The document summarizes a study investigating suboptimal thiamin status in Cambodian women of childbearing age. The study found high rates of thiamin deficiency in rural Cambodian women. To address this, researchers propose a randomized controlled trial to develop a thiamin-fortified fish sauce for consumption by women. The trial would compare different levels of thiamin fortification to a placebo, with the goal of increasing thiamin levels and reducing the risk of infantile beriberi, a condition caused by maternal thiamin deficiency. The fortified fish sauce, if successful, could potentially be scaled up across Cambodia.

1. Suboptimal thiamin status is common in
Cambodian women of childbearing age
Whitfield, KC, Liu, Y, Karakochuk, CD, Talukder, A, Kroeun, H,
Kevanna, O, Kitts, DD, Li-Chan, ECY, McLean, J, Green TJ
Sponsored by Hosted by
Presented at the International Food Security Dialogue 2014
Enhancing Food Production, Gender Equity and Nutritional Security in a
Changing World
Under-nutrition measures for women and children in Africa and Asia

2. The Fish on Farms project is being jointly conducted by the University of
British Columbia (UBC) and Helen Keller International (HKI), with technical
assistance from World Fish, in Prey Veng Province, Cambodia.
This randomized control trial investigates an integrated Homestead Food
Production models in relation to poverty, gender empowerment, and food
and nutrition security, particularly among women and children.
This is the first project known to rigorously measure the effectiveness of
different models of Homestead Food Production at reducing undernutrition
using biochemical and anthropometric measurements.

3. University of British Columbia Ministry of Health, Cambodia
Dr. Tim Green, Associate Professor, Human Nutrition Ministry of Planning, Cambodia
Dr. Judy McLean, Assistant Professor, Human Nutrition
Dr. Susan Barr, Professor, Human Nutrition
Dr. Larry Lynd, Professor & Director, Collaboration for Outcomes Research & Evaluation
Dr. Tony Farrell, Professor, Centre for Aquaculture and Environmental Research
Dr. David Kitts, Professor, Food Science & Associate Dean of Research
Dr. Ian Forster, Centre for Aquaculture and Environmental Research
Jen Foley, Fish on Farms Program Coordinator
Helen Keller International - Cambodia Graduate Students
Dr. Zaman Talukder Kyly Whitfield (PhD, Nutrition)
Mr. Hou Kroeun Crystal Karakochuk (PhD, Nutrition)
Ms. Ly Sokhoing Vashti Verbowski (MSc, Nutrition)
Field Research Team Pardis Lakzadeh (MSc, Public Health)
Jeff Tang (BSc, Science)

4. Karen People of Mae La Refugee Camp
• Thai-Burmese border; settled in
1986
• High infant mortality rate
unrelated to major killers
• diarrhea and respiratory illness
• Between 1987 – 1990, infantile
beriberi caused 40% of all
infant deaths
McGready et al 2001; Luxemburger et al 2003; Stuetz et al 2012

5. Background: Thiamin
• Vitamin B1
• Thiamin diphosphate (TDP)
plays major role in carbohydrate
metabolism
• Pentose-Phosphate Pathway
• Kreb’s Cycle
• Modulates neuronal and neuro-
muscular transmissions
Images from: Beltramo, E (2011)

6. Infantile beriberi
• Stems from thiamin (vitamin B1)
deficiency
• Symptoms
• signs of right-sided heart failure
• rapid breathing
• generalized edema
• distinctive, hoarse cry
• Presents around 3 months of age
• Infant AI: 0.2 mg/day
• AI based on [breast milk thiamin] from apparently replete
women
• Root cause: maternal thiamin deficiency

7. Thiamin deficiency
© Kyly Whitfield 2012

8. Rationale

9. Research question
What is the current
level of thiamin
deficiency among
women of childbearing
age (20-45y) in rural
and urban Cambodia?
© Kyly Whitfield 2013

10. Regional (urban/rural)
n=160 per region
16 villages per
region
10 women per
village
Protocol
Purposeful
Selection
Random Selection:
Lists
Random Selection:
Draw

11. Protocol
© Kyly Whitfield 2013
© Kyly Whitfield 2013
© Kyly Whitfield 2013

12. Protocol
© Kyly Whitfield 2014

13. Results
Phnom Penh
(n=146)
Prey Veng
(n=156)
Vancouver
(n=50)
Age
(years; mean±SD)
32.6 ± 7.2 35.1 ± 6.3 26.4 ± 4.6
Body Mass Index
(kg/m2
; mean±SD) 23.4 ± 4.1 21.6 ± 2.9 22.4 ± 3.8
Ethnicity
Khmer
Caucasian
Non-Caucasian
146 (100%)
-
-
156 (100%)
-
-
-
34 (68%)
16 (32%)

14. Thiamin deficiency cut-offs
Thiamin Deficiency Status
Thiamin Diphosphate
(TDP; nmol/L)
Sufficient > 90
Marginally Deficient 70 - 90
Deficient < 70
• Measured using high performance liquid chromatography
(HPLC)

15. 61%
41%
84%
27%
35%
12%
12%
24%
4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Phnom Penh (urban
Cambodia)
Prey Veng (rural
Cambodia)
Vancouver (urban
Canada)
Results
59%
39%
n=146 n=156 n=50

16. Results
Population
Mean TDP ± SD
(nmol/L)
Range
(nmol/L)
Phnom Penh
(urban Cambodia)
100 ± 28 40 - 195
Prey Veng
(rural Cambodia)
87 ± 26 38 - 191
Vancouver
(urban Canada)
128 ± 38 42 - 213

17. What next?
© Kyly Whitfield 2013

18. Randomized Control Trial

19. Rationale
Need to improve maternal thiamin status to decrease the
incidence of infantile beriberi
Infantile Beriberi
• change dietary behaviours
• supplementation
• food fortification

20. Overall Objective
Develop a thiamin-fortified
product that, when
consumed by women of
childbearing age, increases
thiamin in women’s blood to
a level consistent with a low
risk of infantile beriberi.
© Kyly Whitfield 2013

21. Fortified fish sauce

22. Protocol
Best option? There are many condiments that
could be fortified

23. Results
Fish Paste Number of Participants %
Purchase fish paste at market 144 of 320 45%
No brand 144 of 144 100%
Salt Number of Participants %
Purchase salt at market 319 of 320 99%
No brand 173 of 319 54%
Fish Sauce Number of Participants %
Purchase fish sauce market 202 of 320 63%
No brand 26 of 202 13%

24. Intervention
© Kyly Whitfield 2013

25. Fish Sauce Fortification
© Kyly Whitfield 2013
© Kyly Whitfield 2013

26. Fish Sauce Fortification
© Kyly Whitfield 2013
© Kyly Whitfield 2013

27. Randomized Control Trial
6 month, 3 armed, double blind randomized
control trial
Intervention A:
8 mg/mL thiamin
fortified fish sauce
Intervention B:
2 mg/mL thiamin
fortified fish sauce
Control:
Placebo fish sauce

28. Intervention Arms: RCT
Placebo
Intervention
© Kyly Whitfield 2013

29. Potential Significance
• Potential to significantly decrease thiamin deficiency in
Cambodia, which in turn will lower the risk of infantile beriberi
• Possibility of scaling up the production and distribution of
fortified product throughout Cambodia
• Potential for multiple micronutrient fortification; for example:
riboflavin

30. Thank you!