Siti MuslimatunUmi Fahmida

ILSI Seminar on Maternal, Infant and Young Child Nutrition in IndonesiaJakarta, 13 August 2014

SEAMEO RECFON

SMILING

Sustainable Micronutrient Interventions to ControLDeficiencies and Improve Nutritional status and General

Health in Asia

The European Commission

Coordination and support action in the 7th Framework Programme for Research and Technological Development

(FP 7)

"Translation mechanisms for targeting interventions on micronutrients - Mandatory South Asia and South East Asia" (KBBE-2011-2-2-04).

Main expected outcomes of SMILING

To improve micronutrient status of women in reproductive age (including before pregnancy), infants and young children on a large scale,

To identify priority interventions in each Southeast Asian country, and

To develop a plan of action for decision makers and donors for inclusion of these priority interventions into the national Policy of each SEA country.

SMILING concepts and components

SEA as the Centre of the action, taking into account the current, transitional, and future landscapes of the countries

North-South-South collaboration.

The SMILING project has been

conceived around a collaborative

approach, which means developing

and learning together, rather than

bringing in external expertise to teach those less advanced.

INDONESIA Population: 246.9 million

Population

Micronutrient profile

Micronutrient deficiencies profileChildren Women

Vitamin A deficiency 14.6% (2007)1

1.5% (2013)2 N.A.

Anemia 26.3% (2007) 1

29.2% (2013) 2

28.1% (2013)3

(2013) 3

Non pregnant: 22.7% Pregnant: 37.1%

Iron deficiency 15.3% (2013) 2 N.A.

Median urinary iodine excretion

224 g/L (2007) 4

215 g/L (2013) 3(2013) 3

Non pregnant: 190 g/L Pregnant: 163 g/L Lactating: 164 g/L

Zinc deficiency 31.6% (2007) 1 N.A.

Vitamin D insufficiency 42.8% (2013) 2 N.A.

Source: 1 Study on micronutrient status in 10 provinces of Indonesia, 2007; 2 SEANUTS study; 3 Basic health research, 2013; 4 Basic health research, 2007

WP2

Infant and young child feeding practices

IDHS 2007 1 IDHS 20122

Initiation of breastfeeding within 1 hour after birth

44% 49.3%

Exclusive breastfeeding among children 0-5 months

32.5% 41.5%

Meat/fish/poultry consumption among children 6-23 months

60% 59.4%

Fortified baby foods consumption among children 6-23 months

N.A. 25.5%

Children 6-23 months met minimum acceptable diet

41.2% 36.6%

Source: 1 Indonesia DHS, 2007; 2 Indonesia DHS 2012

WP2

Overview on intervention for pregnant and non-pregnant women to improve

micronutrient status

(pre) marital

counseling and family

planning

School health/

nutrition program

?

MCH Care?

Target pregnant women only, such

as IFA

INFANTS

WOMEN OF REPRODUCTIVE AGE

TARGET = all WRA , eg programs such as weekly multi-micronutrient supplementation, nutrition education, birth spacing

TARGET = General Population, eg programs such as:

fortification, poverty reduction, food security, socio-economic development interventions

FOCUS INTERVENTION SPECIFIC TARGETING

INFANTS

(pre) marital

counseling and family

planning

School health/

nutrition program

?

MCH Care?

eg IFA Supplementation: IMPACT = Iron status,

anemia.

INFANTS

WOMEN OF REPRODUCTIVE AGE

eg nutrition education: IMPACT = Nutritional status eg birth spacing: IMPACT= Health of WRA (all aspects)

eg fortification: IMPACT = micronutrient status, eg food aid: IMPACT = nutritional status eg poverty reduction: IMPACT = all aspects of WRA Health

fortification, poverty reduction, food security, socio-economic development interventions

FOCUS INTERVENTION SPECIFIC TARGETING

INFANTS

Interventions for women of reproductive age

Intervention Coverage Impact Impact Impact

Iron Folic acid 33.3% Big impact on iron status but small impact on health outcomes

Focus on iron, vitamin A and iodine

High prevalence of anemia might not

related to iron deficiency.

Prevalence of othermicronutrient

deficiency (such as zinc, vitamin D)

appears to be higher than iron and vitamin

A

Ineffectivemicronutrient intervention

due to addressing

too little micronutrient and too late in

implementation

Postpartum vitamin A

? Small impact onmicronutrient status. No impact on health outcomes

Salt iodization 77.1% Big impact on iodine status and good impact on health outcome

flour, oil fortification

? ?

