Addressing MND

1.
This presentation is part of the
Agriculture and Nutrition Global Learning and Evidence Exchange
(AgN-GLEE)
held in Guatemala City, Guatemala from March 5-7, 2013.
For additional presentations and related event materials, visit: http://spring-nutrition.org/agnglee-lac

2. iLiNS
project
Presentation by:
Omar Dary
Place:
AgNGLEE-Central America
Guatemala City,
Guatemala
6-March-2013
Importance of Food Fortification
and in-Home “Fortification” to
Complement the Nutrient
Adequacy of the Diet

3. Abt Associates | pg 2OD-2013-01
Why stunting has changed little in
Guatemala?
Source: ABC News

4. Abt Associates | pg 3OD-2013-01
Guatemala (ENSMI- 2008-2009)
Wasting (w/h) Underweight (w/a) Stunting (h/a)
1.4 % 13.1% 49.8 %
Ghana (2008-DHS)
Wasting (w/h) Underweight (w/a) Stunting (h/a)
9.0 % 17.8 % 28.0 %
Anthropometric indicators in pre-
school age children < 2 S.D.
Why do not consider other reasons beyond protein-energy
undernutrition?

5. Abt Associates | pg 4OD-2013-01
What about breast-feeding practices,
use of snacks, or stimulus?
Pictures from Dr. Ram Shrestha,
URC, visit to Guatemala 2012.

6. Abt Associates | pg 5OD-2013-01
Causes of stunting and anemia
Type of growth and development
Physical Factors: good
nutrition, good health,
disease resistance
Social Factors (Care) :
Early stimulation, belonging
to a family, attention, love
Genetic, Demographic &
Environmental Factors:
Race, gender, ethnicity,
altitude, sun-exposure,
intestinal flora
“Food Security”
(Foods)
Child/mother health
practices,
Immunization (Health)
Safe water and
hygienic foods,
healthy environments
(Hygiene)
Macronutrients
supply: cereals,
pulses, oil and fats,
animal protein
Some vitamins and
minerals: milk, eggs,
fruits, vegetables,
fortified foods
Avoidance of toxins
and anti-nutritional
factors:
mycotoxins, e.g.
Well absorbed Fe/Zn
(fermentation, meat,
fish, fortification,
supplementation)
Wasting,
underweight
and overweight
Essential fatty acids
supply, mainly n-3
(fatty fish, and certain
vegetable oils)
Non-digestible
oligosaccharides
and fiber: healthy
intestine status.

7. Abt Associates | pg 6OD-2013-01
Stunting is only an indicator; the
important is to correct its causes.
Taken from: Thompson, R. A., & Nelson, C. A. (2001). Developmental science and the media: Early brain
development. American Psychologist, 56(1), 5-15.
Complementary feeding
Nearly half of the “1000 days”
depends on the mother
nutritional status.
Exclusive
lactation
Pregnancy

8. Abt Associates | pg 7OD-2013-01
Nutritional value of breast milk depends
mostly on the mother’s diet
Type I Nutrients (dependent)*
Vit. B-1 60% Choline 56%
Vit. B-2 53% Vit. A¶ 56%
Vit. B-6¶ 80 % Vit. D¶ ? ***
Vit. B-12¶ 16 %** Iodine 6-23 %
Vit. C 50 % Selenium 52 %
Type II Nutrients (independent)
Sufficient Satisfy A.I., but…
Folate Iron
(Niacin)**** Zinc¶
Calcium Copper
Notes:
* Estimated proportion of the Adequate Intake (AI) for the child of an under-nourished mother.
** Not possible to increase during the lactation period; it requires good status pre-pregnancy.
*** Depends on sun exposure.
**** It could be synthetized from the amino-acid tryptophan
¶ Deficiency associated to stunting.
References: Allen LH, Adv Nutr 2012; 3:362-369; and Allen LHGJ, In: Dealange FM WKJ (Ed). Micronutrient
deficiencies in the first months of life. Basel: Karger Ag; 2003. pp 55-88.

9. Abt Associates | pg 8OD-2013-01
Dietary sources of some nutrients
Nutrient Milk
Meat,
poultry
Eggs
Pulses
(beans)
Whole
cereals
Vege-
tables
Fruits
& roots
Sugar, oil,
pol. rice
ref. flours
Vit. B-1 + ++ + +++ ++ + + -
Vit. B-2 +++ ++ ++ + + ++ + -
Niacin (B-3) + +++ + ++ + ++ + -
Vit. B-6 + ++ ++ ++ ++ ++ ++ -
Folate (B-9) - + ++ ++++ + ++ + -
Vit. B-12 ++ + ++ - - - - -
Vit. C + - - - - +++* +++ -
Vit. A +++** + +++ - - (++) ++ -
Vit. D +++** + + - - - - -
Iron - ++++ (+) (+++) (++) (++) (+) -
Zinc - ++++ - (+++) (++) (+) (+) -
Calcium +++ + + (++) (+) (++) - -

10. Abt Associates | pg 9OD-2013-01
Nutrient inadequacy(%) of the most vulnerable member of
the family in the Dominican Republic -2007
Source: Dominican Republic ENCOVI-2007. RED/USAID and the National Office of Statistics (ONE), 2012
Socio-economic
groups
2007 - DHS
Stunting: 9.8%
Underweight: 3.1%
Wasting: 2.2%

11. Abt Associates | pg 10OD-2013-01
Risk of inadequacy during the life course
(relative to energy intake)
Nutrient
Children Women Men
1-3 y old 4-6 y old 19-30 y old  60 y old 19-30 y old  60 y old
Vit. B-2 + + + ++ + +++
Folate (B-9) + ++ +++ ++++ + +++
Vit. B-12 + ++ ++ ++++ + ++
Vit. A +++++ ++++ + +++ + ++
Iron +++ + +++++ +++ +++ ++++
Zinc ++++++ +++++ + ++ ++ ++++
Calcium +++++ ++++++ ++ +++++ + +++
Iodine +++++++ ++++++ +++ ++++ + +++
Source: Dominican Republic ENCOVI-2007. RED/USAID and the National Office of Statistics (ONE), 2012
Questions: 1. Why to extend supplementation with iron from 6-24 months of age to 59 months of age?
2. Why to supply additional folic acid to children younger than 36 months of age?

