Sight and Life Magazine 26(1) 2012 by Sight and Life

VOL. 26 (1) | 2012

Sight and Life 14

LIVING oN $2 A DAY: THE CHALLENGE

VEGETABLE oILs: A RELIABLE soURCE oF VITAMIN A?

MULTIPLE MICRoNUTRIENT NUTRITIoN DIsCUssED

ADDREssING GLoBAL HIDDEN HUNGER THRoUGH PPP

Contents 07 10

Editorial

Congress Reports

Sight and Life Publishes Milestone History of the Battle against Hidden Hunger

The 1st International Conference on Nutrition and Growth (N&G) March 1–3, 2012 – Paris, France

Field Reports

14 Living on $2 a Day: The Challenge 16

18 Are Vegetable Oils Always a Reliable Source

64 Report from Muhimbili Report on Evaluation of Implementation of WHO’s 10 Key Eye Health Activities in Dar es Salaam

28 Multiple Micronutrient Nutrition: Evidence

Special Feature Nutrition: Scaling It Up

of Vitamin A? A Critical Evaluation of Analytical Methods for the Measurement of Oxidative Rancidity

from History to Science to Effective Programs Workshop Proceedings: 2nd World Congress of Public Health, Portugal, 2010

Report from Burkina Faso The Healthy Eyes Activity Book Helps Spread the Word on Malnutrition and Hygiene

Report from Dominican Republic Fighting Preventable Blindness

Obituary

Remembering Lois Englberger (1949 – 2011)

The Phil Musgrove Legacy Fund

Sight and Life Interview A Day in the Life of Dr David Nabarro

News

Letters to the Editor A Letter from Kenya

Publications

Imprint

Disclaimer

Opinion 1: A Perspective on the Delivery of Micronutrient Interventions: What are the Needs?

Opinion 2: Ongoing Development of Field Tools is Required

Positions and Statements

52 Addressing Global Hidden Hunger Through

Private-Public Partnership

Ten Years of Innovation and Partnership: Better Nutrition for Half a Billion People

⇢

Casimir Funk

Welcome The Godfather of Vitamins It is scarcely an exaggeration to say that this magazine would not exist but for the work of the Polish-American biochemist Casimir Funk. Indeed, it is scarcely an exaggeration to say that Sight and Life itself would not exist but for his efforts. In 1912, Casimir [born Kazimierz] Funk (1884–1967) attempted to isolate from rice bran a naturally occurring substance that he believed might have the effect of counteracting beriberi. His original name for the substance he discovered, “vitamine”, has come down to us is the slightly altered form of “vitamin”. Funk played a decisive role in the development of an entire scientific framework of thought which the world now takes for granted. He was, one might say, the godfather of the vitamins movement.

“Funk played a decisive role in the development of an entire scientific framework of thought” A hundred years ago, Casimir Funk was one of a number of scientists attempting to isolate the anti-beriberi substance from rice bran, although Jansen and Donath are considered the first to have isolated thiamin (the anti-beriberi vitamin) in crystalline form. This occurred in 1926. At that time, European rice hulling machines were introduced to Asia for the processing of rice. However, the hulling process stripped the rice of its vital nutritional elements. As a consequence, new health problems began emerging among the people and animals that relied upon rice as a staple food or feed. Symptoms included weakness, fatigue, and, as the condition progressed, apathia, polyneuropathy, paralysis, cardiomyopathy and heart failure. This is the dietary deficiency disease we know as beriberi. Funk realized that a compound inside of the rice bran that had been removed in the hulling process could in fact cure patients. He gave the substance that he discovered the name “vitamine”– a combination of “vita” (Latin for “life”) and “amine” (= nitrogen compound).

From “vitamine” to “vitamin” The first vitamin to be named was vitamin A. The use of the letter A was the brainchild of the American biochemist EV McCollum. He objected to Casimir Funk’s term “vitamine”, using instead the term “fat-soluble A” because the substance discovered by McCollum did not contain nitrogen (amines are organic compounds derived from ammonia, and always contain nitrogen). A few years later, in 1921, the British biochemist Sir Jack Cecil Drummond suggested combining the use of letters of the alphabet with the term “vitamin” (rather than “vitamine”) to denote a range of related organic micronutrients. These micronutrients consequently became known as vitamins A, B, C and so on. The naming process involved the work of more than one mind, then. And the discovery of many of the vitamins we know today was not to fall to Casimir Funk himself. The first Nobel Prize for the discovery of vitamins went to Sir Frederick Gowland Hopkins and Christiaan Eijkman in 1929 in Physiology or Medicine. The 1937 Nobel Prize for Medicine went to the Hungarian biochemist Albert Szent-Györgyi for the discovery of vitamin C, while the 1937 Nobel Prize for Chemistry went jointly to the Swiss biochemist Paul Karrer and the British biochemist Sir Walter Norman Haworth for the discovery of the chemical structure of vitamin A. Casimir Funk, however, postulated the existence not only of his first “vitamine”, which was in time to become known as vitamin B1, or thiamin, but also of vitamins B2, C and D before these had been chemically isolated. The molecular formula for thiamin was determined by Robert R Williams in 1933. Thiamin was first synthesized by Williams in 1936. Williams then patented its manufacture and established a foundation based upon the royalties.

⇢

EDITORIAL

A unique insight In a distinguished scientific career that spanned two world wars, Funk studied in Switzerland and worked in France, Germany, Great Britain and the United States, as well as his native Poland. He had roles both in academia and in industry, improved manufacturing methods for a range of commercial drugs, and became President of the Funk Foundation for Medical Research. The Polish Institute of Arts and Sciences of America (PIASA) presents the Casimir Funk Natural Sciences Award every year to a Polish-American scientist. And 2012 is being celebrated as the Year of Vitamins – a milestone that would never have been possible without the discovery Funk made in 1912.

“Funk was the first scientist to suggest the existence of an entire family of organic substances essential for life” Funk was not the first person to postulate a link between disease prevention and the intake of certain foods (the Ancient Egyptians were aware that eating liver could prevent xerophthalmia, or night blindness), but he was the first scientist to suggest the existence of an entire family of organic substances essential for life, and the first to give these substances a name that made their function clear. Although he never received a Nobel Prize for his work, and although many other distinguished scientists were active across many countries at the same time as Casimir Funk, the insight which prompted him to coin the term “vitamine” was unique. We owe him much, and it is fitting to honor his work in this, the first edition of our magazine to be issued in the Year of Vitamins.

Elsewhere in this issue we review the second edition of his seminal 1922 work The Vitamines. We also report on the launch of our Sight and Life publication Micronutrients, Macro Impact: The story of vitamins and a hungry world. This unique work tells the story of our organization’s evolution within the context of the world’s growing understanding of the complexity of micronutrients and their interaction within the human body. It draws on documentary evidence as well as recent interviews with leading thinkers in the micronutrient area to tell a story that is more urgent than ever. Micronutrients, Macro Impact is being published at a time when no fewer than 2 billion people worldwide suffer from micronutrient malnutrition and face the physical and social – and therefore also the economic – consequences of that deprivation. Just as vitamin science undergoes a renaissance and we look forward to the discoveries of a new century of vitamins, the need for the work of Sight and Life and its partner organizations is greater than ever. We know much more nowadays than even the great mind of Casimir Funk could envisage. The burden of knowledge compels us to act. With best regards,

Vitamin A Discovery: 1909

MILESTONE HISTORy OF THE BATTLE AGAINST HIDDEN HuNGER

Sight and Life Publishes Milestone History of the Battle against Hidden Hunger

Micronutri Macr Impact the micronutrient arena to tell a complicated story in simple, robust and compelling terms.

The Year of Vitamins The publication of Micronutrients, Macro Impact Impact coincided with the 100th anniversary of the creation of the word ‘vitamine’ by Casimir Funk and the accompanying recognition of the vital role that vitamins play in human health and development. For this reason, the launch of this work was combined with the kick-off of DSM’s celebration of 2012 as the Year of Vitamins.

Micronutrients, Macro Impact: A complicated story told in simple and compelling terms.

On 10 February 2012 a major milestone was reached in the history of Sight and Life. Life. This day witnessed the launch of the Sight and Life publication Micronutrients, Macro Impact: The story of vitamins and a hungry world at the global headquarters of DSM Nutritional Products in Kaiseraugst, Switzerland. Sight and Life came into existence in 1986 to provide vitamin A to the victims of famines caused by the Ethiopian Civil War of the 1980s. For 25 years, we have worked to combat the global scourge of malnutrition. Created to mark the quarter-centenary of our foundation, Micronutrients, Macro Impact tells the story of our evolution within the context of the world’s growing understanding of the complexity of micronutrients and their interaction within the human body. It draws on documentary evidence from the Sight and Life archive as well as recent interviews with leading thinkers in

“The vital role of vitamins”

Honoring the close link between Sight and Life and the employees of DSM – many of whom contribute to DSM’s partnership with the United Nations World Food Programme – Jacoline van Blokland, Head of Global HR at DSM, opened the event. She welcomed the guests who had travelled from many parts of the globe as well as the employees of DSM Nutritional Products’ Swiss headquarters, before handing over to Stephan Tanda, DSM Managing Board member with responsibility for the company’s Nutrition activities.

The devastating effects of malnutrition In a deeply moving address, Stephan spoke of the devastating effects of malnutrition – not only on the populations who suffer from this scourge, but also on the generations who come after them. Stephan continued: “Nutrition is at the heart of DSM’s activities. We serve every section of society with products that have the potential to increase health and wellness.

SIGHT AND LIFE | VOL. 26 (1) | 2012

MILESTONE HISTORy OF THE BATTLE AGAINST HIDDEN HuNGER

Nutrition and HIV/AIDS, Keith West, George G Graham, Professor of Infant and Child Nutrition at Johns Hopkins Bloomberg School of Public Health, and Stephan Tanda himself gave their impressions of the book and placed it in its historical, scientific and socio-political context.

ients, ro Twenty-five years on, the scourge of hunger remains in many parts of the globe.

We have a responsibility to our customers, to the consumers who use our products, and of course to our shareholders. But we also have a responsibility to the people in the world who are unable to provide themselves with a healthy and nutritious diet. “At a time when the UN World Food Programme is marking its 50th anniversary and the DSM-WFP collaboration its 5th, we are faced with the scourge of hunger and the burden of malnutrition in large parts of the globe. The number of people going to bed hungry every night has in fact reached almost one billion, and maternal and child undernutrition is the underlying cause of 3.5 million deaths in children under five each year.

A rich mine of information Klaus Kraemer explained the origins of the work. “The idea of writing this book was born almost five years ago, while we were clearing out the Sight and Life storage room,” he recalled. “We didn’t want to throw away the wealth of fact sheets, reports, statements and working papers we found, without archiving them. The original plan was to summarize this rich mine of information in a book. After completing the first two chapters, however, we decided to change the scope of the work and to write the history of micronutrients for a broader audience. This meant that the book had to draw on more than just existing documentary material. A number of key thinkers in today’s micronutrient field had to be interviewed to provide the relevant information and insights. At the same time, complicated science had to be framed in robust and accessible language for the educated lay reader.”

“Bringing about positive change” Saskia de Pee then spoke of the collaboration between Sight and Life, DSM and the WFP over the past five years. “This partnership has enabled WFP to really develop its expertise in delivering better nutrition,” she observed. “We have been able to hire staff, raise awareness of the role of food in preventing disease and mortality, improve the nutritional value

“Looking forward to the next 25 years” “We are here today to honor the dedication of the colleagues at Sight and Life who have worked for 25 years to improve the nutritional status of the world’s most disadvantaged populations. But although there is much to be proud of, today is not a day for celebration. Micronutrients, Macro Impact is being published at a time when no fewer than 2 billion people worldwide suffer from micronutrient malnutrition and face the physical and social – and therefore also the economic – consequences of that deprivation. The burden of knowledge compels us to act. Today is a day not just for looking back on the past 25 years, but for looking forward to the next 25.” Stephan Tanda’s remarks were followed by a lively podium discussion chaired by Jonathan Steffen, who writes the Day in the Life interviews in this magazine. Klaus Kraemer, Director of Sight and Life, Saskia de Pee of the WFP’s Department for

“Sight and Life will position itself at major global intersections of nutritional science and public health.”

MILESTONE HISTORY OF THE BATTLE AGAINST HIDDEN HUNGER

direction, just as Sight and Life itself has always been an agent for positive change.” Following on from the podium discussion, Manfred Eggersdorfer, SVP Nutrition Science and Advocacy at DSM, kicked off the company’s celebration of 2012 as the Year of Vitamins. “I hope that as a global organization, we will all join together to celebrate 2012 as the Year of Vitamins and initiate many activities,” he remarked, “externally, to advocate to customers, policy-makers, consumers and key nutrition stakeholders the importance of vitamins, and internally, to continue on our path of further successful vitamin research and development. As we journey into the next 100 years, DSM remains at the cutting edge of the science of vitamins.” A nutritious diet can reverse the spiral of deprivation (still from “The Nutrition Factor”).

of existing food products, and also develop new ones thanks to the support of DSM. The expertise and reach of Sight and Life in communication and advocacy, meanwhile, has been very helpful, because it reaches a large number and variety of stakeholders in the countries where we work. Public-private partnerships such as the one with Sight and Life /DSM enable us to access valuable skill sets and experience and to jointly collaborate to bring about positive change.” Keith West followed, placing the publication of Micronutrients, Macro Impact within the context of the past quartercentury of nutrition science. “We are on the brink of an incredibly exciting era in micronutrient research,” he said. “New technologies are yielding insights into biological mechanisms of micronutrients as never before. Fueled by advances in “omics”, epidemiology and intervention research, our abilities to reveal roles, interactions and broad benefits of micronutrients will be a defining future agenda in public health. Witnessing its legacy of thought leadership, collaborative research and commitment to the world’s poor over its first 25 years, I am certain that in its next 25 Sight and Life will position itself at major global intersections of nutritional science and public health in ways that will lead us to reveal and prevent the scourges of hidden hunger.” Creating a movement for change Stephan Tanda concluded, “Micronutrients, Macro Impact demonstrates that the work of Sight and Life and other key players in the micronutrient arena is more vital today than ever. The chance of bringing about lasting improvements in the nutritional status of millions of people worldwide has never been greater. But making this possibility into a reality requires the creation of a movement for positive change. I hope this book will be a trigger for positive change in this

“Forming strong collaborations” Rick Greubel, President, Human Nutrition & Health at DSM Nutritional Products, followed on from Manfred Eggersdorfer by underlining the relevance of Micronutrients, Macro Impact and stressing the company’s ongoing commitment to Sight and Life. “The power of Sight and Life,” he said,“ lies in its ability to form strong collaborations with leading non-profits, academia, governments and the private sector to improve the nutrition and health of so many around the world. At today’s unique event, we can see these collaborations in action at first hand. This is a proud day for Sight and Life and all DSM employees.” The Nutrition Factor The event concluded with the screening of a powerful new short film about Sight and Life which explains the devastating effects of hidden hunger on health, growth and social and economic development – the ‘Nutrition Factor’. The screening was followed by a mini-symposium on ‘Micronutrients: From the Past to the Future’ involving participants from the Global Alliance for Improved Nutrition (GAIN), Groupe de Recherche et d‘Echange Technologique (GRET), the Universities of Hohenheim and Newcastle, and Vitamin Angels, as well as DSM, Sight and Life and WPF. Cutting-edge science was presented, and key issues of the day discussed in a series of lively breakout sessions between the excellently presented and prepared lectures.

SIGHT AND LIFE | VOL. 26 (1) | 2012

Download or order Micronutrients, Macro Impact from our website Micronutrients, Macro Impact: The story of vitamins and a hungry world can now be downloaded or ordered from the Sight and Life website (www.sightandlife.org). Micronutrients, Macro Impact may be downloaded as a PDF free of charge.

Printed copies may be ordered on receipt of proof of a donation to the amount of at least €20 to the United Nations World Food Programme (www.wfp.org). Please send an appropriate receipt or screen shot, along with your full postal address, to info@sightandlife.org, using the subject header Micronutrients, Macro Impact: BOOK ORDER.

The Nutrition Factor available for viewing online The new Sight and Life film is available for viewing on the Sight and Life website (www.sightandlife.org). “Every person on the planet needs a nutritious diet to grow and thrive. But there are two billion people suffering from malnutrition in the world today. This means that two people in seven do not receive sufficient nutrition. They are trapped in a vicious spiral of deprivation. But that spiral

can be reversed. And it can be reversed by something as simple as nutrition. We call it the Nutrition Factor …” With powerful images, memorable graphics and a strong narrative, the film tells a universal story in just a few minutes. Please check it out (in the Media /Videos section of our site or on YouTube) to see how the vicious spiral of deprivation works, and what can be done to help reverse it.

LIVING ON $2 A DAy: THE CHALLENGE

Living on $2 a Day: The Challenge

Living on $2 a Day Jane Badham Sight and Life, Life, Basel, Switzerland

Learning to live on $2 a day is a challenge in the affluent West.

To mark Sight and Life’s 25th anniversary and DSM’s celebration of 100 Years of Vitamins, Sight and Life launched the “$2 a Day Challenge” – an initiative designed to increase participants’ awareness of the daily plight of the world’s poor. Just over 100 members of staff from Sight and Life and DSM Nutritional Products, Kaiseraugst, signed up. By living for a week with no more than $2 (US) per person per day to pay for all their food and drink, they pledged to sacrifice their comforts and experience the reality and challenges of poverty and hunger.

“You never really know a man until you understand things from his point of view, until you climb into his skin and walk around in it” Harper Lee, To Kill a Mockingbird

The Sight and Life $2 a Day Challenge menu was based on the cost of food at a major retail outlet in Johannesburg, South Africa, in order to give participants an idea of what can be bought with $2 a day in a developing country. Participants were also given a shopping list, recipes and a guide to help them plan for the challenge. These resources, as well as Sight and Life team member Jane Badham’s photo-and-blog diary of the challenge, can be accessed on our Facebook page (www. facebook.com/pages/sight-and-Life/180588875382186) and our blog at www.sightandLifeToday.tumblr.com. Some insights from Jane’s blog diary give a glimpse of this humbling experience:

DAY 1: Statistics are Real People “One billion people suffer from hunger and every day 16,000 children die from hunger- related causes – that’s one child every five seconds ... It is easy to forget that each of these individuals, each child, also has a face and a family.”

DAY 2: Living on the Breadline “I am mindful of mothers who today sent their children to school on nothing more than a cup of tea and perhaps a slice of bread, knowing that it is not enough and that they will be hungry in class and probably won’t be able to concentrate. I feel drawn to the plight of those mothers who dream that their child will have a better life than they have, but who must wonder if that will ever be a reality.” DAY 3: Waste Not, Want Not “Wow, how easily we throw things out – use a tea bag once and throw it away, a little jam left at the bottom of the bottle and we don’t rinse it out, a soft patch on the tomato and we throw it away.” DAY 4: Stimulating Versus Survival “The definition of challenge is ‘a test of one’s abilities or resources in a demanding but stimulating undertaking’ – indeed for me this challenge, for just seven days, is stimulating but I feel for the millions who have to live each day on $2 – for them it cannot be stimulating. For them, it is simply about survival.”

