Design and evaluation of a lipid-based nutrient supplement to enrich local complementary foods:
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Design and evaluation of a lipid-based nutrient supplement to enrich local complementary foods: Results from Ghana. Kathryn G. Dewey, PhD Program in International & Community Nutrition University of California, Davis. Complementary feeding (6-24 mo): need for fortified products.

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Kathryn g dewey phd program in international community nutrition

Design and evaluation of a lipid-based nutrient supplement to enrich local complementary foods: Results from Ghana

Kathryn G. Dewey, PhD

Program in International & Community Nutrition

University of California, Davis


Complementary feeding 6 24 mo need for fortified products

Complementary feeding (6-24 mo): need for fortified products

  • Difficult to meet nutrient needs of infants (especially iron & zinc) without fortified foods

  • Commercially produced fortified complementary foods are being evaluated in several countries – key issue is cost

  • Home-fortification of complementary foods is a less costly alternative

    • Sprinkles (micronutrients only)

    • Lipid-based products (e.g. “Nutributter”)


Advantages of lipid based products for home fortification

Advantages of lipid-based products for home fortification

  • Stable, resistant to spoilage, prevent micronutrients from interacting

  • Provide some additional energy (and increase energy density of complementary foods)

  • Provide essential fatty acids

  • May enhance absorption of fat-soluble vitamins

  • Taste good; can mask taste of other nutrients such as B vitamins

  • Can be consumed alone or mixed with other foods

  • Can easily divide the dose during the day

  • Can be locally produced & stimulate local economy


Kathryn g dewey phd program in international community nutrition

Randomized controlled trial of home fortification of complementary foods with 3 types of micronutrient supplements in Ghana

S Adu-Afarwuah1, A Lartey2, KH Brown1, A Briend3, S Zlotkin4, KG Dewey1

1Prog. Intl. Nutr., UC Davis

2 Univ. of Ghana, Legon

3 Inst. de Recherche pour le Développement, Paris, France

4 Hospital for Sick Children, Univ. of Toronto, Canada


Study design

Study design

  • At 6 mo, infants (n=313) randomly assigned to receive supplement daily, 6-12 mo

    • Sprinkles (Fe, Zn, Vit A, Vit C, folate)

    • Nutritabs (all of the above plus 11 other micronutrients)

    • Nutributter (19 micronutrients plus fat; 108 kcal/d)

  • Anthropometric & biochemical assessment at 6 & 12 mo; diet & morbidity assessed weekly; motor development observed at 12 mo

  • Non-intervention group (n=96), eligible but not randomly selected for the intervention, assessed at 12 mo only


Sprinkles sp per sachet d

Sprinkles (SP) (per sachet/d)

  • Vitamin A (μg RE) 300

  • Vitamin C (mg) 50

  • Vitamin D3 (μg) 7.5

  • Folic acid (μg) 150

  • Iron (mg) 12.5 (microencapsulated, fumarate)

  • Zinc (mg) 5 (gluconate)


Nutritabs nt per tablet d

Nutritabs (NT) (per tablet/d)

  • Vitamin A (μg RE)-400

  • Vitamin C (mg) -30

  • Folic acid (μg) -80

  • Vitamin B1(mg) -0.3

  • Vitamin B2(mg) -0.4

  • Vitamin B3(mg) -4.0

  • Pantothenic acid (mg)- 1.8

  • Vitamin B6(mg) - 0.3

  • Vitamin B12 (μg) - 0.5

  • Iron (mg) - 9.0 (sulfate)

  • Zinc (mg) - 4.0 (oxide)

  • Calcium (mg) -100 (carbonate)

  • Potassium (mg) -152 (chloride)

  • Copper (mg) -0.2 (sulfate)

  • Selenium (μg) -10 (sodium selenite)

  • Iodine (μg) -90 (potassium iodate)


Nutributter nb per 20 g dose d

Nutributter (NB) (per 20 g dose/d)

Based on RNI, 6-12 mo

  • Vitamin A (μg RE)-400

  • Vitamin C (mg) -30

  • Folic acid (μg) -80

  • Vitamin B1 (mg) -0.3

  • Vitamin B2 (mg) -0.4

  • Vitamin B3 (mg) -4.0

  • Pantothenic acid (mg)- 1.8

  • Vitamin B6 (mg) - 0.3

  • Vitamin B12 (μg) - 0.5

  • Iron (mg) - 9.0 (sulfate)

  • Zinc (mg) - 4.0 (sulfate)

  • Copper (mg) -0.2 (sulfate)

  • Selenium (μg) -10 (sodium selenite)

  • Iodine (μg) -90 (potassium iodate)

  • Calcium (mg) -100 (phosphate)