Compilation of food composition table and its quality assessment

Result from Quality Assessment of Food Composition Table (FCT)

Final FCT: 174 food items, 39 food subgroups, 16 food groups limited to foods consumed by the women and children

...Quality Assessment of FCT

WP3

NQI = normalized quality Index

45

4

10

7

3 3

6

32

6

0

2

6 6 6

2 21

2 2 2 21

0

2

4

6

8

10

12

Fe Zn Ca Vit A Vit B1 Vit B2 Vit B6 Vit C

nu

mb

er

of

foo

d it

em

s

C (NQI:

Linear programming to develop complementary feeding recommendations

based on Basic Health Survey data 2010Using Optifood software

Methods: Sample and Sampling

Data from the National Basic Health Research (Riskesdas) 2010:

Nationally representative

All data from breastfed children 6-23 months are included

Dietary assessment using 24-hr recall

Additional data:

Portion size was adjusted based on other previous studies in rural, periurban and urban areas.

Market survey to obtain food prices to obtain food prices per 100 gr edible foods.

WP4

Results (1) Problem NutrientsWith/without commercially available fortified foods

6-8 months 9-11 months 12-23 months

Fortified

foods

Problem

Nutrient

%RNI

(max)

Problem

Nutrient

%RNI

(max)

Problem

Nutrient

%RNI

(max)

Included Ca

Niacin

Fe

Zn

61 (106)

76 (107)

26 (60)

96 (102)

Fe 88 (92) None -

Not

included

Ca

Niacin

Fe

Zn

Thiamin

62 (97)

74 (98)

37 (60)

50 (66)

95 (105)

Fe

Zn

81 (88)

66 (71)

None -

Note: Absolute problem nutrient Partial problem nutrient

WP4

Results (2): systematic analyses of complementary feeding recommendations

Inclusion of fortified foods reduce the number of nutrients which are not adequate in the diet :

Without fortified foods: 3-4 inadequate nutrients (B1, B3, calcium, iron, zinc)

With fortified foods: 0-1 inadequate nutrients (iron)

WP4

6-8 month olds, breastfed

Systematically Tested = Veg-7, GLV-4, MFE-7, Soy-7, Liver-2,

Fruit-7, F-biscuit-7

Food-based recommendations # N Nutrient 65% RNI Cost

(IDR)

No fortified foods available

Fruit-7 + MFE-7 + GLV-4 + Soy-7

Veg-7 + Liver-2 + Soy-7

Veg-7 + Fruit-7 + Soy-7 + MFE-7

Veg-7 + Soy-7 + GLV-4 + Liver-2

Veg-7 + Liver-2 + Soy-7 + Fruit-7

Fruit-7 + Liver-2 + Soy-7 + GLV-4

Fruit-7 + MFE-7 + GLV-4 + Soy-7 + liver-2

Fortified foods available

Veg-7 + F-foods-7

MFE-7 + Veg-7 + F-foods-7

MFE-7 + Soy-7 + F-foods-7

MFE-7 + Fruit-7 + F-foods-7

Liver-2 + Veg-7 + F-foods-7

Soy-7+ Veg-7 + F-foods-7

Liver-2 + Soy-7 + F-foods-7

7

8

8

8

8

8

8

10

10*

10*

10*

10*

10*

10*

B1 (64), B3 (45), Fe (26), Zn (39)

B3 (52), Fe (31), Zn (38)

B3 (54), Fe (32), Zn (41)

B3 (52), Fe (29), Zn (39)

B3(52), Fe (31), Zn (38)

B3(46) Fe (29), Zn (38)

B3(48) Fe (30), Zn (41)

Fe (25)

Fe (28)

Fe (40)

Fe (28)

Fe (30)

Fe (38)

Fe (37)

2070

1608

2248

1608

1830

1785

2123

1196

1828

2554

2515

1408

1810

1725

WP4

9-11 month olds, breastfedSystematically Tested = Fruit-7, MFE-7, GLV-7, Soy-7, F-biscuit-7, F-cereal-4, liver-1

Food-based recommendations # N Nutrient 65% RNI Cost

(IDR)