LIVING ON $2 A DAy: THE CHALLENGE

SIGHT AND LIFE | VOL. 26 (1) | 2012

DAY 5: Words are Easy, Living is Harder “The most obvious victims (of hidden hunger) are in developing countries, where the diet, as I am now experiencing, does not provide them with the variety of foods that ensure that they get the micronutrients that they need.” DAY 6: The Great Divide “We often suggest to people that they buy what’s in season and buy in bulk to reduce the cost, but today I am acutely aware that buying in bulk is not an option for the poor, as firstly they often don’t have the kind of cash on hand to buy large amounts, and secondly few people living on $2 a day have a fridge!” Day 7: Where To From Here? Lead From Where You Stand “The $2 a Day Challenge has made me determined to ... continue to speak up and speak out, where and when I can, as the voice of the less fortunate and the vulnerable, towards food and nutrition security for all.”

The Sight and Life $2 a Day Challenge Menu: Days 1 and 3

Breakfast

Lunch

Day 1

Day 3

Porridge oats

100 g tub yoghurt

1 banana, sliced

1 apple

PB & J sandwich

Tuna pasta bake

2 tbsp peanut butter

(leftovers from Day 2)

3 slices bread 2 tbsp jam Dinner

Broccoli & cheddar

Chilli con carne

cheese soup

Dry rice (¼ cup / 60 g)

1 slice toast 1 tsp margarine Other

2 black tea bags

60 mL milk

2 tsp sugar

A Reality Check: Anthony Hehir of DSM’s Quality For Life™ Initiative Shares His $2 a Day Experience For the past week, I lived on $2 a Day, standing by the half of the world’s population who live on this amount, or less, for food and drink each day. It was both a powerful and humbling experience, and really put things back into perspective for me. During the week, I was pretty much always hungry. The quantity was not all that small; however, I soon realized how easy it is for me to simply snack on something when hunger calls, or eat more at a meal if I know it may be a longer time before my next meal. Many friends asked me why I was doing this challenge and told me it would change nothing. Well, to them I say – it has at least changed me. It has changed my perception, my gratitude, my mindfulness, and my insight. I am stronger and better for it, and don’t regret it for one minute. Maybe I didn’t create a mass movement towards eradicating hunger in the world (not that I expected to!), but hey, you know what, Rome wasn’t built in a day.

The “butterfly effect” is a theory where something as tiny as a butterfly flapping its wings in one part of the world could be the catalyst for a hurricane in another part of the world several weeks later. If my butterfly effect (eating on $2 a Day) has simply made you think a bit more critically about food, nutrition, and those less fortunate than yourself, I have achieved my goal this past week. Who knows …? Maybe, one day, hunger and malnutrition could be a thing of the past. And, if we all flap our butterfly wings in our own small way, the power of the collective could have tremendous results. What have we got to lose?

To read the full story of Anthony’s week, go to: http://sightandlifetoday.tumblr.com/post/17942458478/thebutterfly-effect-and-the-power-of-the-collective

Nutrition: Scaling It Up Each year 2.8 million children under 5 die from undernutrition. Scaling up spending on simple proven nutrition interventions can help stop this. If we spent $ 11.8 (US) billion a year we could: Save 1.1 million children’s lives

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Prevent stunting in 150 million children

= 15 000 children

We could also improve the nutrition of billions �� Million children get multiple micronutrient powders �� Million women get iron folic acid supplements �� Million children get complementary food �� Million children get vitamin A supplements �� Million children get therapeutic zinc �.� Billion people get iodised salt �.� Billion people get iron fortification of staple foods

Sources: Black, R.E. et al., 2008. Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences. The Lancet , 371 (9608), 243–260. Download: http://bit.ly/oZrR2U Horton, S., 2010. The World Bank. Scaling Up Nutrition — What Will It Cost? Download: http://bit.ly/nDJLQp Médecins Sans Frontièrs, 2009. Malnutrition: How Much is Being Spent? An Analysis of Nutrition Funding Flows 2004–2007. Download: http://bit.ly/nLOOHD Taken from ‘The Best Start’ by World Vision International www.childhealthnow.org

Rich countries’ current spend of $ 171 million saves just 15 000 children

$ 11.8 BILLION Would Be Spent On

52 %

Complementary / Therapeutic Feeding

25 %

Micronutrients and Deworming

13 %

10 % Capacity Development

Behavioural Change

Focus On Families Just $ 42 per family stops child undernutrition before it starts. In severe cases, however, costs can increase by up to 5 times as therapeutic feeding is required.

$10.44

Iodised oil capsules and salt, iron fortification of staples

$10.80

$2.00

$42*

Iron Folic Acid

Micronutrient powders

$4.40

Vitamin A and zinc supplementation

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ARE VEGETABLE OILS ALWAyS A RELIABLE SOuRCE OF VITAMIN A?

Are Vegetable Oils Always a Reliable Source of Vitamin A? A Critical Evaluation of Analytical Methods for the Measurement of Oxidative Rancidity Marc Pignitter, Veronika Somoza Department of Nutritional and Physiological Chemistry, university of Vienna, Austria

Introduction Vitamin A is essential for eye health and the proper functioning of the immune system. It is found in foods such as milk, liver and eggs as retinol, and in red and orange fruits, red palm oil, and green leafy vegetables in the form of provitamin A carotenoids. The amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in fruits and vegetables, daily intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow, or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world, and particularly in countries with the highest burden of under-five deaths. A child deficient in vitamin A faces a 25% greater risk of dying from common ailments, such as measles, malaria, or diarrhea. Programs to prevent and control vitamin A deficiency enhance a childâ&#x20AC;&#x2122;s chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals, and contribute to the well-being of children, their families and communities. The following three major deficiency control strategies are all meant to complement ongoing public health measures for child health and development: supplementation, dietary diversification, and food fortification. A safe, efficient strategy Current international recommendations call for high-dose vitamin A supplementation every four to six months, targeting all

children between the ages of six and 59 months, living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency, and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life, and helps replenish the mothersâ&#x20AC;&#x2122; stores of vitamin A, which are depleted during pregnancy and lactation. Dietary diversification in the developing world is hard to implement, since non-animal sources of vitamin A account for greater than 80% of intake for most individuals. In order to meet the nutrition needs of children, it would be necessary for intake of these sources to increase up to tenfold. Feasible control of deficiency through dietary diversification would require the increased consumption of bioavailable, vitamin A rich foods of animal origin, coupled with the continued promotion of nutritious fruits and vegetables. Although multiple interventions to this effect have been carried out, scale-up of these efforts is limited by natural resources. Food fortification is being introduced in more and more countries, and holds great hope for the long-term control of vitamin A deficiency. Multiple products currently serve as vehicles: vegetable oils, margarine, milk, sugar, complementary food supplements, and various types of flour are among the most common. Although fortification can take several years to initiate, and longer still to reach all at-risk children and their families, it is an effective and sustainable approach to vitamin A and other micronutrient nutrition.

â&#x2021;˘

sIGHT AND LIFE | VOL. 26 (1) | 2012

â&#x20AC;&#x153; Dietary diversifi cati on in

the developing world is hard to implement, since non-animal sources of vitamin A account for greater than 80% of intake for most individuals â&#x20AC;?

Are Vegetable Oils Always a Reliable Source of Vitamin A?

figure 1: Relative oxidation rates of fatty acids H (410 kJ/mol)

Induction period (h)

18:0

Relative oxidation rate 1

H (322 kJ/mol) 18:1 (9) 18:2 (9, 12)

18:3 (9, 12, 15)

H (272 kJ/mol)

H (171 kJ/mol)

“Vegetable oil fortification with vitamin A is currently one important strategy to lower the prevalence of vitamin A deficiency” Vegetable oil fortification Vegetable oil fortification with vitamin A is currently one important strategy to lower the burden of vitamin A deficiency. Assuming that all vegetable oil consumed in the 75 developing countries for which data from the Food and Agriculture Organization of the United Nations (FAO) is available was fortified to a level of 60 IU/g retinyl palmitate – as currently practiced by the United Nations World Food Programme (WFP) – and given an assumed average retention of vitamin A through storage and cooking of 60%, this will provide 44% of the WHO Safe Level for vitamin A of 600 µg RE/day, or 2,000 IU/d, for adolescents (10 –18 years old). This calculation was based on 70 g of oil. However, loss of vitamin A during storage and cooking has a crucial impact on its delivery. Although vitamin A can be uniformly distributed in oil and is easily absorbed from oil, it is unstable when exposed to light − particularly ultraviolet (UV) light – air, oxidizing agents, and heat. Heavy metals and acids, even in trace quantities, can accelerate its decomposition. It can be assumed that there is a direct relationship between the stability of vitamin A and the oxidation status of the oil. The higher the markers of lipid oxidation, the greater the loss of vitamin A. Using high quality oil, and protecting the oil from oxidization and rancidity, is therefore basic to preserving the vitamin A.

100

1200

1.34

2500

Edible vegetable oils are often exposed to elevated temperatures during processing, shipping and /or storage. High temperatures and the presence of oxygen favor the process of oxidative rancidity, which results in the formation of characteristic off-flavors and less palatable oils.1 The rate of oxidative rancidity strongly depends on the degree of unsaturation of the fat.2,3 The degree of unsaturation is determined by the number of double bonds in the fatty acid molecules − a neighboring double bond decreases the energy of the hydrogen binding to the carbon. A high number of adjacent double bonds facilitates the detachment of the hydrogen atom (Figure 1). A high concentration of polyunsaturated fatty acids (PUFAs) renders the vegetable oil more prone to oxidation, resulting in a loss of PUFAs due to the formation of early and advanced volatile and non-volatile lipid oxidation products. As high levels of PUFAs are considered beneficial in terms of sustaining health,4 the oxidative quality control of oils containing high amounts of PUFAs, such as soy bean oil,5 becomes essential not only for the evaluation of the sensory quality of vegetable oils, but also for the determination of their nutritional value. Oxidative stability is mainly affected by processing conditions that imply the application of high temperatures, oxidants, enzymes (lipoxygenases), moisture, light and oxygen.6,7 Photosensitization facilitated by transparent packaging might induce the formation of singlet oxygen, which has been reported to react 1,500 times faster with linoleate than with oxygen in its triplet ground state8 and, thus, may promote oxidative rancidity. In contrast to lipid peroxidation, which only occurs in the presence of enzymes, lipid autoxidation in foods is based on a free radical chain reaction, starting off with an endothermic reaction by the loss of a hydrogen atom in the presence of oxidation initia-

ARE VEGETABLE OILS ALWAyS A RELIABLE SOuRCE OF VITAMIN A?

SIGHT AND LIFE | VOL. 26 (1) | 2012

figure 2: Time dependent decrease of antioxidants, unsaturated fatty acids and formation of lipid autoxidation products in vegetable oils Oxygen consumption

Value

Unsaturated fatty acids

Antioxidants

Propagation

Nonvolatiles

Termination

Hydroperoxides

Volatiles

Initiation

Time

tors, such as traces of metals, light or heat.9–11 After the removal of the hydrogen atom at the initiation of lipid autoxidation, the carbon-centered radical undergoes molecular rearrangement to form stabilized conjugated dienes, following oxygen uptake to finally yield peroxyl radicals. During the stage of propagation (Figure 2), the peroxyl radical abstracts a hydrogen atom from another fatty acid to form the lipid hydroperoxide, a marker for early oxidation stages.11

“A universal method suitable for the evaluation of early lipid autoxidation processes in edible oils is still lacking” Due to the instability of lipid hydroperoxides, secondary decomposition products, such as aldehydes, ketones, alcohols, hydrocarbons, esters, furans and lactones, are formed. However, lipid hydroperoxides can also be oxidized to yield epoxyhydroperoxides, oxohydroperoxides, bihydroperoxides, cyclic peroxide and bicyclic endoperoxide.11 The secondary oxidation products can further decompose into monohydroperoxides, which may result in the formation of volatile products. Lipid hydroperoxides have also been reported to undergo condensation reactions that terminate the autoxidation process by forming dimers and polymers, which may also break down into volatile compounds.11 Due to these rather complex mechanisms of lipid oxidation, a variety of analytical methods have been developed to investigate the different stages of lipid oxidation. However, a

universal method suitable for the evaluation of early lipid autoxidation processes in edible oils is still lacking. Evaluation of analytical methods upon oxidation of vegetable oils, unsaturated fatty acids and antioxidants decline over time, while an increase of oxygen consumption and the formation of hydroperoxides as primary oxidation products can be observed. However, hydroperoxides readily decompose, making their analytical monitoring difficult. Advanced oxidation products such as volatile and non-volatile compounds have much longer half-life times, and are more commonly analyzed as markers of lipid autoxidation. Figure 3 depicts a simplified pathway of lipid autoxidation, pointing out the analytical methods applied for the quantitative analysis of oxidation products formed in vegetable oils. The loss of PuFAs and the formation of saturated fatty acids are commonly quantified by gas chromatography (GC) or nuclear magnetic resonance (NMR), whereas carbon-centered radicals can be analyzed by electron spin resonance (ESR). After immediate molecular rearrangement, the carbon-centered radicals form conjugated dienes, which are relatively stable, and commonly analyzed by high-performance liquid chromatography (HPLC)uV techniques. Conjugated dienes may undergo oxygen uptake, analyzed by polarography such as Clark electrodes, to finally yield peroxyl radicals which can be quantified by ESR. Peroxyl

⇢

ARE VEGETABLE OILS ALWAyS A RELIABLE SOuRCE OF VITAMIN A?

figure 3: Analytical tools for the detection of primary and secondary lipid autoxidation products Products of lipid oxidation

Analytical tool GC/NMR

PUFA -H∙ ESR Carbon-centered radical

HPLC Conjugated diene Clark electrode

+O₂

ESR O O∙

Peroxyl radical +H∙ HPLC

O O H

Hydroperoxides

Condensation reactions

Scission of C-chain

Dimers, Polymers

Degradation without scission of C-chain HPLC Hydroxydienes

GC Aldehydes (hexanal, propanal)

HPLC Malondialdehyde

Epoxyhydroxy-compounds

HPLC Oxodienes

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radicals easily abstract hydrogen atoms from other fatty acids to form lipid hydroperoxides, also indicators of early oxidation stages,11 that are quantified by means of HPLC-UV. Lipid hydroperoxides may undergo either condensation or degradation reactions, resulting in the formation of dimers or polymers or aldehydes, hydroxydienes or epoxyhydroxydienes, respectively. All of these compounds may be analyzed by means of GC or HPLC techniques.

“One of the most common methods of measuring the oxidative rancidity of vegetable oils is the peroxide value (PV)” Chemical evaluation One of the most common methods of measuring the oxidative rancidity of vegetable oils is the peroxide value (PV).12 The PV determines the amount of peroxides formed during early oxidation stages, expressed as millimoles or milliequivalents of peroxide oxygen per one kilogram of oil. Numerous analytical protocols have been described for the measurement of the PV. The most widely used procedure utilizes the oxidative capacity of lipid (hydro)peroxides to generate iodine from potassium iodide.13–15 Iodometric titration employs starch as the indicator and sodium thiosulfate as the titrant. One of the drawbacks of the PV method is the instability of the hydroperoxides, which leads to an initial increase, followed by a decrease of the hydroperoxides during the progress of lipid oxidation (Figure 2). Major concerns also relate to the accuracy of the measurement, pointing to the absorption capacity of unsaturated fatty acids for iodine and the additional release of iodine from potassium iodide by oxygen.16 –17 Other possible obstacles comprise variation in sample weight, the type of solvent, variation in reaction time and temperature, and the constitution of the peroxides.14 Furthermore, it has been reported that the method failed to measure low PVs due to inaccurate determination of the titration end-point, leading to the introduction of electrochemical techniques.18 Alternative empirical colorimetric assays were developed, such as the analysis of ferric thiocyanate formed by oxidation in the presence of peroxides19 or 1,5-diphenylcarbohydrazide, yielding a red color after reaction with oxidized lipids.20 Although widely used, the different inherent drawbacks of the determination of the PV have prevented this method from being recommended as a standard method for the evaluation of the oxidative rancidity of vegetable oils. One of the most commonly used chemical assays to determine secondary oxidation products is the thiobarbituric acid (TBA)

Are Vegetable Oils Always a Reliable Source of Vitamin A?

test.21 Two molecules of TBA condensate at low pH and high temperature with one molecule of malondialdehyde, a decomposition product of oxidized PUFAs, to form a pink chromogen that can be quantified spectrophotometrically at a wavelength of 532 nm. The selectivity of the TBA assay can be further improved by utilizing the fluorescent property of the TBA chromogen.22 However, malondialdehyde is solely released from peroxides derived from fatty acids containing three or more double bonds.23 The fatty acid composition of the oil under investigation therefore has to be considered, rendering comparisons between different oils unreliable. It has also been noted that the TBA test is not specific to malondialdehyde, but also gives pink chromogens with sugars, lipids, urea, oxidized proteins and other aldehydes not derived from oxidation.24–27 Prior HPLC separation and different absorption maxima of chromogens might reduce the limitations in specificity.28–29 However, an inevitable drawback of the TBA assay might be the additional assay-borne generation of malondialdehyde as an artifact, due to heat and acid treatment of lipid hydroperoxides.24,30 Despite some inherent disadvantages of the TBA assay, this method is widely used to rapidly screen large numbers of samples. The Kreis test was one of the first methods to be applied to determine the oxidative deterioration of vegetable oils.31 In this test, phloroglucinol reacts with epoxy aldehydes or their acetals under acidic conditions to form a red color. The Kreis test does not provide reliable information on the degree of lipid oxidation, since samples free from rancidity were shown to give positive results, probably due to the presence of aldehydes.17 In addition, some food additives, such as vanillin, were identified to interfere with the Kreis test.32 The Kreis test is therefore not considered to be a reliable rancidity index. Carbonyl compounds Several assays have been developed to analyze the carbonyl compounds derived from lipid autoxidation. One of the most commonly used assays for the detection of total carbonyl compounds is based on the formation of 2,4-dinitrophenyl hydrazones in the presence of carbonyl compounds and trichloroacetic acid.33 Due to the required experimental conditions of high temperature and low pH, the decomposition of lipid hydroperoxides is promoted, thereby interfering with the assay.34 Prior reduction of hydroperoxides to non-carbonyl compounds could not prevent the generation of additional carbonyl substances.35 –36 Holm et al.37 suggested quantifying aldehydes by using benzidine acetate without the application of high temperatures or strong acids. Since benzidine acetate is carcinogenic, a similar method using p-anisidine has been proposed. P-anisidine reacts with 2-alkenals, forming reaction products that can be assessed photometrically at a wavelength of 350 nm.38 However, this absorption maximum was demonstrated to shift

Are Vegetable Oils Always a Reliable Source of Vitamin A?

towards longer wavelengths with increasing double bonds in the molecule, thereby impeding comparisons between different vegetable oils.39 To calculate the total oxidation (totox) value, the following equation including the p-anisidine value (AV) and the PV is used: totox value = 2 PV + AV.39 The totox value combines information about the early and advanced stages of lipid deterioration, rendering it a valuable parameter for rancidity evaluation of vegetable oils.

