projects in food fortification and infant/young child nutrition aiming to improve the nutrition of almost 600 million people. The Food Fortification subsection of the Our Programs page outlines the different levels of GAIN grants and initiatives in this area. Project leaders are working to establish and strengthen national food fortification programs in several developing countries with efforts to fortify such products as cooking oils, maize meal, wheat flour, and sauces. Smaller-scale targeted projects focus on four main program areas: schools, maternal and child health, populations affected with HIV/AIDS, and policy development. GAIN also supports global initiatives, one of which focuses on fortification of food that is being distributed to refugees, internally displaced persons, and other vulnerable groups. GAIN explains the direction of its work in the Why Fortification? portion of its website, including a brief discussion of why GAIN has decided to channel its resources into fortification along with scientific data to support this move. Overviews of the five primary micronutrient deficiencies—vitamin A, iodine, folate, iron, and zinc—discuss how these nutrients are used in the body, how deficiencies in each impact health, and the primary sources of the nutrients in food. Four major strategies for eliminating nutritional deficiencies are laid out on the Possible Responses page along with the pros and cons of each.

Public-Private Sector Alliances for Food Fortification: Time for Optimism

The Global Alliance for Improved Nutrition (GAIN) was launched at the United Nations General Assembly Special Session on Children in May 2002 as a global and regional alliance of public private and civic groups committed to eliminating micronutrient deficiencies. The Bill & Melinda Gates Foundation provided GAIN with its principal funding which has been complemented by grants from international and bilateral agencies. GAINs vision is of a world in which malnutrition is no longer a human and social development constraint. In May 2002 the UN General Assembly Special Session on Children re-emphasized the micronutrient goals of the early 1990s: Achieving the sustainable elimination of vitamin A deficiency by 2010 reducing anaemia prevalence including iron deficiency by one third by 2010 and virtually eliminating iodine deficiency disorders by 2005; accelerating progress towards reduction of other micronutrient deficiencies through dietary diversification food fortification and supplementation. (excerpt)