  • Potassium (mg) -152

  • Total energy (kcal) -108

  • Linoleic acid (g) -1.29

  • Linolenic acid (g) -0.29

RNI minus amount from other sources

RNI minus amount from other sources

Plus some P, Mg and Mn, mainly from the ingredients


Study design1

Study design

Potential participants: n=612

Approx. 75% randomly selected for

intervention at 5 mo (n=442)

Not selected

at 5 mo (n=170)

Randomized into 3 Intervention groups at 6 mo (n=313)

SP: n=105

NT: n=105

NB: n=103

SP: n=98

NT: n=102

NB: n=98

NI: n=96

SP= Sprinkles; NT=Nutritabs; NB= Nutributter; NI=Non-intervention


Seth adu afarwuah explains some details to study mother

Seth Adu-Afarwuah explains some details to study mother

Picture by Dr. K.H. Brown


A child at 9 mo being weighed in her home

A child at 9 mo being weighed in her home

Picture by Seth Adu-Afarwuah, UCD and Univ. of Ghana,


Measuring the head circumference of a nine month old boy in his home

Measuring the head circumference of a nine-month-old boy in his home

Picture by Seth Adu-Afarwuah, UCD and Univ. of Ghana,


Kathryn g dewey phd program in international community nutrition

A field worker demonstrates to a study mother how she should administer Nutritabs to her child. We provided a plastic cup and a stainless steel spoon to the mother to help her measure the appropriate amount of food (about 3 spoonfuls) and mix it with the supplement.

Picture by Dr. K H Brown, UCD


Kathryn g dewey phd program in international community nutrition

Assessment of motor development at 12 mo at the laboratory. The little girl holding the table is going through the “standing with assistance” procedure, whilst the other boy has already been through all the assessment procedures.

Picture by Seth Adu-Afarwuah, UCD and Univ. of Ghana,


Iron status ferritin 12 ug l at 12 mo

Iron status: Ferritin < 12 ug/L at 12 mo

b

a

a

a


Anemia hemoglobin 100 g l at 12 mo

Anemia: Hemoglobin < 100 g/L at 12 mo

b

a

a

a


Growth and energy intake from cf 6 12 mo

Growth and energy intake from CF, 6-12 mo

SP = Sprinkles; NT= Nutritabs; NB = Nutributter; CF = Complementary foods.


Length for age z scores of intervention sp nt nb and non intervention ni groups

Length-for-age z-scores of intervention (SP, NT, NB) and non-intervention (NI) groups

NB

SP, NI

NT

SP=Sprinkles; NT=Nutritabs; NB=Nutributter; NI=Non-intervention


Motor development walking at 12 mo

Motor development: % walking at 12 mo

a

a

a

b


What is responsible for improved outcomes in the nutributter group

What is responsible for improved outcomes in the Nutributter group?

Possible explanations:

  • Increased energy intake

  • Favorable ratio of essential fatty acids

  • Inclusion of milk


Path analysis of observed effects

Path analysis of observed effects

Potential intermediary variables:

-Energy from CF -FA status

Dependent variables:

-Weight gain

-Length gain

Exogenous variable:

Group assignment


Does increased energy from cfs explain effect of nutributter on weight and length gain

Does increased energy from CFs explain effect of Nutributter on weight and length gain?

Controlling for baseline values, child sex and maternal height.

SP=Sprinkles, NT=Nutritabs, NB=Nutributter.

Answer: Yes (partially) for weight gain; No for length gain


Plasma fatty acid analyses

Plasma fatty acid analyses

  • Individual fatty acids and fatty acid classes

    • 14:0, 16:0, 18:0, 20:0, 22:0 and 24:0

    • 16:1n7, 18:1n7, 18:1n9, 20:1n9 and 24:1n9

    • 18:2n6, 18:3n6, 20:2n6, 20:3n6 and 20:4n6

    • 18:3n3, 20:5n3, 22:5n3 and 22:6n3

  • Total fatty acids

    • Saturated fatty acids (SFA)

    • Monounsaturated fatty acids (MUFA)

    • n-6 fatty acids

    • n-3 fatty acids

    • Polyunsaturated fatty acids (PUFA)

  • Ratios

    • PUFA:SFA

    • n-6:n-3 PUFA


Plasma linolenic acid mg l at 12 mo

Plasma α-linolenic acid (mg/L) at 12 mo

1 Mean ± SD adjusted for baseline values, mean BF frequency at 6-12 mo and sex; 2 Mean ± SD adjusted for BF frequency in the week prior to 12 mo and sex.

** Different from NB, p< 0.05; * Different from NB, p <0.08.


Plasma dha mg l at 12 mo

Plasma DHA (mg/L) at 12 mo

1 Mean ± SD adjusted for baseline values, mean BF frequency at 6-12 mo and sex; 2 Mean ± SD adjusted for BF frequency in the week prior to 12 mo and sex.