“The Clark-type electrode, a sensitive oxygen sensor, might be a promising tool to characterize early stage lipid oxidation” Combination of the PV analysis with polarographic methods has also been demonstrated to provide valuable results up to PV of 250 mmol/kg.40 Polarographic methods are used to determine the oxygen consumption. The Clark-type electrode, a sensitive oxygen sensor, might be a promising tool to characterize early stage lipid oxidation. Physical evaluation The detection of conjugated dienes is a widely accepted physical method to assess the oxidative rancidity of vegetable oils.41 Oxidation of PUFAs results in the generation of conjugated double bonds, which exhibit absorption maxima in a range of 230 to 375 nm. Conjugated dienes were reported to absorb at 234 nm, whereas secondary oxidation products, such as diketones, were shown to have their absorption maxima at 268 nm.42 Due to their rapid and simple performance, and their independence of chemical agents and reactions or color development, analyses of conjugated dienes are widely accepted for the evaluation of the lipid oxidation status in PUFA-rich vegetable oils. However, this method shows limited sensitivity in more saturated oils, such as palm olein, due to the lack of double bonds.43 The conjugation of PUFA dienes might also be assessed by qualitative methods such as refractometry44 or infrared spectroscopy.45 The application of nuclear magnetic resonance (NMR) spectroscopy for the evaluation of oxidative stability of vegetable oils has also been shown to be a promising technique.46–47 The NMR method analyzes the change of the fatty acid profile in oils by calculating the ratio of aliphatic to olefinic protons. Wanasundara et al.47 observed a constant increase in the ratio of aliphatic to olefinic protons during the storage of canola and soybean oil, concluding that storage of the oils was associ-

ated with the progressive oxidation of unsaturated fatty acids. Small changes in the fatty acid profile analyzed by means of NMR comprise early and advanced stages of lipid deterioration, thereby outperforming most of the methods used for the assessment of oxidative rancidity of edible oils. Electron spin resonance (ESR) spin trapping techniques have also been applied to determine early oxidative events in palm oil.48 A widely applied spin trap that studies free radical formation during the storage of oil is N-tert-butyl-α-phenylnitrone (PBN). A linear correlation was obtained between the PV and ESR results using PBN,49 although higher sensitivity for early oxidative changes is achieved by ESR techniques. Disadvantages of the ESR techniques include the fact that spin adducts are only stable for a short amount of time, requiring the addition of the spin trap after sampling and immediate recording of the ESR signals. In addition, the ESR spin trapping technique has not been recommended for application in complex food systems containing antioxidants due to possible interactions with PBN,49 since PBN is known to inhibit lipid autoxidation in an antioxidant-dependent manner. Thereby, the spin traps form spin adducts with peroxyl radicals which rapidly decompose into alkoxyl radicals. Alkoxyl radicals, in turn, might be trapped by a new molecule PBN. In the presence of antioxidants, the radical scavenging activity of PBN is reduced due to higher rate constants of antioxidants with the respective free radicals.49 Thus, spin traps might be useful antioxidants, but are also valid candidates to investigate the oxidative stability of vegetable oils.

“Gas chromatography (GC) is widely used to determine volatile compounds that are generated by hydroperoxide scission” Chromatographic evaluation Gas chromatography (GC) is widely used to determine volatile compounds, such as hexanal and pentane, that are generated by hydroperoxide scission.50–52 GC provides information about the underlying mechanism of lipid oxidation. Convenient GC methods have been developed for the direct injection of the oil onto the column, however, resulting in an unstable chromatographic baseline and the shortening of column life.53 Thus, a U-tube, which was connected to the GC, was implemented for the isolation of volatile compounds.54 Another possibility with regard to on-column injection is to vacuum distil the volatiles into a cold trap prior to GC analysis.55 Alternatively, GC is often used for headspace analyses,56 whereby the volatile is accumulated by

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heating in the headspace of a tube and subsequently injected onto the GC capillary. Here, high temperatures are required; they represent a drawback in terms of this method, since high temperatures might increase further reactions of the peroxides and secondary oxidation products. Furthermore, the partitioning of the volatiles between the vapor and the liquid oil might pose some uncertainties. Lipid oxidation was also monitored by combining solid phase microextraction (SPME) with GC.57 Prior extraction of volatiles with SPME was assessed to be an environmentally friendly method due to the omission of toxic solvents. In addition, more reliable information on the oxidative stage is provided, as compared to classical methods such as AV. The results obtained with SPME-headspace-GC-mass spectrometry (MS) also showed good correlation to AV. All GC methods are limited to thermally stable compounds. Thus, non-volatile lipid oxidation products are favorably analyzed by means of HPLC coupled to UV or MS detectors.58 Steenhorst-Slikkerveer et al.58 developed a normal-phase HPLC/MS method for the detection of non-volatile triacylglyceride oxidation products, such as epoxy-triacylglyceride, oxo-triacylglyceride, hydroperoxy-triacylglyceride, hydroxyl-triacylglyceride and glycerides with two intact fatty acid chains and one short chain with an aldehyde or hydroxyl group. The proposed method can be used to characterize and quantify non-volatile triacylglyceride oxidation products, although reference standards have to be synthesized for this method. Besides normal phase chromatographic methods, reversed phase HPLC techniques have also been described to separate and analyze mixtures of conjugated diene hydroperoxide isomers, but only according to cis-trans isomerism. To separate the hydroxyl or hydroperoxide substituent according to the position on the parent chain normal phase chromatography is used.59 Normal phase HPLC techniques, therefore, allow differentiation between different isomers, such as 13-hydroperoxy dienes and 9-hydroperoxy dienes. Normal phase HPLC coupled with MS or UV detection might have the potential to emerge as a method, which combines the determination of early and advanced lipid oxidation products. Another promising HPLC method, concomitantly evaluating primary and secondary oxidation products, was developed by Márquez-Ruiz et al.60 Trilinolein samples were first fractionated using solid phase extraction to separate polar from non-polar fractions. Subsequently, the polar fraction was analyzed by high-performance size-exclusion chromatography using a refractive index detector. Applying this methodology, oxidized monomers, dimers and polymers of methyl linoleate were detected. It could be shown that the amount of oxidized monomers represents the early oxidation stage, while dimers and polymers were indicative for advanced oxidation. This method has been successfully applied to study oxidative alterations in sunflower oils.61

Are Vegetable Oils Always a Reliable Source of Vitamin A?

“Future research has to provide scientific evidence for the most reliable marker of lipid oxidation with respect to vitamin A stability” Concluding remarks Lipid oxidation critically determines the bioavailability of vitamin A from vegetable oils. Most of the assays developed to evaluate lipid oxidation detect either primary or secondary oxidation products, thereby limiting conclusions on the progress of lipid oxidation. For many assays, the application is restricted by inherent drawbacks. Therefore, evaluation of the oxidative rancidity in edible oils concomitantly to the analysis of vitamin A stability usually requires the application of different methods, which comprise the measurements of early and advanced oxidation products. Methods that combine the concomitant detection of primary and secondary oxidation products are scarce. NMR, HPLC and high-performance size-exclusion chromatography methods were discussed as three superior methods applied for the detection of the change of the fatty acid profile, conjugated diene hydroperoxides /hydroxides and condensation products of hydroperoxides. To analyze volatile compounds such as hexanal or propane, SPME-headspace-GC-MS has been demonstrated to be a reliable technique. Detection of non-volatile compounds, such as epoxides, oxo- or hydroxy-dienes, might be carried out by HPLC or LC-MS. However, quantitative analyses by means of all of these chromatographic methods require reference standards, which might not be commercially available. The chemical synthesis of these reference compounds, which should ideally be labeled with stable isotopes for quantitative stable-isotope dilution analysis, is, in many cases, a major hurdle for the quantitative evaluation of lipid autoxidation. Non-chromatographic methods for the detection of early stage lipid oxidation include the determination of oxygen uptake by a Clark-type electrode, and the measurement of the peroxyl radical-derived alkoxyl spin adducts using ESR. However, future research has to provide scientific evidence for the most reliable marker of lipid oxidation with respect to vitamin A stability.

Correspondence: Veronika Somoza, Department of Nutritional and Physiological Chemistry, University of Vienna, Althanstrasse 14, A-1090 Vienna, Austria E-mail: veronika.somoza@univie.ac.at

Are Vegetable Oils Always a Reliable Source of Vitamin A?

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09. Frankel EN. Prog. Lipid Res. 1980;19:1. 10. Kamal-Eldin A, Makinen M, Lampi AM. Lipid Oxidation Pathways. Champaign, Illinois: AOCS Press, 2003;1–36.

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12. Antolovich M, Prenzler PD, Patsalides E et al. Methods for testing antioxidant activity. Analyst 2002;127:183–98.

13. Lea CH. The effect of light on the oxidation of fats. Proceedings of the Royal Society of London Series B - Containing Papers of a Biological Character 1931;108:175–189.

14. Wheeler DH. Oil Soap 1932;9:89. 15. Swoboda PAT, Lea CH. Determination of the Peroxide Value of Edible Fats by Colorimetric Iodometric Procedures. Chemistry & Industry 1958;1090–1091.

16. Rossell JB, Hamilton RJ. Analysis of Oils and Fats. In: Classical analysis of oils and fats. London and New York: Elsevier Applied Science Publishers, 1986.

17. Mehlenbacher VC. The Analysis of Fats and Oils. Garrard Press, 1960. 18. Fiedler V. JAOCS 1974;51. 19. Lips A, Chapman RA, McFarlane WD. Oil Soap 1943;20:240. 20. Stamm J. Bull Soc Pharm Esthonia 1925;5:181. 21. Sinnhuber RO, Yu TC. 2-Thiobarbituric Acid Method for the Measurement of Rancidity in Fishery Products. 2. The Quantitative Determination of Malonaldehyde. Food Technology 1958;12:9–12.

22. Yagi K. Assay for Blood-Plasma or Serum. Methods Enzymol 1984;105:328–331.

23. Janero DR. Malondialdehyde and Thiobarbituric Acid-Reactivity as Diagnostic Indexes of Lipid-Peroxidation and Peroxidative TissueInjury. Free Radic Biol Med 1990;9:515–540.

24. Gutteridge JM. Aspects to consider when detecting and measuring

1993;621:77–81.

30. Gutteridge JM, Quinlan GJ. Malondialdehyde formation from lipid peroxides in the thiobarbituric acid test: the role of lipid radicals, iron salts, and metal chelators. J Appl Biochem 1983;5:293–9.

31. Kreis H. Chem. Ztg. 1902;26:897. 32. Kerr RH, Sorber DG. The analytical detection of rancidity. Industrial and Engineering Chemistry 1923;15:383–385.

33. Henick AS, Benca MF, Mitchell JH. Estimating Carbonyl Compounds in Rancid Fats and Foods. JAOCS 1954;31:88–91.

34. Schultz HW. Lipids and Their Oxidation. Westport, Conn: AVI Publishing Co, 1962.

35. Mizuno GR, Chipault JR. Interference of Peroxides with Determination of Total Carbonyls in Autoxidized Fats. JAOCS 1965;42:839–8.

36. Fioriti JA. Reduction of Hydroperoxide Interference in 2,4-Dnp Determination of Carbonyls. JAOCS 1965:42:743–8.

37. Holm U, Ekbom K., Wode G. Determination of the Extent of Oxidation of Fats. JAOCS 1957;34:606–609.

38. Holm U. Abstracts, International Society for Fat Research Congress, Yoteberg, Sweden 1972.

39. Holm U, Ekbom K. Proceedings. International Society for Fat Research Congress, Gothenburg, Sweden 1972.

40. Lewis WR, Quackenbush FW, Devries T. Polarographic Studies of Organic Peroxides in Nonaqueous Solutions. Anal Chem 1949;21:762–765.

41. Stangelo AJ, Ory RL, Brown LE. Comparison of Methods for Determining Peroxidation in Processed Whole Peanut Products. JAOCS 1975:52:34–35.

42. Akoh CC, Min DB. Food Lipids: Chemistry, Nutrition and Biotechnology. New York: Marcel Dekker, 2002;465–487.

43. Yoon SH, Kim SK, Shin MG et al. Comparative Study of Physical Methods for Lipid Oxidation Measurement in Oils. JAOCS 1985;62:1487–1489.

44. Arya SS, Ramanuja S, Vijayara PK. Refractive Index as an Objective Method for Evaluation of Rancidity in Edible Oils and Fats. JAOCS 1969;46:28–8.

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45. Ahlers NHE, Mctaggart NG. The Determination of Hydroxyl, Ketone and Ester Groups in Autoxidised Fatty Esters and Related Compounds by Infra-Red Spectroscopy. Analyst 1954;79:70–76.

46. Wanasundara UN, Shahidi F, Jablonski CR. Comparison of Standard and NMR Methodologies for Assessment of Oxidative Stability of Canola and Soybean Oils. Food Chem 1995:52:249–253.

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48. Raitio R, Orlien V, Skibsted LH. Electron spin resonance spectroscopy for evaluation of early oxidative events in semisolid palm oil. Eur J Lipid Sci Technol 2011;113:208–213.

49. Velasco J, Andersen ML, Skibsted LH. Electron spin resonance spin trapping for analysis of lipid oxidation in oils: Inhibiting effect of

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Vegetable Oils. JAOCS 1977;54:454–457.

54. Min DB. Correlation of Sensory Evaluation and Instrumental Gas-Chromatographic Analysis of Edible Oils. J Food Sci 1981;46:1453–1456.

55. Blumenthal MM, Trout JR, Chang SS. Correlation of Gas-Chromatographic Profiles and Organoleptic Scores of Different Fats and Oils after Simulated Deep Fat Frying. JAOCS 1976;53:496–501.

56. Duthie GG. Measuring Oxidation and Antioxidant Status Invivo. Chemistry & Industry 1991;42–44.

57. Doleschall F, Kemeny Z, Recseg K et al. A new analytical method to monitor lipid peroxidation during bleaching. Eur J Lipid Sci Technol 2002;104:14–18.

58. Steenhorst-Slikkerveer L, Louter A, Janssen HG et al. Analysis

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51. Pongracz G. Determination of Rancidity of Edible Fats by Headspace Gas-Chromatographic Detection of Pentane. Fette Seifen Anstrichmittel 1986;88:383–386.

52. Frankel EN. Volatile Lipid Oxidation Products. JAOCS 1982;59: A269–A269.

53. Waltking AE, Zmachinski H. Quality Control Procedure for Gas-Liquid Chromatographic Evaluation of Flavor Quality of

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59. Chan HWS, Levett G. Autoxidation of Methyl Linoleate, Separation and Analysis of Isomeric Mixtures of Methyl Linoleate Hydroperoxides and Methyl Hydroxylinoleates. Lipids 1977;12:99–104.

60. MarquezRuiz G, MartinPolvillo M, Dobarganes MC. Quantitation of oxidized triglyceride monomers and dimers as a useful measurement for early and advanced stages of oxidation. Grasas Y Aceites 1996;47:48–53.

61. Crapiste GH, Brevedan MIV, Carelli AA. Oxidation of sunflower oil during storage. JAOCS 1999;76:1437–1443.

MuLTIPLE MICRONuTRIENT NuTRITION

Multiple Micronutrient Nutrition: Evidence from History to Science to Effective Programs Workshop Proceedings: 2nd World Congress of Public Health, Portugal, 2010 1

David I Thurnham Northern Ireland Centre for Food and Health, university of ulster, Coleraine, uK

06. The use of micronutrient powders (MNP) in emergency situations has given variable results; however, this may be due to the unsuitability of the biomarkers used.

07. A comprehensive guide on the use of biomarkers for Key messages 01. Multiple micronutrient (MMN) supplements have been introduced to overcome drawbacks in single micronutrient

programmers is needed.

08. More experimental work is advised before programs are started.

supplementation to improve diets.

09. New work on the genetic polymorphisms affecting the 02. Main nutrients of interest are vitamin A, iron, zinc, folate and vitamin B₁₂.

activity of the enzyme converting β-carotene to vitamin A has shown the existence of potentially important ethnic differences.

03. Evidence for the existence of other micronutrient deficiencies is largely circumstantial and based on the knowledge that many people in developing countries

10. Most micronutrient interventions to date have been delivered using the “health” platform.

exist on very poor diets.

11. Three other delivery platforms exist: market-based, 04. Randomized controlled trials in pregnant and lactating women have largely shown poor responses to MMN

agriculture and social protection. However, much information is still needed for their successful implementation.

supplements, compared to iron and folate.

12. The World Health Organization (WHO) is systematically 05. The poor response by women is partly due to the fact that all women routinely receive iron and folate supplements. The lack of macronutrients may also dilute any benefit from the supplements.

collecting micronutrient statistics and program results to provide an international database for programmers.

sIGHT AND LIFE | VOL. 26 (1) | 2012

â&#x20AC;&#x153; Poor diets potenti ally limit

human growth and development, and health is also impaired direct ly or indirect ly â&#x20AC;?