12. Abt Associates | pg 11OD-2013-01
Anemia prevalence on 6-59 m children -
Dominican Republic 2009
Source : Amarilis Then Paulino, MSP. 2011. 2009-Micronutrient Survey

13. Abt Associates | pg 12OD-2013-01
Results of a real fortification program:
Wheat flour in Jordan-2010
Nutrient
Additional content (mg/kg) % EAR
Expected Real Children Women
Iron –FeSO4 34 27 52 % 20 %
Vitamin A 1.5 1.2 29 % 52 %
Indicator
Children (3-5 years old) Women (15-49 years old)
2002 2010 2002 2010
Iron Def. (ferr.
(<11 & < 12 ng/mL)
10.1 % 4.8 %* 20.0 % 19.8 %
Anemia
(<11 &12 g/dL)
20.2 % 17.0 % 29.3 % 30. 6 %
IDA 26.1 % 13.7 %* 38.7 % 35.1 %
Serum retinol
(<0.7 mol/L)
15.2 % 18.3 % - 4.8 %

14. Abt Associates | pg 13OD-2013-01
Combining food vehicles to increase coverage
and the solution (additional micronutrient intakes)
Source: Dominican Republic ENCOVI-2007.
RED/USAID and the National Office of Statistics
(ONE), 2012
Source: Martorell R. Caracterización de los patrones de
consumo aparente en Centro América

15. Abt Associates | pg 14OD-2013-01
Theoretical contribution (%EAR) through
fortified food for 1-2 y old children in D.R.
Nutrient
Diet
Wheat flour/
Salt (I)
Rice/ sugar
(Vit A)
Maize flour
Total
(extremes)
P-20 P-80 P-20 P-80 P-20 P-80 P-20 P-80 P-20 P-80
Vit. B-2 85 170 5 22 0 0 0 7 90 198
Folate (B-9) 73 205 13 61 68 193 0 26 155 488
Vit. B-12 61 255 0 0 40 114 0 15 100 384
Vit. A 42 123 0 0 31 131 0 0 73* 254
Iron 77 131 5 24 4 10 0 11 86 176
Zinc 42 101 0 0 3 9 0 5 46 115
Calcium 22 50 0 0 0 0 0 0 22 50
Iodine ? ? 112 224 0 0 0 0 112 224
* Vit.A capsules: 200,000 IU = 60 mg = 0.278 mg/d if 80% absorpt. = 127% EAR of vit. A for 1-2 year old children.

16. Abt Associates | pg 15OD-2013-01
In-home “fortification” (% EAR-INCAP)
for children 1-2 years old in the D.R.
Nutrient
Breast
milk*
Diet –
P-20
Diet +
FF P-20
MNP-
WHO
MNP-
Guate.
MNP-
TAG**
LNS***
Vit. B-1 25 106 140 - - 42-125 75
Vit. B-2 50 85 90 - - 42-125 100
Niacin (B-3) 25 149 179 - - 50-150 100
Vit. B-6 100 128 160 - - 42-125 450
Folate (B-9) 117 73 154 - 76 42-125 113
Vit. B-12 100 61 100 - - 43-129 71
Vit. C 169 192 192 - 77 77-231 231
Vit. A 130 42 73+supp 143 48 63-190 190
Iron 9 77 86 231 77 62-185 166
Zinc 94 43 46 93 44 36-108 108
Calcium 44 22 22 - - - 20
* From mother with good nutrition, 39% energy supply; ** Technical advisory group: 60-180 days supply, WHO
formula for emergencies; *** Lipid Nutrient Supplements: They also contain n-3 and n-6 essential fatty acids.

17. Abt Associates | pg 16OD-2013-01
Anemia Prevalence in
1999
0
10
20
30
40
1-2y.old
2-5y.old
6-11y.old
Adolescents
Women
Wheat Flour
consumption
250 g/day
Iron Fortification
Level
20.0 mg/kg as
Ferrous Sulfate
(+10 intrinsic)
Iron Intake through
wheat flour
5.0 mg/day
Micronutrient Level
% EAR
in 650
mL/day
Iron (As ferrous
sulfate)
10 mg/L 112%
Vitamin A 300 µg/L 68%
Vitamin C 70 mg/L 182%
Zinc 5.0 mg/L 96%
Anemia in 1-2 year old Children
After Fortification of Milk
0
10
20
30
40
1999
2000
Impact of milk fortification in Chile. Skim milk
is a natural source of vit. B-2, B-12, calcium

18. Abt Associates | pg 17OD-2013-01
Population coverage
Additional intake
Target fortificationMass fortification
Supplements for home
“fortification”
Supplements
ODM-2011-3-Micr.Mex.
Dietary Diversification
Nutrition specific interventions

19. Abt Associates | pg 18OD-2013-01
The risk of not integrating
ODM-2011-3-Micr.Mex.
MandatoryVoluntary
General population
Specific groups
Coverage
Compliance
Mass
fortification
Target
fortification
Market driven
fortification
And this without
considering the
supplements
Principles and concepts are UNIVERSAL, but the solutions are LOCAL (need and context)