Plasma saturated fatty acids total at 12 mo

Plasma saturated fatty acids (% total) at 12 mo

1 Mean ± SD adjusted for baseline values, mean BF frequency at 6-12 mo and sex; 2 Mean ± SD adjusted for BF frequency in the week prior to 12 mo and sex.

** Different from NB (p< 0.05).


Correlations of plasma fatty acids at 12 mo with weight and length gain 6 12 mo

Correlations of plasma fatty acids at 12 mo with weight and length gain 6-12 mo

1 Pearson correlation coefficient for all children in intervention groups. Adjusted for baseline FA values, mean BF frequency at 6-12 mo of age and child sex


Do changes in fatty acid status explain the effect of nutributter on growth 6 12 mo

Do changes in fatty acid status explain the effect of Nutributter on growth 6-12 mo?

Controlling for baseline values, child sex and maternal height.

SP=Sprinkles, NT=Nutritab, NB=Nutributter

Answer: Yes (partially) for length gain; No for weight gain


Summary of potential explanations

Summary of potential explanations

  • Nutributter increased energy intake from comp. foods, increased blood PUFA levels (+33-40% in ALA) and decreased blood SFA levels.

  • Path analysis suggests that

    • Increased energy intake from CFs explained (part of) the impact on weight gain, but not length gain

    • The shift in plasma FA explained (part of) the impact on length gain, but not weight gain

  • However, growth effect could also be due to milk content


Acceptability

Acceptability

  • Supplement consumption (% of days, 6-12 mo): SP 86%, NT 88%, NB 88%

  • Child accepted food “well” when mixed with supplement: SP 90%, NT 78%, NB 86%

  • > 97% of mothers in all 3 groups a) liked giving the supplement, b) thought it helped child’s health & c) wanted to purchase in future


How much willing to pay us cents day

How much willing to pay? (US cents/day)

* p < 0.05; ** p < 0.01


Summary of results

Summary of results

  • All 3 supplements were well accepted

  • All 3 supplements improved iron status compared to the Non-Intervention group

  • Only Nutributter improved growth

  • Motor development was improved by all 3 supplements, but the effect was largest with Nutributter

  • Providing a larger set of micronutrients in a lipid-based product (with milk powder?) confers benefits beyond those of providing just a few selected key micronutrients


Kathryn g dewey phd program in international community nutrition

Lipid-based Nutrient Supplements (LNS): Convergence of approaches for treatment (SAM/mod malnut) & primary prevention?

  • RUTF (LNS in large doses) effective & feasible for treatment of SAM in the community

  • LNS (moderate dose) more effective than cereal-legume blends for supplementary feeding of moderately malnourished children

  • LNS for home fortification (small daily dose) more effective than preparations with micronutrients only

    Daily ration of LNS can be chosen based on needs of target population & cost constraints

    Goal: integrate CTC with programs for prevention of malnutrition


Lns network

LNS Network

  • Development and evaluation of lipid-based nutrient supplements (LNS) for prevention of malnutrition: an innovative food-based approach

  • University of California, Davis, USA

  • University of Tampere, Finland

  • University of Malawi

  • University of Ghana

  • Many advisors and observers


Research agenda lns network

Research agenda, LNS Network

  • Development and testing of new LNS formulations and doses for children 6-24 mo

    • EFA content, zinc content, milk + / -, ration/day

  • Supplementation of pregnant and lactating women

  • Large-scale effectiveness trials (primary outcome: stunting)

  • Socio-economic studies; cost-benefit evaluation

  • Partnerships and scaling up LNS interventions


Publications ghana study

Publications (Ghana study)

  • Adu-Afarwuah, S., Lartey, A., Brown, K. H., Zlotkin, S., Briend, A. and Dewey, K. G. (2007), Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development, Am J Clin Nutr, 86: 412-20.

  • Adu-Afarwuah, S., Lartey, A., Brown, K. H., Zlotkin, S., Briend, A. and Dewey, K. G. (2008), Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana, Am J Clin Nutr, 87: in press.


Acknowledgments ghana study

Acknowledgments (Ghana study)

  • Nestle Foundation and the Human Nutrition Institute of the International Life Sciences Institute (via USAID) for funding

  • Regional and municipal health administration, and laboratory staff in Koforidua, Ghana

  • Study team, nurses, mothers in Ghana

  • Laboratory of Dr. Bruce German at UC Davis for fatty acid analyses

  • Diane Vandepeute for administrative support at UC Davis

  • Jan Peerson for statistical support at UC Davis


Project staff in koforidua ghana

Project staff in Koforidua, Ghana

Picture by Unknown


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