Multiple Micronutrient Nutrition

Introduction Multiple micronutrient (MMN) preparations have been introduced to overcome the inadequacies of single micronutrient interventions to improve the diet. Their use has not been entirely successful, in that the effects of MMN have not always shown the expected added benefit over single nutrients. In 2010, a symposium was organized in Portugal at the 2nd World Congress of Public Health Nutrition to examine some of the issues emerging in workers’ attempts to incorporate MMN nutrition into effective programs. In the article below, I discuss some of the highlights from the papers presented. The rationale for MMN supplementation Single nutrient intervention studies to prevent those deficiencies with the greatest public health importance, namely vitamin A and iron, have been carried out in many parts of the world. The variable responses in different populations have led researchers to speculate that they are due to other limiting dietary nutrients. This seemingly reasonable explanation is understandable, since a diet that lacks a specific nutrient is quite likely to be poor, i.e. lacking in variety and /or quantity. Vitamin E, for example, is present in almost every food we eat, as it is a component of plant and animal membranes, and serious deficiencies are rare. Vitamin A, on the other hand, is more limited in its distribution. It occurs in its precursor form, β-carotene, in green vegetables and orange /yellow fruits, and it is present in small amounts as retinol or retinyl esters in animal products, such as liver, meat, milk and eggs. If diets are poor in meat products, not only is the risk of vitamin A deficiency increased, but also the risk of other micro- and macronutrient deficiencies is raised. Animal products also supply fat to the diet, which is not only an important source of energy but also a vehicle to enhance the absorption of fat-soluble vitamins and β-carotene. Thus, the absence of animal or fish products in a diet potentially impairs the utilization of other nutrients from other foods – that is, poor diets potentially limit human growth and development, and health is also impaired directly or indirectly. Eleven papers describe the symposium proceedings.1 The first paper presents an overview of the issues discussed,2 while the second traces the evolution of thought that brings us to where we are today.3 Dr Ross4 tackles one of the thorny issues that programmers overlook – namely, the need to justify an intervention and its methodology experimentally before embarking on human trials. Dr Lietz also outlines the need for experimental work to define the genetic profile of a target population, where individual differences may influence the outcome of the intervention.5 Three papers discuss MMN interventions, in terms of the need,6 the evidence from randomized controlled studies (RCT) for the effects of MMN interventions in developing countries,7 and the use of nutritional biomarkers for program evalu-

ation8 . One paper is devoted to the evidence obtained from program experience on the use of MMN powders.9 The final three papers look at the issues around how to identify appropriate “platforms” or mechanisms for the delivery of MMN (health, agriculture, market-based and social protection),10 considerations concerning efficacy, adequacy and plausibility when examining the results of MMN trials with a view to planning further implementation11 and, finally, translating research into action.12 The need for MMN supplements The term “multi-micronutrient” first appeared in the 1950s and was synonymous with essential nutrients, i.e. trace elements and vitamins.3 In the proceedings, several of the authors point out that very little is known about current MMN status in most of the countries of the developing world, with the exception of vitamin A, iron and iodine. The real needs are therefore not known; the rest of the micronutrients in MMN supplements are there “just in case.” That is, after providing nutrients to prevent nutrient deficiencies known to be present in a population, the growth and development of the recipients is not restricted by the deficiencies of other micronutrients. As a result, the major donor agencies have designed the MMN supplement to provide a mixture of nutrients that provide enough of each ingredient to meet the recommended nutrient intakes of each component, as shown in Table 1 for pregnant and lactating women,13 and for children aged six to 23 months.14 There is, however, one drawback, namely that the supplement is designed for individuals who receive adequate amounts of the macronutrients energy, protein and fat, although poor responses to MMN supplements suggest that that might not always be the case.11

“Most of the investigative work on MMN status internationally was carried out in the 1950s and 1960s” Most of the investigative work on MMN status internationally was carried out in the 1950s and 60s, after the formation of the Interdepartmental Committee on Nutrition for National Defense (ICNND) in the United States. Nutritional surveys were conducted by the ICNND in 33 countries in which the United States had strategic interests. The survey manual for these studies outlined the main physical signs for the detection of malnutrition and described biochemical methods for the detection of hemoglobin, serum vitamins A and C, urinary riboflavin and thiamin. The results showed that micronutrient deficiencies, especially anemia and vitamin A and iron deficiencies, were highly prevalent in many countries. Dr Richard Semba,3 however, points out that there were no cross-tabulations of results, i.e. the existence

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TABLe 1: Multi-micronutrient supplements for pregnant and lactating women Supplementary

Formulation for pregnant and

Micronutrient powder for children 6 –24 months of age b

micronutrient

lactating women a

Multi-micronutrient formulation

Vitamin A μg RE Vitamin D μg

Nutritional anemia formulation

800

400

300

–

Vitamin E mg

–

Vitamin C mg

Vitamin B1 mg

1.4

0.5

–

Vitamin B2 mg

1.4

0.5

–

Niacin mg

–

Vitamin B₆ mg

1.9

0.5

–

Vitamin B12 μg

2.6

0.9

–

Folic acid μg

400

150 c

160 c

Iron mg

12.5

Zinc mg

4.1

Copper mg

0.56

–

150

–

Selenium μg Iodine μg

Amounts recommended by uNICEF/WHO/uNu for pregnant and lactating women in developing countries for 6 and 3 months respectively.13 One sachet contains 1 Recommended Nutrient Intake (RNI) in ~1 g and is consumed in one day.14 Frequency of consumption will depend on estimated child needs and programmatic feasibility for delivery. So 90 sachets for a 6 month period will provide on average 3 – 4 sachets per week or an additional intake of 50% of the RNI for each micronutrient/day. c Dietary folate equivalents a

of multiple deficiencies in individuals was not calculated. It is interesting that the nutritional information that stimulated the ICNND surveys arose from a nutritional survey in Korean army troops, which showed a high prevalence of many micronutrient deficiencies. young men are not usually the group within a community to show evidence of micronutrient deficiencies. However, at that time the army rations for the Korean troops were, no doubt, modeled on local preferences and food availability. Troops restricted to barracks would have had little opportunity to supplement their diets. History has shown that groups of people living in restricted circumstances are more susceptible to malnutrition than people eating similar diets, but without physical restriction of their movements. For example, thiamin deficiency has been reported in children living in boarding schools, prisoners in jail15 and Chinese laborers working in the tin mines of Malaya,16 while vitamin C and thiamin deficiency was found in early migrants to North America who were restricted by the long cold winter months to their cabins, with minimal food.17 Where diet is restricted through ignorance, poverty or social or environmental circumstances, quality deteriorates and the risk of dietary deficiencies increases.3 To what extent do the revelations of the 1950s apply today? It is estimated that two billion people worldwide are anemic18 and, similarly, that millions are affected by iron deficiency and

deficiencies of other nutrients, such as vitamin A and zinc.6 Programs tend to focus on iron, iodine and vitamin A and, to a slightly lesser extent, on zinc and folic acid, because evidence of their deficiencies exists and they have important functional outcomes of public health concern. Semba, however, illustrates the strong circumstantial evidence for the existence of other micronutrient deficiencies in people who are extremely poor (Figure 1). The figure, based on the work of Bloem and colleagues in Indonesia, shows that, if rice is virtually the only component in the diet of poor people, it will not meet the essential requirements of most micronutrients. The composition of cooked white rice and the recommended nutrient requirements for pre-school children are shown in Table 2. They indicate that all fat-soluble vitamins and most water-soluble vitamins and minerals need to be obtained from other items in the diet. The epidemics of beriberi that spread through Asian countries with the introduction of cheap white rice in the late nineteenth and early twentieth centuries is ample evidence that rice alone will not supply sufficient thiamin to prevent deficiency in any member of the community.19 However, despite the high likelihood of the existence of micronutrient deficiencies in developing countries, there is currently little biochemical evidence for logistic reasons (invasive blood drawing, adequate laboratory facilities, the lack of a cold chain, etc.).7

Multiple Micronutrient Nutrition

figure 1: Influence of socioeconomic status on food consumed and the risk of micronutrient deficiencies

Risk of micronutrient deficiencies

Relative composition of the diet

n ke ic

il k

r l

Fr u

Ve g

Socioeconomic status

LOW

Fr able ui s t Su ga r Oi l Fi sh Eg gs M il k Ch ic ke Be n ef

et Ve g

NOT POOR

Ve ge Fr tab ui le s t Su ga Oi r l Fi sh Eg gs

LESS POOR

Ve ge Fr tabl ui e s t Su ga Oi r l Fi sh

HIGH

MODERATELY POOR

et Fr abl ui e s Su t ga Oi r l

Ve g

VERY POOR

EXTREMELY POOR Diagram to illustrate the association between the relative composition of the diet and the risk of micronutrient deficiencies (with acknowledgements to Dr R Semba and the Journal of Nutrition3)

VERY HIGH

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TABLe 2: Nutrient composition of cooked, long-grain ricea and daily recommended nutrient intakes (RNI) for pre-school childrenb Energy and fat-soluble vitamins Rice Energy Vitamin A

Water-soluble vitamins RNI

130 kcal

1198 kcal

0.55 MJ

5.0 MJe

400 – 450

(μg RE)c Carotene

None available

0.1

5.0 d

5.0

(mg) Vitamin D (μg)

Thiamin

RNI

0.16

0.5 – 0.6

(mg)

(μg RE) Vitamin E

Minerals

Rice

Riboflavin

0.01

0.5 – 0.6

1.5

6.0 – 8.0

1.2

4.2 –12.6

0.09

0.5 – 0.6

150 – 200

0.9 – 1.2

30 – 35

Zinc

0.49

2.9 – 9.6

17 – 22

(mg)

(mg) Pyridoxine

RNI

(mg)

(mg) Niacin (total)

Iron

Rice

Selenium (μg)

(mg) Folate (μg dietary folate equivalents) Vitamin B₁₂ (μg) Vitamin C (mg)

Values shown are for 100 g 43 Values shown cover the age range from 1–6 years and allowances for low to high bioavailability in the case of zinc and iron44 c RE are retinol equivalents d mg α-tocopherol e RNI for energy is an average to cover the age range and differences between the sexes from 3.9 to 6.6 MJ/day45 a

“What may be adequate in one person or dietary environment may not be in another” MMN requirements when planning interventions The consequences of micronutrient limitations are also influenced by physiological requirements and bioavailability; what may be adequate in one person or dietary environment may not be in another. Infants, children and pregnant or lactating women have higher requirements than other groups in the population, relative to energy requirements, and thus are especially vulnerable to the effects of deficiencies when the diet is poor. However, even mild deficiencies in children may impair both physical and mental development. Seasonal factors are also extremely important in influencing the effects of a supplement on nutritional outcome and should be considered when planning an intervention. Ross argues that public health nutrition has lagged behind many of the other health sciences in embracing animal models

to better understand clinical disease. She argues that human micronutrient intervention studies should be tested experimentally first, to refine the design (Table 3).4 However, the investigations outlined in Table 3 are particularly relevant to highdose, one- or two-nutrient(s) studies, such as the α-tocopherol, β-carotene (ATBC) study,20 but could equally apply to the Pemba trial, where doses akin to requirements were used.21 In the ATBC study, 20 mg β-carotene was given daily to smokers, while children in the Pemba study received 12.5 mg iron. In both, there were adverse effects of treatment. Ross believes that animal studies to pre-test and refine such interventions might have led to a better outcome.4 Both studies were done in subjects potentially exposed to high levels of inflammation: tobacco smoke in the ATBC study and endemic malaria in the Pemba trial. Inflammation alters the serum concentrations or biomarkers of many nutrients (Table 4) and is a factor which is commonly overlooked in micronutrient studies. In such cases, it is easy to assume that deficiency exists, especially when there is uncertainty concerning the dietary supply of most nutrients or sunlight irradiation, as in the case of vitamin D, or a limited knowledge of lifestyle factors. Not only do

MuLTIPLE MICRONuTRIENT NuTRITION

TABLe 3: Some advantages from conducting animal studies prior to human intervention trials â ´ Objective to investigate

Potential outcome /advantage for human study

Dose range

> Better dose selection if only a single dose can be tested

Single versus multi-nutrient

> Better understanding of interactive effects; better selection of treatments to be included or not needed

Variability

> Better power analysis to assure adequate sample size

Biomarker testing

> Better biomarker selection

Direct testing on tissues that are not available in human studies

> Better understanding of physiological effects underpinning observed outcomes

Long-term follow-up

> Better understanding of potential safety and efficacy in vivo

depressed concentrations of serum nutrients contribute to overestimates of those at risk of deficiency, but supplements may antagonize a potentially protective physiological mechanism. Two recent studies in malaria-endemic areas have both shown the adverse effects of iron-containing supplements: the Pemba study21 and a second in a rural area of the Handeni District in Tanzania.22 In both cases, iron was given with folic acid and, in Tanzania, 30% of children displayed sub-clinical inflammation (CRP > 8 mg/L). Inflammation is known to influence both zinc and

iron metabolism and the serum concentrations of both nutrients fall substantially within the first 24 hours following the onset of infection.23 Iron was associated with adverse effects in both studies, but not the zinc supplement. Likewise, folate was probably not linked to the adverse effects, since earlier iron supplementation studies did not include folate but still increased the risk of malaria.24,25 Furthermore, inflammation is not known to have any effects on serum folate.26 Lastly, an important observation in the Tanzanian study was that the increase in malaria

TABLe 4: Serum micronutrients and biomarkers influenced by inflammation Group

Serum biomarker

Effect of infection / inflammation

Fat-soluble micronutrients

Retinol a

> Rapid fall in serum concentration

25-Hydroxy-cholecalciferolb

> Rapid fall in serum concentration

Water-soluble micronutrients Minerals

Carotenoids

> Low concentrations associated with inflammation

Vitamin C

> Rapid fall in serum concentration

Vitamin Bâ&#x201A;&#x2020;

> Low concentrations associated with inflammation

Iron

> Rapid fall in serum concentration

Zinc

> Rapid fall in serum concentration

Selenium

> Low concentrations associated with inflammation

Copper

> Slow rise in concentration associated

Hemoglobinc

> Low concentrations associated with inflammation

Ferritinc

> Rapid rise in serum concentration

Transferrin receptorsc

> Low concentrations associated with inflammation

Zinc protoporphyrinc

> Low concentrations associated with inflammation

Ceruloplasmind

> Slow rise in concentration associated

with inflammation Mineral biomarkers

with inflammation

Retinol is an important biomarker of vitamin A status 40 25-Hydroxy-cholecalciferol is the biomarker of vitamin D status 46 c Biomarkers of iron status 41,47 d Biomarker of copper status a

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occurred in iron-deficient children and not in those that were replete;22 this is contrary to the findings of the Pemba study, which suggested that iron-replete children on iron supplements were more at risk from malaria. It has been suggested that the results of the Pemba trial could have been predicted,27 but they also illustrate that much more research is needed to understand the influence of nutrients on children exposed to disease and, especially, to malaria. In contrast to the two supplementation studies, a study using Sprinkles™ to supply similar amounts of iron (12.5 mg/day) in a malaria-endemic area in Kenya showed moderate reductions in anemia and no adverse effects of treatment based on hospital admissions.28 The MNP was given with food and therefore may be better managed by a child than a concentrated dose of iron, as provided by a capsule or tablet. However, it is doubtful if the use of the MNP was as regular in Kenya as it was in Pemba or Handeni, as the intervention was dependant on consumer purchases. Although almost 90% of the children had used Sprinkles™ in the period studied, over 60% only used it a little more than once a week.29 In supplementation studies, most nutrients are supplied in the form in which they are needed by the body; however, in the case of vitamin A, trials involving β-carotene have been done, especially in women of reproductive age, as vitamin A in this form is not teratogenic. However, Lietz and colleagues described some previously unexpected limitations in the enzyme converting β-carotene to retinal in this supplement. They showed that there are a number of phenotypic variations of the enzyme responsible for converting β-carotene to retinal that reduce the catalytic activity.5,30,31 The distribution of some of these enzyme variations with the poorer catalytic activity may also differ depending on ethnic origin, being more common in Asian (70%) than European/American (30%) or African (20%) populations.5 These observations reinforce the call for experimental work to precede human intervention where trials with β-carotene are involved.

“People who are replete are less likely to respond to MMN supplements and the effect will dilute the overall response to an intervention program” Factors affecting MMN delivery The objective of the paper by Neufeld and Cameron6 was to review the information from dietary intake, serum biomarkers and formal and informal health systems that can be used to identify the need for and assist in designing micronutrient programs.

Multiple Micronutrient Nutrition

They point out that most biomarkers identify deficiency and cannot be used to assess whether intakes are optimized or in excess. The inability to assess whether iron intakes are optimal from iron biomarkers is particularly well illustrated in communities where hemoglobinopathies are common (see below). The authors recognized the confounding effects of inflammation on ferritin, but failed to note that several other important micronutrients are affected by inflammation or that depression of serum vitamin concentrations through inflammation can lead to overestimations of nutrient deficiencies (Table 4). People who are replete are less likely to respond to MMN supplements and the effect will dilute the overall response to an intervention program. In the case of diet, they recognize that there are many ways to calculate nutrient intake (information from consumers, wholesalers, importers, etc.) but that bioavailability is more difficult to estimate, as uptake by the body depends on multiple factors. So, in the case of iron, there are facilitators and inhibitors (vitamin C and phytate, respectively) and the type of iron used will also influence bioavailability. However, dietary data are particularly scarce for those regions of the world with higher vulnerability to micronutrient deficiencies: the authors only found published data for five countries in Africa, four in South and Central America and four in South East Asia. Hemoglobinopathies also influence iron metabolism.32 Thalassemia mutations are extremely common in South East Asia and the Middle East: up to 25% of Thai people are carriers of α-thalassemia; there are regions of Thailand, Laos and Cambodia where up to 60% of people are carriers of hemoglobin E (HbE);33 and there are many millions of people in China who are carriers of the α- and β-thalassemia gene.34 People who carry the homozygote or compound heterozygotes (HbE/βthalassemia) of these genes display ineffective erythropoiesis, which stimulates iron absorption even if stores are adequate, and have an increased risk of iron excess. Recent work with heterozygotes of these conditions suggests that some may also display similar, although milder, characteristics32 and a higher risk of anemia.33 In heterozygotes for α- or β-thalassemia, iron utilization is lower than in controls and iron absorption is not appropriately regulated, despite modestly higher concentrations of serum ferritin and storage iron. In the compound heterozygote (HbE/β-thalassemia), iron utilization was depressed, iron absorption and body iron stores were markedly higher and additional dietary iron would not be beneficial, despite the presence of anemia. In people carrying the HbE trait (heterozygotes), the most common hemoglobinopathy in Thailand, iron utilization and absorption did not differ from that of the controls. Thus, in regions where there is a high prevalence of these traits, particularly the thalassemias, iron should be targeted at groups vulnerable to iron deficiency (women and children). If food fortification with iron is used, iron stores should be moni-

MuLTIPLE MICRONuTRIENT NuTRITION

TABLe 5: Population biomarkers for nutrients vitamin A, iron, zinc, folate and vitamin B12 Nutrient

Measurement of statusa

Vitamin A

> Serum retinol and history of night blindness > Supported by dose response test in subsample if possible

Iron

> Hemoglobin and serum ferritin > Supported by serum transferrin receptors and zinc protoporphyrin > Supported by indicators of underlying infection to interpret serum ferritin

Folate

> Serum folate and red blood cell folate

Vitamin B12

> Serum B12

Dietary intake should be determined as an indicator of nutrient deficiency and underlying infection should be measured using the acute phase proteins, serum C-reactive protein and Îą1-acid glycoprotein.40,41 See also Table 4 for influence of inflammation on biomarkers.

tored in groups with a low iron turnover, such as men or postmenopausal women, to detect excessive exposure, if present.32 Knowledge of other programs ongoing within countries and of global data resources may help to design context-appropriate interventions to improve micronutrient status. Within-country programs may also provide access to pre-existing structures within countries. There are also national and other sources of data available from WHO and uNICEF, such as Multiple Indicator Cluster Survey (MICS) reports to assist in planning trials and Vitamin and Mineral Nutrition Information System (VMNIS),12 Department of Health Surveys (DHS), reports from ministries and non-governmental organizations and peer-reviewed literature. (See also the paper on WHO activities in this supplement.)12 These provide data of varying quality and usefulness, but should be used to identify the need and its location within country. They emphasized that monitoring and evaluation systems should be in place to detect changes in micronutrient status over time. Consistent collection and reporting of such information would allow for more accurate mapping of nutritional shortfalls and provide information on whether existing interventions are meeting the required need.6 Where are we now? The objectives of the review by Christian and Tielsch were, first, to show the role of statistical methods to demonstrate the efficacy of nutritional intervention in the developing world and, secondly, to summarize some of the evidence for the beneficial impacts of MMN supplements in pregnant women and young children on a number of outcomes.7 A randomized control trial (RCT) is considered the gold standard to evaluate the efficacy of a nutritional intervention. The key characteristic is the concept of comparing like with like. That is, the intervention and control groups should have the same degree of risk for the outcome being examined. Ideally, neither the investigators nor the

subjects will be aware of who is receiving which treatment, to avoid introducing bias. In addition, subjects are randomly allocated to the treatment groups, which can be at the level of the individual or, in large trials, at a village or community level. However, comparability, blinding and randomization alone are not sufficient to guarantee a satisfactory result, since factors specific to a community (infections such as malaria, exposures such as arsenic, aflatoxin or genetic conditions such as hemoglobinopathies) may obscure any differences in the outcome of the intervention. There is therefore also a need to replicate RCTs under different settings. Data from RCTs are analyzed by metaanalysis or systematic reviews to provide an average effect for the outcome of interest. In the case of systematic reviews, the data included will be restricted to only those studies that meet defined criteria.7