No fortified foods available

Fruit-7 + GLV-7 + Soy-7

MFE-7 + GLV-7 + Soy-7

Fruit-7 + MFE-7 + GLV-7 + Soy-7

Fruit-7 + MFE-7 + GLV-7 + Soy-7+ Liver1

Fortified foods available

Fruit-7 + Soy-7 + F-foods-7

MFE-7 + Soy-7 + F-foods-7

GLV-7 + Soy-7 + F-foods-7

MFE-7 + Soy-7 + F-foods-7 + Fruit-7 + GLV-7

7

7

7*

7*

10

10

10

10

Ca (64), B3 (47), Fe (32), Zn (34)

Ca (63), B3 (50), Fe (34), Zn (34)

Ca (65), B3 (51), Fe (35), Zn (39)

Ca (65), B3 (51), Fe (35), Zn (40)

Fe (34)

Fe (36)

Fe (44)

Fe (51)

2051

2125

2457

2457

2813

2889

2807

3935

WP4

12-23 month olds, breastfedSystematically Tested = Veg-7, GLV-4, MFE-7, Soy-7, Liver-2, Fruit-7, F-biscuit-7

Food-based recommendations # N Nutrient 65% RNI Cost

(IDR)

No fortified foods available

Dairy-7 + Fruit-7 + Liver-2 + GLV-7

MFE-7 + GLV-7 + Soy-7 + Fruit-7 + Liver-2

MFE-7 + Dairy-7 + Liver-2 + GLV-7

Fortified foods available

MFE-7 + GLV-7 + Soy-7+ F-foods-7

8

8

8*

11

B1 (62), B3 (38), Fe (50)

Ca (51), B1 (52) , B3 (37)

B1 (62), B3 (42), Fe (52)

None

7021

3338

7400

WP4

Feeding Message

ComponentAge group of children

6-8 mo 9-11 mo 12-23 mo

Breastfeeding Every day on demand

Every day on demand

Every day on demand

Frequency of:- Main meal- Snack

2x/dayAt least 1x/day

3x/dayAt least 2x/day

3x/dayAt least 2x/day

Meat/fish/poultry/eggs Every day or liver 2x/weeks

Every day Every day

Soybean product Every day Every day Every day

Vegetables Every day - -

Green leafy vegetables - Every day Every day

Fruits - Every day -

Fortified foods Every day Every day Every day

Results (3): simulation with home fortification (MNP)

Adding multiple micronutrient powder (MNP) at alternate day to the diet (MNP-alone) will not fulfil adequacy of iron and calcium unless diet is optimized (MNP+FBR)

For 9-11mo and 12-23mo, adequacy of calcium will not be fulfilled unless fortified foods are also included in the diet

When optimized diet including fortified foods are consumed (FBR+Fortified), 1-2 times week of MNPalready fulfill adequacy of all nutrients. Note: With more frequent MNP consumption there may

be concern with acceptability and tolerable upper limit of intake for some nutrients

WP4

Number and type of nutrients that are

Stakeholders perspective on the proposed interventions to address

micronutrient problemsUsing Multiple Criteria Mapping (MCM) technique

combination of quantitative and qualitative approacheshttp://www.multicriteriamapping.com/

Core optionsDevelop, increase/extend fortification of specific products with

single/multiple micronutrients particularly targeted for pregnant womenand woman of reproductive age

Provision of multi micronutrients powder for complementary foods for 6-23months infants and for main meals for children 24-59 months accompanied

with behaviour change communication

Increase coverage of daily iron folic acid supplementation for pregnantwomen and when anemia prevalence >40%, continue until 90 days

postpartum

Weekly multiple micronutrients supplementation for women of reproductive age at age 15 30 years

Food-based recommendations to meet nutritional needs and dietarydiversity of children and women of reproductive age using locally available

foods, local food pattern and affordable foods

Comprehensive and regularly updated food composition database to support dietary assessment for profiling of nutritional problem and assessing

effectiveness of food and nutrient interventions

Types of stakeholders (perspective)WP6

0 1 2 3 4

Funders

UN Organization

International NGO

Private sector

Society/Local NGO

Researcher/Academe

Government

number

Issues selected by stakeholders to appraise options

27

21

14 13

5 5

0

5

10

15

20

25

30

Fre

qu

en

cy

WP6

Overall appraisal

0 10 20 30 40 50 60 70 80 90 100

Food fortification for pregnant women and WORA (C)