â&#x20AC;&#x153;The impact on birth weight was larger in women with a higher BMI and there was also an increase in large-for-gestational-age birthsâ&#x20AC;? In the last decade, there has been a global interest in establishing the efficacy of the united Nations International Multiple Micronutrient Preparation (uNIMAPP) formulation of 15 micronutrients for pregnancy (Table 1).13 Meta-analyses of the effects of antenatal MMN supplements in 12 RCTs35,36 revealed a small but significant increase in birth weight (22.4 g, 95% CI 8.3, 36.4) and an 11% reduction in low birth weight (CI 3,19). There were no significant effects on preterm births or prenatal mortality. The uNIMAPP preparation was tested in nine of the trials. However, the fact that all trials were largely conducted using the standard

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of care of iron-folic acid as the control groups probably accounts for the small effects. That is, folate and iron deficiencies are the major micronutrient deficiencies in pregnant women in developing countries and the addition of other micronutrients had little impact on birth outcomes. However, an important observation was that the impact on birth weight was larger in women with a higher BMI. There was also an increase in large-for-gestationalage births.35 Habicht and Pelto suggest that the latter observations may indicate that many women were also deficient in one or more macronutrients and therefore could not benefit fully from the supplement.11 In children, MMN as supplements, powders or fortified readyto use foods are being used to address MMN deficiencies in developing countries. Outcomes of interest range from birth weight to child growth, infant morbidity, mortality and nutrient status and cognitive function. Christian and Tielsch reported that comparisons of height/length or weight for those receiving three or more micronutrients, compared to fewer micronutrients, found small effects of 0.13 cm (0.06, 0.21) and 0.14 g (0.03, 0.25) respectively. There was little evidence of effects on morbidity or cognitive function7 and other workers also report that evidence for the effectiveness of micronutrient supplements given as powders (MNP) in large-scale programs on these outcomes is scarce.9 The efficacy of MNP in the treatment of anemia in moderately anemic children and well-controlled trials has been clearly demonstrated.37 Nevertheless, information about the impact of MNP in large-scale programs is scarce. The aim of the paper by Rah and colleagues was to briefly review experience and data collected during impact evaluation in recent large-scale MNP programs. More than 80 MNP programs have been carried out at sub-national or pilot scale, targeting children under five years of age and conducted in many different countries across several regions. Most programs have been implemented either in refugee camps or as part of an emergency response. They report that consumption of 90 sachets by a child within a flexible time-frame of 90 to 180 days is considered sufficient to improve micronutrient intake to approach recommended levels (Table 1). The recommendation of 60 doses over two to four months is efficacious in reducing anemia; however, these results were obtained under controlled conditions. The joint statement recommended 15 micronutrients38 and, in general, that composition was maintained in the MNP in different studies, except where there were known to be other components in the diet or environment that might compete (malaria, tannins and phytic acid) or lead to an excess (on-going supplementation programs, fortified foods, e.g., vitamin A in oil, etc.) when small changes were made. Examples of the changes made to maintain the availability of the MNP contents are provided by the authors.9

Multiple Micronutrient Nutrition

“Because anemia is influenced by so many factors, hemoglobin may not be the most appropriate biomarker to use” The impact of MNP (MixMe™) is reported in a number of refugee camps. The main outcome assessed was hemoglobin concentration, as a proxy indicator of micronutrient deficiencies, and anthropometric measurements and morbidity in the prior two weeks, to assess nutritional status and health. In all cases, prevalences of anemia were high (> 45%) at the start but, after the introduction of MNP, some results increased, some fell and others did not change. There was mostly a small positive effect of MNP on stunting and, in one camp, there was evidence that the cumulative incidence of diarrhea fell over three years. Subjects were mostly used as their own controls in these evaluations, so other changes could have taken place to negate any impact of MNP. The authors recognized these considerations as important and suggested that, because anemia is influenced by so many factors, it may not be the most appropriate biomarker to use.9 Biomarkers of program impact evaluation in developing countries Wasantwisut and Neufeld8 outlined the activities of the program group within the Biomarkers of Nutrition for Development (BOND) initiative. In countries where micronutrient deficiencies are prevalent, the programs in place require biomarkers of exposure and status to monitor programs and evaluate impact. The goal of BOND is to provide guidance for the selection and interpretation of biomarkers that meet ranges of interests among food and nutrition stakeholders.39 The BOND group has focused on five micronutrients: iron, zinc, vitamin A, folate and vitamin B12. Although the focus of the working groups was at the population level, the individual use and interpretation of appropriate biomarkers was also discussed (Table 5). The authors also pointed out that biomarkers of micronutrients within a program context are not enough; there is a need to include proxy measures of factors that influence micronutrient utilization or metabolism, e.g., growth, dietary intake (of both nutrients and inhibitory factors like phytate) and infection rates. Biomarkers of iron, vitamin A and zinc are strongly influenced by inflammation,40,41 (Table 4) but there is no evidence for any effects on folate or vitamin B12.26 The information is needed so that program managers have a clear understanding of the situation to effectively plan and implement programs. Finally, the group suggested that program managers would benefit from specific information related to the use of biomarkers, e.g., sample size, timing and frequency of measurements to meet specific program

MuLTIPLE MICRONuTRIENT NuTRITION

TABLe 6: Methods of delivery of MMN Platform of program delivery

Methods

Health

> Tablets or syrups > Fortification

> Micronutrients commercially incorporated in foods > Bio-fortification > Home fortification e.g. MNP

> Diet modification Agriculture

> Promote consumption of bio-fortified crops; homestead food production (HFP) generally limited in scale; HFP targeted at women to increase household availability as well as generating income from sale of crops.

Market based

> In many setting delivery has been through the private sector in retail markets; promotion of staple foods as well as fortified complementary foods; uncertainty as to whether can reach the poorest people.

Social protection of individuals and households

> CCTs (conditional cash transfers) provide monetary transfers conditional on compliance with a number of criteria e.g. attend preventive health services, maintain school-age children at school. > SFPs (school feeding programs) can be a vehicle for MMN interventions and particularly effective at reaching girls. However, they fail to reach children in the critical window of pregnancy to 24 months.

objectives. Capacity development for in-country processing of samples is also required. The group considered that there was a good case for the development of a guide to encompass this information, to assist program managers to plan and implement programs. Identify ing potential programs and platforms to deliver MMN interventions to at-risk populations The paper by Olney and colleagues discussed the types of MMN intervention programs available and those that might be used more effectively to improve status.10 They identified four broad types of delivery platform (health, agriculture, market-based and social protection) (Table 6), seven performance criteria and four program elements. They discussed the critical knowledge gaps and highlighted what was needed to improve the effectiveness of current intervention methods in at-risk populations. The Health platform has been widely used to promote MMN interventions and, together with messages to promote behavioral change, has been well accepted and appropriately utilized in many countries. There has been high coverage, excellent compliance and a positive impact in reducing some micronutrient deficiencies. Programs are well targeted at women and children. However, the potential to deliver MMN intervention is largely dependent on the reliability and consistency of supplies, and inputs, well-trained health staff and sustainability may well depend on services of beneficiaries. In developing countries, these are often critical constraints. The agriculture platform is particularly suitable for promotion of the production and intake of micronutrient-rich foods,

including biofortified crops. Programs have generally been successful in promoting increased intake of micronutrient-rich foods, but have been criticized for their low coverage. However, it was pointed out that the Helen Keller International (HKI) program to promote homestead food production was reported to have improved food security in five million vulnerable Bangladeshi people. Market-based programs are gaining increased attention, as it is hoped that consumer demand for the MN-rich products will promote sustainability and increase health and welfare.10 However, there is concern that a marketing approach will not reach the very poor. The marketing of Sprinklesâ&#x201E;˘ in Kenya29 has shown that sellers have to be well trained to convey the right messages to consumers and must be regularly encouraged to buy stocks by inducements. Tracking of sales and use by the local population in the Kenyan study suggested that only 33% of households had purchased Sprinklesâ&#x201E;˘ at the time of the visits but, although 90% of children had used MNP at some time, consumption was only ~1 sachet per week. Both increased consumer awareness of the product and a perceived benefit to the children may be needed to increase the effectiveness of a market-based approach. Olney and colleagues discussed two social protection platforms. The first, conditional cash transfer programs, have been praised for their remarkable impact on reducing poverty, food insecurity and, in some cases, gender inequalities, although they have only had a variable impact on micronutrient status.10,42 Other workers have pointed out that more research on beliefs around traditional and modern biomedical practices, socio-

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cultural norms, gender relations and the everyday experience of poverty in many dimensions are needed to obtain a better understanding of the many influences on health care decisions, before these programs can be used to impact on micronutrient status.42 The second platform discussed was the school-feeding program as a means of intervention. The programs are popular because of the logistic simplicity of targeting schools and reaching girls before pregnancy (Table 6). The programs are not necessarily independent, since a condition of receiving a cash donation may be to ensure that girls attend school to a certain age.

Multiple Micronutrient Nutrition

by baseline birth weight values. They argued that present standards for implementing and interpreting RCT in nutrition needed to be re-examined. They considered that the current approach to efficacy studies did not enable the adequacy of the dose and the plausibility of the results to be assessed and they called for modifications to include intermediary behavioral and biological steps between intervention and biological outcomes. As ethical considerations will restrict much alteration in the design of human intervention studies, the request translated into a need for more experimental work to precede the human interventions.

“Governments must have the political “Individuals who are replete do not will to make long-term investments in the provision of effective MMN programs for pregnant and lactating women and young children” The authors concluded that each of the systems described has the potential to deliver MMN interventions, but that much still needs to be done. Key strengths include good targeting of poor populations and, in some cases, women and children under two years of age. However, all of the programs were found to have weaknesses which should be addressed. Sustainability was believed to be most likely achieved through agricultural and/or market-based platforms and profits could potentially feed back into the system to reach the poorest of the poor. Finally, governments have to be encouraged and have the political will to make long-term investments in the provision of effective MMN programs for pregnant and lactating women and young children. Is more research needed? In the last paper in the proceedings, Habicht and Pelto questioned whether there had been sufficient scientific scrutiny of the results of RCT to justify their implementation without further research. They pointed out that the efficacy of MMN supplementation had been established by state-of-the-art RCT and that these trials had also provided strong evidence of widespread deficiencies. However, the magnitude of the impact of the trials intended to demonstrate a health benefit had generally been inadequate. The authors gave as an example the small benefits to birth weight obtained by MMN supplementation of pregnant women, where the mean added weight gain by the infants of the supplemented mothers was only 22 g.35 The authors recognized that the controls were also being supplemented with iron and folate, so any effect from the comparison of the two groups was due to the other micronutrients in the supplement. Even so, the impact of the MMN was not related to the presumed need of the infants judged

respond to additional micronutrients and will clearly dilute the impact of the intervention” Adequacy and plausibility of response The authors argued that RCT, which compared MMN against iron and folate and did not contain a third group that received no intervention, was most likely to underestimate the added benefit of the other micronutrients. The danger of such a result was that the magnitude of results might not be sufficiently large to demonstrate a public health benefit for MMN. The benefit must be weighed against all the other costs of implementing the program and had to be adequate for policy considerations. The benefit or response to the MMN supplement would also be diluted by the fact that, in any population with endemic undernutrition, there will always be individuals who were not deficient. Individuals who are replete do not respond to additional micronutrients; clearly, these individuals will dilute the impact of the intervention. Other factors can also dilute the response, such as the lack of fat to enable the absorption of fat-soluble vitamins or genetic factors that impair the response to the added micronutrients. Thus, assessment of the potential to respond to an intervention requires knowledge of many factors. However, a partial solution may be to include a group of nutritionally replete individuals in the study, who are exposed to the same environmental circumstances to provide a “replete normal response.” As well as assessing the adequacy of the response, the plausibility of the results must also be interpreted. The authors argued that, where results were counter-intuitive, they should be followed up to identify the factors to explain them. They suggested that the absence of a dose response in relation to a baseline deficiency may occur because the supplement cannot be used by the people receiving the intervention. Food is not supplied in MMN trials and limitations in dietary protein and energy are very likely to diminish any response to MMN.

Multiple Micronutrient Nutrition

Finally, the authors pointed out that failure to properly account for adequacy and plausibility following efficacy studies can impact on implementation. There is already evidence from the limited impact documented from the MMN efficacy trials that donors are losing interest in MMN interventions. To meet this challenge, the efficacy trial findings should be put into the context of what is already known about the essentiality of micronutrients for performance, health and survival. However, efficacy research must also be expanded and better linked to program development and implementation. The authors argued that more research is needed on the factors influencing the program impact pathway. They pointed out that understanding the relative merits of the different pathways will become overridingly important when a variety of program platforms (health, agriculture, market-based and social protection)10 are tested as potential delivery mechanisms for MMN. Translating research into action For the WHO, research is defined as the development of knowledge with the aim of understanding health challenges and mounting an improved response to them. In 2009, the WHO adopted a new process by which recommendations for safe and effective micronutrient intervention were developed, ensuring the use of best practices and available evidence. Pena-Rosas and colleagues12 outlined the steps involved, leading to the methodology to assess overall evidence quality and strength. Guidelines were being developed for iron and vitamin A supplementation, home fortification with MNP and the fortification of staple foods. The paper focused on the process currently being followed by the WHO Department of Nutrition for Health and Development to produce global guidelines on safe and effective nutrition interventions, especially in respect of micronutrients.

“Appeals were made for all inter ventions to be monitored and reported so that others can benefit from the collective experience”

cases, specific evidence that suggests that other micronutrient deficiencies co-exist. Unfortunately, randomized controlled trials of MMN in pregnant and lactating women have demonstrated only small benefits and several speakers discussed the reasons for this limited effectiveness. MNPs have been shown to be effective under controlled conditions, but their use in emergency situations produced inconsistent results. Speakers discussed the limited usefulness of some biomarkers and indicated that better biomarkers were needed for those working in the field. An appeal was made for more experimental work to precede micronutrient intervention programs, to gather appropriate background information in target populations to improve effectiveness and reduce the risk of tragedies. It was also pointed out that most programs to date had approached intervention from a health perspective. Three other options were presented, namely agricultural, market-based and social protection schemes. The authors noted some successes, but also that a lot more information was needed on biomedical practices, sociocultural norms, gender relations and everyday experience of poverty before some of these platforms could be adapted for MMN interventions. Finally, it was pointed out that the WHO is collecting information on intervention programs. The data is available to assist researchers, but appeals were made for all interventions to be monitored and reported so that others can benefit from the collective experience. Editor’s note: Workshop Proceedings: 2nd World Congress of Public Health, Portugal, 2010: Evidence in Multiple Micronutrient Nutrition: From History to Science to Effective Programs can be obtained from Sight and Life upon request. Correspondence: David I Thurnham, 46 High Street, Little Wilbraham, Cambridge, CB21 5JY, UK E-mail: di.thurnham@ulster.ac.uk

References 01. Kraemer K, Semba RD, Neuhouse M. Multiple micronutrient nutrition: Evidence from history to science to effective programs. J Nutr 2012; 142:136–209.

Conclusions A workshop on MMN interventions was held in Lisbon, Portugal in 2010. The objective was to discuss the successes and shortcomings of the programs in developing countries that aim to provide up to one recommended nutrient intake (RNI) per day of the major micronutrients to women of reproductive age and young children. Vitamin A, iron and iodine deficiencies are known to affect many millions of women and children in developing countries, but there is also circumstantial and, in some

02. Kraemer K, de Pee S, Badham J. Evidence in multiple micronutrient nutrition: from history to science to effective programs. J Nutr 2012; 142:138S–142S.

03. Semba RD. The historical evolution of thought regarding multiple micronutrient nutrition. J Nutr 2012; 142:143S–156S.

04. Ross AC. Use of laboratory studies for the design, explanation, and validation of human micronutrient intervention studies. J Nutr 2012; 142:157S–160S.

05. Lietz G, Oxley A, Leung WC et al. Single nucleotide polymorphisms

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upstream from the ß-carotene 15,15'-monoxygenase gene influence

22. Veenemans J, Milligan P, Prentice AM et al. Effect of supplementa-

provitamin A conversion efficiency in female volunteers. J Nutr

tion with zinc and other micronutrients on malaria in Tanzanian

2012; 142:161S–165S.

children: A randomised trial. PLoS Med 2011; 8:e1001125.

06. Neufeld LM, Cameron BM. Identifying nutritional need for multiple micronutrient interventions. J Nutr 2012; 142:166S–172S.

07. Christian P, Tielsch JM. Evidence for multiple micronutrient effects based on randomized controlled trials and meta-analyses in developing countries. J Nutr 2012; 142:173S–177S.

08. Wasantwisut E, Neufeld LM. Use of nutritional biomarkers in program evaluation in the context of developing countries. J Nutr 2012; 142:186S-190S.

09. Rah JH, de Pee S, Kraemer K et al. Program experience with micronutrient powders and current evidence. J Nutr 2012; 142:191S–196S.

10. Olney DK, Rawat R, Ruel MT. Identifying potential programs and

doi:10.1371/journal.pmed.1001125.

23. Beisel WR. Trace elements in infectious processes. Med Clin North Am 1976; 60:831–849.

24. Smith AW, Hendrickse RG, Harrison C et al. The effects on malaria of treatment of iron-deficiency anaemia with oral iron in Gambian children. Ann Trop Paed 1989; 9:17–23.

25. Oppenheimer SJ, Gibson FD, MacFarlane SBJ et al. Iron supplementation increases prevalence and effects of malaria: report on clinical studies in Papua New Guinea. Trans R Soc Trop Med Hyg 1986; 80:603–612.

26. Galloway P, McMillan DC, Sattar N. Effect of the inflammatory

platforms to deliver multiple micronutrient interventions. J Nutr

response on trace element and vitamin status. Ann Clin Biochem

2012; 142:178S–185S.

2000; 37:289–297.

11. Habicht JP, Pelto GH. Multiple micronutrient interventions are efficacious, but research on adequacy, plausibility, and implementation needs attention. J Nutr 2012; 142:205S–209S.

12. Pena-Rosas JP, De-Regil LM, Rogers LM et al. Translating research

27. Oppenheimer SJ. Comments on background papers related to iron, folate, malaria and other infections. Food Nutr Bull 2007; 28:S550–S509.

28. Suchdev PS. Nyando integrated child health and education project.

into action: WHO evidence-informed guidelines for safe and effec-

2009. Nairobi, 4th Africa Nutritional Epidemiology Conference

tive micronutrient interventions. J Nutr 2012; 142:197S–204S.

<http://imtf.org/blog/2010/10/29/ANEC%204%20Nairobi%20

13. UNICEF/UNU/WHO. Composition of a multi-micronutrient supplement to be used in pilot programmes among preg-

Declaration>.

29. Suchdev PS, Ruth L, Obure A et al. Monitoring the marketing,

nant women in developing countries. [http://www.idpas.org/

distribution, and use of Sprinkles™ micronutrient powders in rural

pdf/059CompositionofMult-MicronutrientSupplement.pdf]. 1999.

western Kenya. Food Nutr Bull 2010; 31:S168-S178.

New York, UNICEF.

30. Leung WC, Hessel S, Méplan C et al. Two common single nucleotide

14. HF-TAG. Programmatic guidance brief on use of micronutrient pow-

polymorphisms in the gene encoding beta-carotene 15,15’-monoxy-

ders (MNP) for home fortification. 2011. Home Fortification Techni-

genase alter beta-carotene metabolism in female volunteers. FASEB

cal Advisory Group, <http://www.gainhealth.org/hftag/document>.

15. de Montmollin D, MacPhail J, McMahon J et al. Outbreak of beri-beri in a prison in West Africa. Trop Doct 2002; 32:234–236.

16. Platt BS. Epidemiology and clinical features of endemic beriberi. Proceedings of a conference on beriberi, endemic goitre and hypervitaminosis A. Proc F A S E B 1958; 17(Suppl 2):3–20.

17. Carpenter KJ. The history of scurvy and vitamin C. Cambridge: Cambridge University Press; 1986.

18. World Health Organization, Centres for Disease Control and Preven-

J 2009; 23:1041–1053.

31. Lietz G, Lange J, Rimbach G. Molecular and dietary regulation of beta,beta-carotene 15,15’-monooxygenase 1 (BCMO1). Arch Biochem Biophys 2010; 502:8–16.

32. Zimmermann MB, Fucharoen S, Winichagoon P et al. Iron metabolism in heterozygotes for hemoglobin E (HbE), alpha-thalassemia 1, or beta-thalassemia and in compound heterozygotes for HbE/betathalassemia. Am J Clin Nutr 2008; 88:1026–1031.

33. George J, Yiannakis M, Main B et al. Genetic hemoglobin disorders,

tion (CDC). Assessing the iron status of populations. 2nd. Geneva:

infection, and deficiencies of iron and vitamin A determine anemia

WHO Press; 2007.

in young Cambodian children. J Nutr 2012; in press.

19. Thurnham DI. Beriberi. In: Caballero B, Allen L, Prentice A, eds. Encyclopedia of Human Nutrition. 2nd ed. Oxford: Elsevier; 2005. 269–278.

20. Rowe PM. Beta-carotene takes a collective beating. Lancet 1996; 347:249.

21. Sazawal S, Black RE, Ramsan M et al. Effects of routine prophylactic

34. Angostiniosis M, Modell B. Global epidemiology of hemoglobin disorders. Ann N Y Acad Sci 1989; 850:251–269.

35. Fall CH, Fisher DJ, Osmond C et al. Multiple micronutrient supplementation during pregnancy in low-income countries: a metaanalysis of effects on birth size and length of gestation. Food Nutr Bull 2009; 30:S533–S546.

supplementation with iron and folic acid on admission to hospital

36. Ronsmans C, Fisher DJ, Osmond C et al. Multiple micronutrient

and mortality in preschool children in a high malaria transmission

supplementation during pregnancy in low-income countries: a

setting: community-based, randomised, placebo-controlled trial.

meta-analysis of effects on stillbirths and on early and late neonatal

Lancet 2006; 367:133–143.

mortality. Food Nutr Bull 2009; 30:S547–S555.

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37. De-Regil LM, Suchdev PS, Vist GE et al. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev 2011; 9:CD008959.

38. WHO/WFP/UNICEF. Preventing and controlling micronutrient deficiencies in populations affected by an emergency. 2010. Internet, http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf.

39. Raiten DJ, Namaste S, Brabin B et al. Executive summary--Biomarkers of Nutrition for Development: Building a Consensus. Am J Clin Nutr 2011; 94:633S-650S.

40. Thurnham DI, McCabe GP, Northrop-Clewes CA et al. Effect of subclinical infection on plasma retinol concentrations and assessment of prevalence of vitamin A deficiency: meta-analysis. Lancet 2003; 362:2052-2058.

41. Thurnham DI, McCabe LD, Haldar S et al. Adjusting plasma ferritin concentrations to remove the effects of subclinical inflammation in the assessment of iron deficiency: a meta-analysis. Am J Clin Nutr 2010; 92:546-555.

42. Adato M, Roopnaraine T, Becker E. Understanding use of health

qualitative research in Latin America and Turkey. Soc Sci Med 2011; 72:1921-1929.

43. National nutrition database for standard reference. [Release 24]. 2011. http://www.ars.usda.gov/bhnrc/ndl, United States Department of Agriculture.

44. FAO/WHO. Vitamin and mineral requirements in human nutrition. 2ed. 2004. http://www.who.int/nutrition/publications/ micronutrients/9241546123/en/index.html, Geneva: World Health Organisation, 2004.

45. FAO/WHO/UNU. Human energy requirements Report of a Joint FAO/ WHO/UNU Expert Consultation. http://www.fao.org/docrep/007/ y5686e/y5686e06.htm#bm06.4, Geneva: World Health Organisation, 2001.

46. Reid D, Toole BJ, Knox S et al. The relation between acute changes in the systemic inflammatory response and plasma 25-hydroxyvitamin D concentrations after elective knee arthroplasty. Am J Clin Nutr 2011; 93:1006-1011.

47. Grant FK, Suchdev PS, Flores-Ayala R et al. Correcting for inflammation changes estimates of iron deficiency among rural Kenyan preschool children. J Nutr 2012; 142:105-111.

services in conditional cash transfer programs: insights from

Opinion 1: A Perspective on the Delivery of Micronutrient Interventions: What are the Needs? Shibani Ghosh and Jeffrey B Blumberg Friedman School of Nutrition Science and Policy Tufts university, Boston, MA, uSA

In Response to: Evidence in Multiple Micronutrient Nutrition: From History to Science to Effective Programs David I Thurnham Northern Ireland Centre for Food and Health university of ulster, Coleraine, uK

Despite substantial evidence collected for over a hundred years concerning the impact of micronutrient deficiencies on health, and some notable successes, such as the fortification of staple foods in North America and Europe, efforts to control micronutrient deficiency disorders only gained prominence in the international nutrition community at the beginning of the 1980s.1, 2 This situation has been attributed to the hidden nature of the ef-

fects of complex micronutrient disorders; the slow generation of a suitable evidence base; and the emphasis on treating clinical manifestations of malnutrition associated with specific macroand micronutrients with supplementation or fortification.1 We now have a greater understanding of common multiple and concurrent deficiencies, but we continue to debate important issues regarding the need for basic and applied research, along with the ways to identify the most effective approaches to program implementation.3 In this issue of Sight and Life magazine, Dr David Thurnham provides a comprehensive overview of a workshop held during the 2nd World Congress of Public Nutrition in September 2010 in Portugal that examined the current knowledge, gaps and future needs concerning multiple micronutrient (MMN) programs.4 It is clear that we must soon address several crucial areas to generate an actionable evidence base for MMN and more quickly translate this into effective policies and programs. For example, on a translational level, we need to understand the role of inflammation and infection in altering MMN needs and utilization and the factors that affect the targeting and delivery of MMN

sIGHT AND LIFE | Vol. 26 (1) | 2012

programs. This information will help allow us to test the efficacy and effectiveness of traditional market- or program-based MMN fortification and supplementation interventions as well as emerging strategies such as biofortification and homestead food production. Importantly, we also need to test the replicability of these platforms in different settings. Biofortification of staple crops is one innovative strategy for bringing MMN to a population, although much work remains to transform it from research efforts to on-going programs. As an example with some success, vitamin A rich Orange Flesh Sweet Potato has shown itself to be effective in improving the vitamin A status of children in Mozambique and Uganda.5 Nonetheless, there are likely to be challenges from concerns and perceptions about the use and dissemination of genetically modified crops. Awareness generation at the policy level, and appropriate regulatory mechanisms, are required to ensure that biofortified crops benefit the population while also managing trade and regulatory affairs in predominantly agricultural economies.

“Market approaches to MMN programs should rely on private sector engagement but extend to deeper levels of collaboration with the public sector” Market approaches to MMN programs hold significant potential in some regions but, importantly, would not likely reach very poor populations. Market approaches should rely on privatesector engagement but go beyond the traditional delivery of non-public goods and beyond the usual definition of corporate social responsibility to deeper levels of collaboration with the public sector in building and supporting initiatives that are selfsustaining. Careful consideration must also be given to the role of social marketing and messaging. Despite advances in basic science and the development of a limited set of field-friendly biomarkers, the lack of information on the prevalence of MMN deficiency and/or the inadequate capacity for collecting these public health data remain key issues in developing countries. While national efforts like the Department of Health Surveys and Multiple Indicator Cluster Surveys are useful, information is still not present for all countries, and the biomarkers, when they are even available, are non-specific (e.g., hemoglobin for anemia) and lack detail at the regional/ district level. We must urgently address the need for in-country capacity to develop surveillance systems that will allow for the generation of epidemiological and biochemical data on MMN deficiencies. We have seen some success with individual micro-

Opinion 1

nutrients, e.g., the large-scale, periodic vitamin A surveys in Nepal. Such assessments are often dependent on both external and bilateral donors, but to continue to receive these resources, we need to better highlight the importance of these investments within the context of national policies. It has been emphasized that we need to separate “evidencebased medicine” from evidence-based practice in considering MMN programs.6 Of course, developing effective doses and combinations of MMN; defining optimal forms for each micronutrient; and identifying field-friendly biomarkers continue to be important issues. However, much more attention should be given to making effective the implementation and the delivery of MMN. While we presume there is sufficient evidence around “proven interventions” to advocate specific micronutrient and MMN programs, little is actually known about how to scale up such interventions sub-nationally or nationally.7,8 While some key issues for program delivery have been outlined,9 it is essential we understand the potential to transfer micronutrients through different delivery platforms and the barriers and facilitators of each one. As not all delivery platforms are program-based, we need to develop a new research agenda as well. The topics here include factors such as the political environment, donor commitment, internal program and delivery processes, periodic review of program impact pathways, and cost- and impact-effectiveness across variable delivery systems. Conducting clinical trials and related human studies under real-world conditions can be markedly constrained or even impossible due to the enormous ethical, financial, logistical or political challenges that may be involved. Even when such studies are feasible, they have serious external validity limitations, because it is not uncommon to find that not all populations or population subgroups respond in the same way to programs or other interventions. So we need to be flexible and not require only the strongest evidence from a large body of research before moving forward to try and solve today’s problems of MMN deficiencies.

Correspondence: Shibani Ghosh, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts 02111, USA; Nevin Scrimshaw International Nutrition Foundation E-mail: shibani.ghosh@tufts.edu Jeffrey B Blumberg, Friedman School of Nutrition Science and Policy; Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, 02111 USA E-mail: jeffrey.blumberg@tufts.edu

OPINION 2

References 01. Allen LH. Interventions for micronutrient deficiency con-

05. Low JW, Arimond M, Osman N et al. A food-based approach introducing orange-fleshed sweet potatoes increased vitamin A intake

trol in developing countries: Past, present and future. J Nutr

and serum retinol concentrations in young children in rural

2003;133:3875S–3878S.

Mozambique. J Nutr 2007;137: 1320–1327.

02. Underwood BA. From research to global reality: The micronutrient story. J Nutr 1998;128:145–151.

03. Allen LH, Peerson JM, Olney DK. Provision of multiple rather than two or fewer micronutrients more effectively improves growth and other outcomes in micronutrient-deficient children and adults. J Nutr 2009;139:1022–1030.

04. Thurnham DI. Evidence in multiple micronutrient nutrition: From history to science to effective programs. Sight and Life Magazine 2012; 1:28–43.

06. Kraemer K, de Pee S, Badham J. Evidence in multiple micronutrient nutrition: From history to science to effective programs. J Nutr 2012;142:138S-142S.

07. Bhutta Z, Ahmed T, Black R et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371:417–440.

08. Shekar M. Delivery sciences in nutrition. Lancet 2008;371:1751. 09. Habicht J-P, Pelto GH. Multiple micronutrient interventions are efficacious, but research on adequacy, plausibility, and implementation needs attention. J Nutr 2012; 142:205S–209S.

Opinion 2: Ongoing Development of Field Tools is Required Usha Ramakrishnan Hubert Department of Global Health, Rollins School of Public Health at Emory university, Atlanta, uSA

The concept of multiple micronutrients is not new, and has been recognized as important in developed and developing countries since the middle of the 20th century. In this issue of Sight and Life, Dr Thurnham provides an excellent summary of current knowledge and directions for the way ahead on the issue of multiple micronutrient (MMN) interventions, based on a series of presentations that were made in the 2nd World Congress of Public Health, held in Portugal in 2010 and published in the Journal of Nutrition in January 2012. The rationale for MMN interventions, especially in resource-poor settings, is convincing, but the complex and varied findings from several welldesigned efficacy trials, systematic reviews and meta-analyses pose several challenges if we want to move ahead with largescale programs. Efficacy studies vary with regard to the nature of the intervention provided, in terms of composition and delivery (supplements, fortified foods, micronutrient powders), what the comparison group received, the outcomes evaluated and the characteristics of the study populations. The context or nature of the setting presents the most important challenge, to both the scientific community and the implementers who are faced with deciding which interventions to promote and support in programs.

Effectiveness studies At this stage, as pointed out by Habicht and Pelto,1 there is a need for studies which are designed to provide better answers to plausibility and behavioral variation, in addition to biological variation. It is unlikely that additional efficacy trials will provide this information in a cost-effective manner. Rather, large, well-designed effectiveness studies, which carefully evaluate the implementation-related issues and also include appropriately selected control groups, should be carried out. The interplay between other factors, such as macronutrient availability, infections, etc, can also be addressed by combining them with other strategies. The possibility of adverse effects should not be ignored, but does not justify inaction, especially in populations where there is widespread evidence of poor micronutrient status based on dietary intakes and/or biomarkers. For example, if prenatal MMN intervention studies had been carried out as placebo-controlled trials, rather than by comparing to iron-folic acid (IFA), the estimates of their benefit might have been larger and the possible increased risk of neonatal mortality might have been minimized. Research on the formulation of MMN interventions which contain safe levels of micronutrients for subgroups, such as those infected with HIV or malaria, is still needed. The coverage of IFA during pregnancy also remains suboptimal, and strategies are needed to ensure adequate and timely access to prenatal care, quality of care and services such as the detection and management of high-risk pregnancies, counseling, etc., irrespective

Opinion 2

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of whether we provide IFA or MMN-supplements during pregnancy. Similarly, very few programs routinely provide micronutrient interventions to young children, with the exception of high dose vitamin A supplements and /or zinc supplements for sick children in certain settings. Increased attention and integration with programs that promote optimal infant and young child feeding is also needed. A major hurdle The lack of information on the extent of micronutrient deficiencies remains a major hurdle, which needs attention. Poor diet quality and /or diversity, which are often characterized by indicators such as low or no animal food intake, and high dependence on single staples, such as rice or maize, are often used as proxy measures of multiple micronutrient malnutrition, along with macroeconomic indicators such as poverty, which also capture food insecurity and /or poor macronutrient intakes. Information on intakes of specific micronutrients, however, is often limited because the tools to assess nutrient intakes, such as 24-hour dietary recalls, are time and resource intensive. To date, anemia is the only biomarker that can be easily used in field-based settings, but this remains problematic, as it may be due to factors that are not amenable to MMN interventions. Although the lack of field-friendly, low cost, and minimally invasive methods to measure biochemical indicators of specific micronutrients, such as iron, folic acid, etc., is viewed by some as the reason for the limited progress, research studies have also demonstrated the limitations of indicators such as serum ferritin, which are influenced by non-nutritional factors such as infection, inflammation and genetics. The number of tests which would be required to appropriately interpret micronutrient status is becoming increasingly higher, complex and unrealistic for programmatic settings. This, however, may still be needed if there are concerns of harm, which may happen in the case of micronutrients such as iron and β-carotene.

“The greatest need is for cost effective, field-based techniques to measure iron status and markers of inflammation” Finally, the limited information on the etiology of anemia remains a major issue and affects the ability of programs to deliver appropriate interventions. The greatest need is for cost-effective, field-based techniques to measure iron status and markers of inflammation, which would provide accurate estimates of the magnitude of iron-deficiency anemia, as well as overall iron de-

ficiency. The concerns about excess iron for certain sub-groups also require low cost methods, which will allow us to estimate the contribution of genetic factors, such as thalassemia, to low hemoglobin levels in certain populations. Biochemical indicators for other micronutrients, namely vitamins A, B12, folic acid and zinc, will also be useful to monitor programs. The field has seen some recent developments in terms of lower cost micro-methods for assessing micronutrient status, but limitations to their routine use in large-scale effectiveness studies and programs exist. Serum ferritin, serum transferrin receptor, serum retinol binding protein (RBP) and two inflammatory markers can be simultaneously estimated from a single capillary sample, using a lowcost, rapid multi-protein sandwich ELISA technique. This method allows for the estimation of infection-adjusted vitamin A and iron status, but laboratory capacity is still limited. Recent work suggests that serum RBP and markers of inflammation can also be reliably quantified from dried blood spots (DBS); however, the use of DBS for assessing serum ferritin has proven to be more difficult. Breast milk retinol is another promising indicator; samples are relatively simple to collect, but the analysis still relies on costly, sophisticated HPLC equipment. A rapid field tool that utilizes fluorometric analysis to assess vitamin A in milk is currently undergoing validation testing, but costs will need to come down for it to be applied in programs. Assessment of zinc, vitamin B12, and folate status remains expensive, technically complicated, and/or invasive. Continued development of less invasive, rapid field tools to reduce costs and maximize validity is needed. In addition, for those micro-methods that have been validated, expansion of laboratory capacity is needed.

Correspondence: Usha Ramakrishnan, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Room 758, 1518 Clifton Road, N.E., Atlanta GA, 30322, USA E-mail: uramakr@sph.emory.edu Acknowledgement The author would like to acknowledge the support of Dr Aimee Girard-Webb, who provided valuable feedback on an earlier version of this piece.

References 01. Habicht JP, Pelto GH. Multiple micronutrient interventions are efficacious, but research on adequacy, plausibility, and implementation needs attention. J Nutr 2012; 142:205S-209S.