Daily Iron folic acid supplementation for pregnant and postpartum women

(C)

MNP for 6-23 months infants and children 24-59 months (C)

Weekly MMN supplementation for WORA (C)

(RULED OUT BY SOME #1) Regularly updated food composition

database (C)

Food-based recommendations for children and WORA (C)

All participants in Indonesia

WP6

Ranking for food fortification for pregnant women and WORA ranked high by issue of impact, feasibility and efficacy high coverage, affordability, safety

WP6

Ranking for daily IFA supplementation for pregnant and postpartum woman: ranked high by issue of effectiveness, feasibility, resources, sustainability targeted to vulnerable groups, infrastructure available, but need Behaviour Change Communication

WP6

Ranking for MNP for infants and young children: ranked second by impact , efficacy, resources efficacious to reduce anemia, high coverage through Growth Monitoring session, but no personnel be assigned to be responsible for the delivery.

WP6

Ranking for weekly MMN supplementation for WORA:

ranked second by effectiveness possibility of low compliance and acceptance,

and no institution to be assigned to. But low cost, and beneficial at long term.

WP6

Ranking for regularly updated food composition database:

ranked third for sustainability not directly address the problem, no

regulation to support, low commitment and priority

WP6

Ranking for food-based recommendation for children and WORA: ranked fourth for impact and efficacy. doubt on sustainability and feasibility, lack of infrastructure and personnel.

WP6

Discretional options proposed by stakeholders

0 10 20 30 40 50 60 70 80 90 100

Supplementation of MMN syrup for children aged 6-59 months (D)

Intrapersonal counseling for IFA (D)

Intervention for children 5-13 years with MNP in water (D)

Daily MMN supplementation for pregnant women (D)

Strengthening nutrition in school curriculum through dailiy practice (D)

Repositioning Nutrition as indicator for development (D)

Weekly MMN supplementation for pre-pubesant girls (D)

Policy process for calcium supplementation during pregnancy (D)

Strengthening local human resources at community level (D)

Strengthening policy on healthy foods and environment (D)

Nutrition education for policy maker (D)

Develop the link between sensitive interventions to improve specific intervention (D)

Discretional options for all participants in Indonesia

WP6

Conclusions

Conclusions

Profile of micronutrient deficiency in Indonesia:

Vitamin A and iodine deficiencies showed an improvement.

Anemia remained high.

Zinc and vitamin D deficiencies emerged.

Other micronutrient deficiencies need to be explored.

The persistently high problem despite the ongoing interventions showed that what are being done might not be effective; and not all that is effective is implemented properly.

Conclusions (2)

Nutrient composition in the food composition table are not available for some nutrients and quality assessment scores are inadequate for most.

Iron, zinc, calcium, and niacin are the typical problem nutrients in complementary feeding of under-two-year-old children in Indonesia

Optimizing complementary feeding including the fortified foods can fulfill nutrient adequacy of the 12-23mo children. For the younger children (6-8mo and 9-11mo), MNP or home fortification (in addition to FBR+fortified foods) at less frequent dosage (1-2 times/week) helps fulfill the adequacy.

Appraisal by stakeholders on option of interventions: On the basis of criteria and weight of criteria selected, the

order of preference: (i) Food fortification for women; (ii) daily prenatal IFA supplementation; (iii) MNP for young children; (iv) MMN supplementation for women; (v) updated FCT, and (vi) Food-based recommendation.

Feasibility and impact are the two most important criteria selected.

Appraisal based on perspectives: Government has highest confidence on MNP for young children.

Private sector, local NGO, and academe/researchers have highest confidence on Food fortification for women.

International NGO, UN agency and Funders have highest confidence on daily prenatal IFA supplementation

Conclusions (3)

Implications

AB

C

Implications Intensify food-based approaches, particularly on

food fortification, while continuing proven micronutrient supplementation programs

Provision of regular, updated and reliable data on food consumption and micronutrient status.

Strengthen the capacity of national and local institutions, particularly for adopting tools and technology for improving nutrition program delivery. Strengthening local institutions capacity will accelerate good nutrition and nutrition-related behavior and address disparities.

THANK YOU

FURTHER INFORMATION:

www.nutrition-smiling.eu