A DAy IN THE LIFE OF DR DAVID NABARRO

Sight and Life Interview

A Day in the Life of Dr David Nabarro At the 2012 World Economic Forum in January of this year, David Nabarro, united Nations Special Adviser on Food Security and Nutrition to the united Nations Secretary General, was presented with the inaugural Sight and Life Nutrition Leadership Award by Dr Klaus Kraemer. In a wide-ranging interview, Dr Nabarro speaks of his lifetime’s work in public health and of the inspirations behind his career of public service.

Sight and Life Magazine (S&L): Dr Nabarro, you have been extremely active and highly influential in the field of public health for many decades. What inspired you to work in this field? David Nabarro (DN): I’ve always been interested in the ways that governments ensure that people who are less well-off are enabled to benefit. At school I worked in a number of community service and social welfare programs, and I was a Community Organizer in york between leaving school and studying at Oxford university. At Oxford, I became interested in student politics and then later, at university College Hospital in London, in medical politics. I realized that ill-health was a question not just of microbes but also of how people live and the degree to which they can exercise choices about whether or not to become sick. It was this interest in the political, economic and social determinants of ill-health that encouraged me to take a posting to Iraq in 1974 with a relief expedition organized by the Save the Children Fund. This was a short-term assignment planned to last for some months before I took up a clinical physician post at university College Hospital in London. However, because of the security situation in the places where I was working, I was unable to return to the uK on time. As the months went by, I became increasingly involved in the efforts of the Kurdish people to maintain their resilience in the face of war. Through this experience, I realized that, although I derived enormous professional satisfaction from

clinical medicine, I would prefer to work on the underlying causes of ill-health. After clinical posts in Oxford and Northampton, I therefore applied to work with Save the Children again, this time in Nepal in 1977. From that moment onwards, my focus was on public health, and in particular on nutrition, maternal health and child health. S&L: Did you ever contemplate a different sort of life? DN: When I was at Oxford university, I worked as a disc jockey and belonged to an enterprise that ran mobile discotheques and organized parties. I did, in fact, think of going into the music business at one point, but I have no regrets about the choices I’ve made. I still love music, by the way! S&L: You trained as a clinician. Is part of your identity still that of a doctor of medicine? DN: yes. I try to examine all issues from the perspective of the people experiencing them and to understand the challenges that they face. I am particularly frustrated when I sense that people are suffering extreme hardship and pain, especially if I sense that it can be avoided. I have not experienced such suffering personally, but I have seen it in many thousands of people during my career. The attempt to empower people so that they are less at risk of suffering and to mitigate their distress remains the prime driver of my life today. In fact, it’s probably stronger now than it ever was before. S&L: You have worked in many parts of the world, including Nepal, South Asia, East Africa and Iraq. Where have your most formative experiences taken place? DN: Each part of my life has informed the others, whether I’ve been working as a doctor, a program manager, an advisor, an aide, a bureaucrat or a diplomat. I sense that there has been continuity in my career. If I had not spent those early years

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Dr David Nabarro

A Day in the Life of Dr David Nabarro

listening to, and exchanging ideas with, village people and health workers in South-East Asia, I think I would be less useful in my work today. That experience informs my current role. Similarly, if I had not had the opportunity of working for the World Health Organization, I would never have had the chance to see what can be achieved by linking political mobilization with a commitment to public health. So I wouldn’t say that one part of my career has been more formative than another; they’re all interlinked.

close quarters with people in need in many settings. As outsiders – supporting relief and development – our problems are minute compared with people who live from day to day in areas affected by war and strife. S&L: Your current role is Special Representative on Food Security and Nutrition for the UN Secretary General. What does the role entail? Could you tell us something about the strategic objectives of the job, and also about the day-to-day reality of it?

S&L: And where do you feel most at home today? DN: My home is where my children are, and I try to be with them as much as possible – although there will always be a conflict between being with them and doing my work. The fact is that travel really matters in a role such as mine. You can’t do the sort of work I’m involved in without getting around the world and meeting with people face to face. S&L: You were stationed in the Canal Hotel in Baghdad, Iraq, and working with the United Nations in that country, when the Canal Hotel was bombed on the afternoon of 19 August 2003. The target of the bombing was the United Nations, which had used the hotel as its headquarters in Iraq since 1991. What effect did that experience have on yourself and your colleagues? DN: The first thing to say is that I had never thought that humanitarian work was neutral and should automatically be protected in a situation of war. I accepted that all who seek to act in a war situation are likely to be seen as part of the conflict by one group or another. It seemed that we might get hit one day. That was indeed what happened: it was a massive explosion, and it claimed the lives of many of my friends and colleagues. Secondly, the moment the bomb went off, I knew that the United Nations would never be the same again. I heard the anguish of people who had been injured, and saw people who were very badly hurt indeed. I knew that everything had changed. And of course the UN system has had to operate differently since then. I remain extremely proud of being part of the United Nations system and of the way that we are present throughout the world, offering support to individuals, societies and nations – often in extremely dangerous places – and never giving up. Thirdly, I was deeply moved by the courage of the people caught in the Baghdad blast – by the way they tried to help each other before worrying about their own discomforts. I witnessed incredible kindness, and some of my deepest friendships today are with people with whom I worked in the immediate aftermath of that explosion. I also remember the amazing support of the American forces, who came by helicopter to help us out. Unfortunately such bombings are increasingly commonplace, and the necessary security precautions make it harder for us to work at

DN: In 2008, when food prices were rising rapidly worldwide, the UN Secretary General Ban Ki-moon decided to establish a high-level task force to ensure that the UN system took an integrated approach to food security. I was brought in to act as Assistant Coordinator of this task force because of my experience – since 2005 – with encouraging different organizations to work together in synergy on avian influenza and pandemic preparedness, and to coordinate them as they do so. I started as Coordinator for the Food Security Task Force in January 2009, and we established a small coordination team with hubs in Rome, New York and Geneva. In 2009, the UN Secretary General asked me to serve as his Special Representative for Food Security and Nutrition. The UN Secretary General is committed to intensified and synergized action on food security and nutrition throughout the UN system. In addition he would like to see all relevant stakeholders working in synergy so as to ensure food security and adequate nutrition worldwide. As his Special Representative, I seek to inform others of his intentions. I also listen to the stakeholders so that I can better understand their perspectives and feed these back to the office of the Secretary General. This has been particularly important in the context of recurrent food and nutrition insecurity in the Horn of Africa and Sahel regions. At the request of the Secretary General, I am working with colleagues to give more attention to policies for improving food security that take account of water, land and energy scarcity, and the need to use all these resources, as well as environmental services, in a sustainable way. Some two months ago, the UN Secretary General asked me to take on the role of coordinator responsible for the smooth running of the Scale Up Nutrition (SUN) movement, so I now have this responsibility as well. S&L: Do you have such a thing as a typical working day, or is every day different? DN: Every day is different, always. Never dull, always busy. The style of work remains the same. Our Coordination Team of 16 people supports the UN system Steering Committee on Avian and Pandemic Influenza, the High Level Task Force on Food

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A Day in the Life of Dr David Nabarro

Security and the Scale Up Nutrition movement. We work together with many different groups and organizations, all of them wanting to make a big impact on the issues. We connect different processes together, always working to ensure that the whole is greater than the sum of the parts, reaching out when the processes seem to be moving apart. If we fail in keeping diverse organizations together, working round a common narrative of empowering others, it really would be difficult to encourage synergy and ensure the best possible outcomes. I work with diplomats from all the world’s governments, officials of all levels from within the UN system, representatives of donor and development agencies, and of course also people from civil society. Most of my work is done by telephone, and I work hard to ensure that everyone’s time is used efficiently and everyone’s voice is heard. While striving to hold a clear strategic line on complex issues, I am also always on the look-out for opportunities to act constructively. I like to think of myself as a strategic opportunist, or ‘stroppist.’ We can’t achieve anything without a sound strategy, but a strategy is nothing if we don’t act on it when opportunities arise and ensure that others are involved in the action. That’s why I work increasingly within partnerships, but find that these work best when located within the context of a wider movement in which many organizations and their people are all moving in the same direction. This is possible if they have a shared purpose and an agreed basis for action.

DN: Bad nutrition – especially during pregnancy, infancy and childhood – creates the conditions which lead to so much of the suffering we see around us today. Bad nutrition undermines children’s intellectual and economic potential and sets the scene for the onset of diseases such as diabetes and cardiovascular disease in later life. Bad nutrition affects approximately one third of all children on the planet – at a minimum. It is a handicap for life. Tackling bad nutrition means supporting all people’s food security, combating chronic hunger, empowering women, and ensuring adequate water supply and sanitation. Through tackling malnutrition, governments and other stakeholders focus on social inequity, women’s autonomy and children in their earliest years. For that reason, I would like the reduction of malnutrition to be a development goal. We must continue to work for an end to hunger and food insecurity, but the absolute need now is to reduce the incidence of chronic undernutrition, or stunting. I’d like to see reduction of chronic undernutrition (ROCUN) – especially in the 1,000 days between pregnancy and the second birthday – addressed not just by government and businesses but by all the people of our world. The SUN movement is for everyone. The tasks for the movement are feasible, cost-effective, and will make a positive difference to the growth of entire nations.

S&L: At the 2012 World Economic Forum (WEF) in Davos, you were presented with the inaugural Sight and Life Nutrition Leadership Award on behalf of the Scale Up Nutrition (SUN) movement. What does this award mean to you?

DN: I have been inspired by so many people – for instance, the mother of Ram, a young Nepalese boy who had severe vitamin A deficiency and eventually lost the sight of both eyes. In 1979, clinic staff in Dhankuta did everything possible to help him, but attempts were ultimately unsuccessful. His mother always treated my colleagues and me with great love. That failure still lives with me as a haunting symbol of the importance of vitamin A. But there are so many other people who have inspired me, each in their different ways – Mahesh Pant and colleagues, who worked for development in East Nepal; Sultana Khanum, who ran a great Nutrition Unit in Bangladesh which confirmed the importance of zinc; John Waterlow, who introduced me to clinical nutrition; Barbara Harris, who explained the value of understanding household economies; and Philip Payne, who helped me to think about complex situations from multiple points of view. So many people have been really generous with ideas and opportunities throughout my life – right up to when I was in Niger last week learning about nutrition and development from Fode Ndiaye and Dr Maimuna.

DN: It’s important to understand that I am not myself leading the SUN Movement. Acting on the instructions of the UN Secretary General, I’m trying to hold processes together and encourage organizations to move in the same direction and work together for agreed goals! Thousands of people and hundreds of organizations have come together in support of the SUN movement – a political and social movement whose members are energized by the wish to make a real difference. It is on behalf of all of them that I had the privilege of accepting the award. The SUN movement is a reflection of remarkable transformations that are happening in our world. S&L: In accepting the award, you stated that ‘Nutrition on its own should become a new development goal as we look beyond 2015.’ Could you explain this statement in the context of the Millennium Development Goals? By what means could Nutrition become a development goal in its own right, and what might be the consequences of this step?

S&L: Do you have a hero or role-model who has inspired you in your life?

S&L: You are at the height of a very influential career, with a long history of public service to look back on. What are the personal achievements that fill you with most pride?

A Day in the Life of Dr David Nabarro

DN: What pleases me most is that many of the issues that attracted my attention when I was a junior doctor are now being addressed by governments and by the international community in a really intensive way. This includes malaria, unsafe pregnancy, diseases of early childhood such as measles and diarrheal diseases, and now nutrition itself. But it’s not just governments and major organizations who are addressing these topics – it’s society as a whole. If my contribution has helped to bring about that transformation and it has empowered people for more secure and resilient livelihoods, I can feel good about my professional life. S&L: You have an extremely busy professional life that involves the shouldering of great responsibilities. What are your interests in private life, and how do you switch off from the demands of work? DN: I’m very close to my family, as I’ve indicated, and I try to spend as much of my time with them as possible. I have a son in his late twenties who sadly broke his neck in a snow-boarding accident in 2007, and his bravery in the wake of that accident is a great inspiration to me. I also love skiing – my all-time favorite sport – as well as music. I have a particular interest in dance music, which follows on from my early days as a disc jockey. S&L: Sight and Life recently marked its 25th anniversary with the publication of a book whose subtitle is The story of vitamins and a hungry world. How do you view the development of Sight and Life in recent years?

DN: Sight and Life plays a key role in advocating the importance of micronutrients in a healthy diet. The magazine itself is full of strong content, extremely accessible and helpful. The organization works hard to stimulate capacity building and the creation of the necessary skills to tackle malnutrition, and I believe that it has advanced this cause in a really useful way. S&L: Do you have a final message for our readers? DN: I do. The battle against malnutrition can be won if we all get behind the movement for Scaling Up Nutrition. This truly is a movement for everyone on the planet. Do get involved in whatever way you can, and try to involve your friends in it. You can create SUN hubs around the world and work together to consign poor nutrition to history. S&L: Thank you for sharing your thoughts with us, Dr Nabarro, and the best of luck to you and all your colleagues with this important work. DN: Thank you.

Dr David Nabarro was interviewed by Jonathan Steffen

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“Economic development depends on nutrition”

Dr David Nabarro (right) receives the inaugural Sight and Life Nutrition Leadership Award from Klaus Kraemer at a breakfast meeting of the World Economic Forum in Davos, switzerland, on 26 January 2012.

The Sight and Life Nutrition Leadership Award has been created to honor individuals or organizations whose work has made a significant contribution to furthering global nutrition security. Presenting the inaugural Nutrition Leadership Award to Dr David Nabarro on the day dedicated to the topic of food and nutrition security at the World Economic Forum in Davos, Klaus Kraemer said, “We are seeing a collaboration never

experienced before. Organizations, foundations, businesses, governments and civil society have come together to support the SUN movement and the countries that have signed up to it. This gives us hope, for by harnessing our individual strengths, we can create real and sustainable change.” Accepting the award, Dr Nabarro was quick to make clear that it was being made not to him as an individual but “to the thousands who have come together to make the SUN shine.” He went on to stress that development has to be sensitive to nutrition issues, as nutrition security is essential not only for individuals but also for societies. “Economic development depends on human capital development, and that depends on nutrition,” Dr Nabarro observed. “Nutrition on its own should become a new development goal as we look beyond 2015.” The Sight and Life Nutrition Leadership Award will be presented every other year. We will welcome nominations for the 2014 award in 2013. To find out more, or to make a nomination, please email info@ sightandlife.org, with the subject header Nutrition Leadership Award. For more information about the SUN movement, please visit www.scalingupnutrition.org.

Positions & Statements

Addressing Global Hidden Hunger Through Private-Public Partnership Federico Graciano DSM Nutritional Products Asia Pacific, Singapore, Singapore Martin W Bloem united Nations World Food Programme, Rome, Italy Klaus Kraemer Sight and Life, Basel, Switzerland

Introduction Despite overwhelming advances in medicine, science and technology, nearly a billion people – including 16 percent of the population of developing countries – were chronically hungry in 2010, according to the united Nations.1,2 This means that they have insufficient food to keep themselves active and healthy, and they do not get all the vitamins and minerals the body needs to function well.3 In developing countries, nearly 200 million children are chronically malnourished and undernutrition contributed to more than one-third of child deaths worldwide in 2009.4,5 In poorer nations, undernutrition affects one out of four preschoolaged children, and, among pregnant women, leads to one out of six infants born with low birth weight. Micronutrient deficiencies, also known as hidden hunger, affect 2 billion people worldwide and contribute to infections, birth defects and impaired physical and mental development. Stunting, a key indicator of chronic hidden hunger, affects about 195 million children globally.6,7

stephan Tanda helping with the distribution of enriched food at a school in Kenya, 2008.

“The impact of hidden hunger may be felt for decades, as the period from conception until 24 months of age irreversibly shapes a person’s health and intellectual ability” A long-term impact Hidden hunger is a lack or loss of dietary quality, resulting in vitamin-mineral deficiencies that diminish health, cognition, function, survival, and economic potential in individuals or populations. Hidden hunger reduces immunity, work productivity and school performance, and also slows down cognitive development and growth; lowered immunity increases illnesses and diseases,

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ADDRESSING GLOBAL HIDDEN HuNGER THROuGH PRIVATE-PuBLIC PARTNERSHIP

DSM-WFP Partnership Facts

DSM-WFP Partnership

Founded in 2007

Number of beneficiaries reached with improved nutrition

More than 10 million

Number of projects

Number of countries

Number of new products developed

Funds raised by DSM employees

€462,000

Number of DSM volunteers and secondees

Number of peer-reviewed papers published

Online nutrition tools for WFP staff

Available to 12,000 employees

which in turn increase nutrient losses and reduce appetite, further increasing vulnerability.8 The impact of hidden hunger may be felt for decades, given its effect on young-child development, as the period from conception until 24 months of age irreversibly shapes a person’s health and intellectual ability. Left unaddressed, micronutrient-deficient children may grow up unable to reach their full intellectual, physical and economic potential.9 A study by the united Nations World Food Programme (WFP) and the uN Economic Commission for Latin America and the Caribbean estimated that the cost of hunger amounts to as much as 11 percent of gross domestic product (GDP) in some countries.10 The direct cost of child and maternal undernutrition in developing countries is an estimated uS$30 billion per year.11 With such staggering challenges, public sector agencies, such as the WFP, are examining how to break the cycle of hunger at its root and develop sustainable solutions through innovative programs. Part of this solution is to establish partnerships with private industry to invest in nutrition solutions aligned with social and economic goals.12,13 Corporate evolution Since the industrial revolution, private industry has focused on finding and serving the most profitable markets. Companies have long leveraged innovations in science and technology to reduce costs and increase bottom lines and returns to shareholders. Since the late 1990s, the concept of a volume-driven market at the “bottom of the economic pyramid” has gained increasing private sector interest.14 Today, large corporations are expanding their reach to include underserved communities, with a range of products distributed through both public and private sector channels. Surveys conducted by the McKinsey Quarterly over the last few years found that executives overwhelmingly support the

idea that the role of corporations in society goes far beyond merely meeting obligations to shareholders. The global business community has embraced the idea that it plays a wider role in society. The majority of McKinsey’s executive respondents agree that generating high returns for investors should be accompanied by broader contributions to the public good.15

“Progressive companies now focus on sustainability and their contribution to the social well-being as a strategic competence in the marketplace” Enlightened corporations realize that their welfare is linked closely to that of the society where they operate, hence blurring the line between business concerns and those of society. While publicity and reputation enhancement may have once been the key objectives of corporate social responsibility (CSR) programs, progressive companies now focus on sustainability and their contribution to the social well-being as a strategic competence in the marketplace.16 A strategic business investment Approaching the social sector not as an object of charity, these companies see social problems as an opportunity for learning and business development, supported by R&D and operating funds rather than philanthropic contribution alone.17 Through this approach, companies have a stake in social problems, and treat the effort the way they would treat any other project central to the their operations, using their best people and their core skills – this is not charity, but a strategic business investment.18

ADDRESSING GLOBAL HIDDEN HuNGER THROuGH PRIVATE-PuBLIC PARTNERSHIP

Improving Nutrition – Improving Lives Over the past years, DSM has maintained a strategic partnership with the WFP to address the problems of malnutrition in the developing world. The partnership, dubbed Improving Nutrition – Improving Lives, is a program that has to date helped approximately ten million people across Nepal, Kenya, Bangladesh,

As a company that emphasizes quality assurance in process, product and service delivery as the basis of its market differentiation, DSM bases its Quality for Life™ commitment on the four pillars of quality, reliability, traceability and sustainability.20 For DSM, a company consistently among the leaders on the Dow Jones Sustainability Index, sustainability has important human development as well as environmental dimensions.

Afghanistan and other countries to enrich their lives through micronutrients.23 DSM has extended this partnership with the WFP until 2013 and will continue to provide technical and scientific support to the organization, supply food fortificants and specialty nutrition products, and will work with the WFP as it develops and rolls

“We cannot be successful, nor can we call ourselves successful, in a society that fails”

out country-specific nutrition strategies. The partnership aims to include micronutrients in WFP’s food basket for at least 80% of WFP’s beneficiaries. Under this partnership, DSM has improved the nutritional quality of blended foods such as maize soy blend, and developed a nutrition-rich blend, called MixMe™, which is provided in sachets and which can be sprinkled over prepared foods. DSM’s NutriRice™ – recomposed vitamin and mineral enriched rice kernels formed by a process that protects the micronutrients during washing and cooking – will also contribute to this program.

Critical to the corporate social innovation approach are partnerships with committed social sector organizations, and leaders who are already working on change. Companies need such partners to bring together diverse constituencies, and to assure the interests of all stakeholders are incorporated and managed appropriately. Committed social partners can also help businesses win access to underserved markets, particularly those in emerging economies and developing countries. The multinational corporation can play a key role in social enterprise, particularly in providing the capital and business resources necessary to catalyze and accelerate social innovation. In some cases, the corporate partner may be in a position to structure distribution relationships or joint venture partnerships that could accelerate access to or the success of a new venture in a market.19 Case study: Royal DSM Royal DSM is a Life Sciences and Materials Sciences company that creates solutions to nourish, protect and improve performance. Its subsidiary DSM Nutritional Products is a leading supplier of vitamins, carotenoids, and other fine chemicals to the feed, food, pharmaceutical and personal care industries. The company has a long tradition as a pioneer in the discovery of new products, formulations and applications for all industry segments.

Royal DSM CEO Feike Sijbesma links the company’s success with its humanitarian efforts, saying: “We cannot be successful, nor can we call ourselves successful, in a society that fails.” Food and nutrition industry specialists have a duty to address the pressing issue of world hunger and malnutrition. DSM commits time and expertise to humanitarian programs, including a number of projects to combat hidden hunger, through its humanitarian initiative Sight and Life and a global partnership with WFP.21,22,23 DSM’s NutriRice™ innovation, which uses reconstituted vitamin and mineral enriched rice kernels to deliver added micronutrients to consumers, can help to reduce hidden hunger in countries where rice makes up a large proportion of the staple diet.24 In 2009, the ground-breaking program won a Global Alliance for Improved Nutrition (GAIN) award for innovation, an example of how commercial expertise can be applied to humanitarian initiatives.25 The company was recognized by the united Nations at the 2011 World Business and Development Awards for its Nutrition Improvement Program, which focuses on the development of food fortification at no added cost to consumers in developing markets.26 At the ceremony, the company was commended for its innovative and targeted solutions, which are specifically designed to meet the requirements of those in the developing world suffering from hidden hunger. The hard work, however, is far from over. DSM is aware that its commitment to humanitarian initiatives must continue, if extreme world hunger and poverty are to be eradicated by the 2015 deadline set by the international community.

Correspondence: Klaus Kraemer, Sight and Life, PO Box 2116, 4002 Basel, Switzerland E-mail: klaus.kraemer@sightandlife.org

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Addressing Global Hidden Hunger Through Private-Public Partnership

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02. Bloem MW, Semba RD, Kraemer K. Castel Gandolfo workshop: an introduction to the impact of climate change, the economic crisis, and the increase in the food prices on malnutrition. J Nutr. 2010;140:132S–5S. Epub 2009 Nov 18.

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13. Bradley D. Beyond product: the private sector drive to perform with the purpose of alleviating global under-nutrition. In: Global Forum

BETTER NuTRITION FOR HALF A BILLION PEOPLE

Ten years of Innovation and Partnership:

Better Nutrition for Half a Billion People The mission of the Global Alliance for Improved Nutrition (GAIN) is to improve the lives of vulnerable populations through access to affordable, better quality, nutritious foods. While 2011 saw the 25th anniversary of Sight and Life and 50 years of the World Food Programme, 2012 is an important anniversary for another valued partner of Sight and Life. This year is GAIN’s 10th anniversary. The alliance is proud to be reaching over half a billion people worldwide, including 253 million women and children. The GAIN partnership model GAIN works to reduce malnutrition by improving the effectiveness of markets to reach low-income consumers. It mobilizes public-private partnerships to implement innovative and sustainable market-based solutions at scale. The partnership model that GAIN pioneered in the nutrition sector has been recognized by the Stanford Social Innovation Review as a model of collaboration that achieves large-scale progress in the face of the urgent and complex problems of our time, as detailed at http://www. gainhealth.org/about-gain/channeling-change-making-collective-impact-work.

“GAIN works to reduce malnutrition by improving the effectiveness of markets to reach low-income consumers” Entrepreneurs – including farmers, storage and transport businesses, food processors and retailers – are the key to producing more nutritious foods and delivering them to all segments of the market. However, the involvement of governments is also necessary to set standards and ensure quality through appropriate legislation and regulation. GAIN works with both business and government; its programs include large-scale food fortification; maternal, infant and young child nutrition, improved agricultural practices to enhance nutrition; and advocacy to effect policy change. In its effort to optimize access to

nutritious foods, GAIN uses different program delivery channels, from market-driven approaches to hybrid models that combine commercial approaches and subsidized programs. Maximum nutrition benefit An example of a GAIN-supported partnership is a project in India, whereby GAIN supports AP Foods to expand its production capacity and improve the formulation of foods and supplements distributed to more than 2 million children. As part of this initiative, AP Foods has taken the significant step of removing unhealthy fats, “trans fats”, from all of its products. In Bangladesh, meanwhile, GAIN partners with the pharmaceutical company Renata Ltd, the non-governmental organization BRAC, Social Marketing Company (SMC) and uSAID to develop and market small sachets of multi-nutrient powders to be used, in conjunction with complementary foods and breastfeeding, to improve the nutrition of infants aged six to 24 months. Millions of sachets have been sold. Studies are under way to sharpen understanding of how they can be best used to bring maximum nutrition benefit to vulnerable households. The Amsterdam Initiative against Malnutrition (AIM) is a coalition of Dutch public- and private-sector organizations, which joined with GAIN in order to end malnutrition for 100 million people in Africa. The coalition includes AkzoNobel, DSM, GAIN, the Government of the Netherlands, Interchurch Organization for Development Cooperation, unilever and Wageningen university. The first AIM project will be implemented in Kenya and will explore a number of options for fortifying the milk consumed by Kenyan children. As it enters its second decade, GAIN is playing an increasingly important brokering role, bringing governments, the private sector, international organizations and academia together in innovative partnerships that can make a real dent in global malnutrition.

To find out more, go to GAIN’s website: www.gainhealth.org

Sharing knowledge for improved nutrition.

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The 1 International Conference on Nutrition and Growth (N&G) st

March 1 – 3, 2012 – Paris, France Klaus Kraemer Sight and Life, Basel, Switzerland

Following the success of the pediatric workshop on nutrition and growth, which was held in Prague in 2010, the 1st International Conference on Nutrition and Growth (N&G) 2012 brought together some 1,200 pediatricians, nutritionists, neonatologists, experts in child development and other specialists to discuss the challenges of the interplay between nutrition and growth of infants and children. The objective of the meeting was to enable the exchange of ideas and knowledge among the different disciplines related to the following topics: > Early nutrition and later growth > Nutrition and growth in childhood and adolescence > Optimal growth of premature infants > The optimal diet for infants born small for gestational age (SGA) > Nutrition and the hormonal system > Macro- and micronutrients > Catch-up growth > Nutrition and growth in children suffering from chronic diseases

> Nutritional supplements > Nutrition and growth during growth hormone therapy > Obesity and growth during childhood and puberty > Vitamins and the hormonal system > Nutrition and diabetes > Early nutrition brain development and cognition

The conference’s structure incorporated parallel, plenary, sponsored plenary, oral and poster sessions. The significant presence of all major infant nutrition companies through sponsorship of sessions and exhibits might explain why nutrition and growth in developing countries was sadly, with a few exceptions, not in the limelight at the conference. However, a considerable amount of information was presented that was of relevance to low- and middle-income countries.

“Wasting, stunting and micronutrient deficiencies are responsible for about one third of all child deaths globally” Child growth indicators Wasting, stunting and micronutrient deficiencies increase the risk of death from various diseases, and are responsible for about one third of all child deaths globally. Infant and child growth is an early indicator, before other malfunctions appear, according to Carlo Agostoni of the Institute of Pediatrics at the university of Milan, Italy. Growth is more sensitive as an indicator of health than is commonly believed. Normal growth depends on energy, protein and micronutrient intakes. Growth failure, particularly in developing countries, is related to mortality, morbidity and impaired brain development, and increases the risk of adult onset non-communicable diseases (NCDs) (Figure 1). Low birthweight (LBW) and stunting (short stature) of infants and young children reduces adult human capital, including

1 ST INTERNATIONAL CONFERENCE ON NuTRITION AND GROWTH

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figure 1: Nutrition, growth and health throughout the lifespan

Growth –> Length –> Weight

Nutrition –> Protein –> Fat –> Carbohydrates –> Micronutrients

Health /disease outcomes –> Mortality –> Morbidity –> Cognition –> Non-communicable diseases

Lifespan –> Lifecycle

poorer cognition, behavioral problems, earlier drop-out from school and reduced income potential. In pooled analyses of five birth cohorts from low- and middle-income countries, weight gain during the first two years of life, followed by birth weight, had the strongest predicting value for schooling attainment. Insulin-like growth factor-1 (IGF-1) Moshe Phillip, of Schneider Children’s Medical Center of Israel, provided a perspective on endocrinology and growth outcomes. Linear growth and skeletal development are dependent on growth hormone (GH) signaling and action. GH primarily exerts its growth effects by regulating the expression of IGF-1

(Figure 2). The formation and release of GH from the pituitary gland is stimulated by growth hormone releasing hormone (GHRH), and inhibited by somatostatin. GH and IGF-1 are important in the regulation of bone mineral accrual and skeletal growth. Although the exact mechanism of IGF-1 on growth is not fully understood, IGF-1 appears to stimulate the differentiation of chondrocytes at the growth plate (epiphysis). Children with Crohn’s disease typically have impaired growth and low IGF-1 levels. Martin Savage of the William Harvey Research Institute, London explained why chronic inflammation, such as Crohn’s disease, in childhood is commonly followed by growth retardation and osteoporosis. Proinflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) are often elevated in such conditions. Improvement of the disease status is often associated with an improvement in growth and skeletal health. This underscores the importance of the concurrent control of malnutrition, infection and inflammation. Milk appears to stimulate linear growth. However, it is not clear which milk components are important. Possible components include proteins, minerals, vitamins or combinations of these. The underlying mechanism for the growth-stimulating effect of milk may be through the stimulation of IGF-1 formation.

“Early malnutrition may have long- lasting effects on the development of obesity and NCDs in adulthood and old age” Early nutrition and risk of adult disease Berthold Koletzko of the Dr von Hauner Children’s Hospital, Munich, Germany reviewed early nutrition, child growth and later obesity and NCD risk. There is increasing evidence that early malnutrition, particularly during the critical 1,000 days window of opportunity – from conception to two years of age – may have long-lasting effects on the development of obesity and NCDs in adulthood and old age, in particular type 2 diabetes, obesity, hyperlipidemia, hypertension, and cardiovascular disease (Figure 3). The NCD risk is compounded by catch-up growth (accelerated growth following a period of growth faltering, caused by malnutrition or illness) during childhood.

N&G Conference participants.

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1 st International Conference on Nutrition and Growth

figure 2: The growth hormone / insulin-like growth factor 1 axis (GH/IGF1 axis) in human growth Liver

Peripheral

JAK2 P

PI3K/AKT Ras/MAPK STAT1, 3, 5a

JAK2 Y Y

JAK2

P P

Endocrine

Y Y

P P

Autocrine Paracrine

IGF

IGF-1-IGF-1R axis

JAK2

PI3K/AKT Ras/MAPK STAT

STAT5b

IGFBP-3 ALS

Cytokines Growth factors

IGF dependent

IGF independent

Growth

Solid arrows: activation processes; dotted arrows: translocation processes. AKT: v-akt murine thymoma viral oncogene homolog, also known as PKB, or protein kinase B; P: phosphorylated residue; Y: tyrosine. Adapted from David A et al. Endocrine Reviews 2011;32:472.

This is based on the original Barker hypothesis of the developmental origin of health and disease (DOHaD). Increasing numbers of studies suggest that dietary factors affect different mechanisms in the early critical developmental phases, which are able to increase susceptibility to several diseases in adulthood, including: > Epigenetic changes (regulation of gene expression, e.g., through methylation)

> Altered organ structure (e.g., vascularization) > Changes in cell numbers (hyperplasia, hypertrophy) > Clonal selection (disproportionate growth of specific cells) > Metabolic differentiation (e.g., enhanced metabolic activity)

There is huge potential to use this knowledge to significantly improve public health and well-being and to reduce the double burden of disease. For example, feeding high protein infant and follow-on formulas during the first year of life is associated with rapid weight gain and an increased risk of adiposity, with a gender bias against girls. This is supported by the observation that breastfed children (breast milk is typically lower in protein than conventional formulas) have lower weight at one year of age and at school age.

“Many people in developing countries experience dramatic seasonal fluctuations in nutritional status, as a consequence of food availability during the wet and dry seasons” New exciting epigenetic data were presented by Andrew Prentice of the London School of Hygiene and Tropical Medicine, London, UK. Many people in developing countries experience dramatic seasonal fluctuations in nutritional status, as a consequence of food availability during the wet and dry seasons. This may also be reflected in seasonal epigenetic changes. Indeed, DNA methylation was elevated in Gambian individuals who were conceived during the nutritionally challenged rainy season. Malnutrition usually increases through the dry season and declines slowly with the coming rain. In another study, the response to a periconceptional multiple micronutrient supplement with 14 vitamins and trace ele-

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1 ST INTERNATIONAL CONFERENCE ON NuTRITION AND GROWTH

Ricardo Uauy of the Institute of Nutrition and Food Technology (INTA), santiago, Chile and Berthold Koletzko of Dr von Hauner Children's Hospital, Munich, Germany, at the 1st International Conference on Nutrition and Growth 2012.

ments (uNIMMAP) on DNA methylation was assessed. Analysis of cord and infant DNA at nine months revealed complex time- and sex-dependent methylation changes in response to the supplement. Micronutrient supplementation during early pregnancy resulted in (1) DNA demethylation, and may program gene activity in later life, (2) little overlap between male and female methylation patterns, and (3) significant postnatal changes. Primarily, genes encoding immune, cancer, cardiovascular, neurological, diabetes, lipid metabolism, myogenic and occular functions, as well as obesity, were affected. Although the study was carried out on a small sample, it suggests new approaches in public health nutrition. This is likely to increase our understanding of the importance of early nutrition interventions targeting the critical period from conception to two years to improve public health and well-being.

â&#x20AC;&#x153;Human milk is inimitably suited to meeting nutrient requirements and to supporting the growth and development of breastfed infantsâ&#x20AC;?

figure 3: Factors related to the development of obesity and non-communicable diseases (NCDs). Adapted from Koletzko B et al. Am J Clin Nutr 2011;94:2036S

Genes and environment

Fetal overnutrition e.g. maternal obesity, high pregnancy weight gain, diet in pregnancy, gestational diabetes

Obesity/visceral obesity, metabolic syndrome, diabetes, hypertension, cardiovascular and other diseases, asthma

Postnatal nutrition and growth e.g. lack of or short breastfeeding, over feeding, excessive protein intake

Fetal undernutrition and low birth weight e.g. maternal nutritional imbalances, placental dysfunction

1st International Conference on Nutrition and Growth

Nutritional lipids and other components of breast milk The composition of human milk makes it inimitably suited to meeting nutrient requirements and to supporting the growth and development of breastfed infants. Sheila Innis of the Nutrition and Metabolism, Child and Family Research Institute, Vancouver, Canada presented intriguing data on nutritional lipids and overlapping functions with other nutrients such as lutein, choline and taurine. Significant attention has been given to adapting the fatty acid profile of breast milk, and to investigating the role of individual fatty acids, such as docosahexaenoic acid (DHA, C22:6 n-3), in infant and young child visual and neurologic development. Less emphasis has been placed on specific aspects of human milk triglyceride biosynthesis. Human milk triglycerides have, preferably, palmitic acid (C16:0) at the sn-2 position of the glycerol backbone, while unsaturated fatty acids are esterified to the sn-1 and sn-3 positions. Other human tissues and vegetable oils typically have palmitic acid at the sn-1 and sn-3 positions and an unsaturated fatty acid at the sn-2 position. This unique structure protects the release of palmitic acid as a free fatty acid in the infant intestine, and thus avoids the formation of

insoluble soaps, which may cause stool hardening and reduce calcium absorption for bone mineralization. The carotenoid lutein has recently been reported to have overlapping roles with DHA. Lutein supplementation increases macular pigment density eccentrically, while DHA increases pigment in the central area of the macula, indicating that both nutrients are important in the prevention of age-related macular degeneration. Similar observations have been made for the accumulation of DHA and lutein in the brain.

Correspondence: Klaus Kraemer, Sight and Life, PO Box 2116, 4002 Basel, Switzerland E-mail: klaus.kraemer@sightandlife.org

International Congress Hidden Hunger: From Assessment to Solutions March 6 – 9, 2013 University of Hohenheim, Stuttgart, Germany The Hidden Hunger International Congress has three objectives: 1. To bring to light and create awareness of the global problem of Hidden Hunger 2. To broaden the discussion of scientific issues into the realm of policy-makers and the public 3. To discuss and document the reasons for, consequences of and solutions to worldwide micronutrient deficiencies Scientists from different areas, field workers, members of non-governmental organizations (NGOs) and representatives from the fields of administration, management and policy will be invited to discuss this topic.

Keynote lectures will be given by Lindsay Allen, Joachim von Braun, Parul Christian, Adam Drewnowski, Timothy Johns, Eileen T Kennedy, Berthold Koletzko, Ruth K Oniang’o, Mercedes de Onis, Ingo Potrykus, Matin Qaim, Patrick Webb, Keith West and others

Contact: Department of Biological Chemistry and Nutrition, University of Hohenheim, Garbenstrasse 30, D-70593 Stuttgart, Germany Tel.: +49 (0)711 459 23822 E-mail: hiddenhunger@uni-hohenheim.de For further information, please read https://hiddenhunger.uni-hohenheim.de

Growing the evidence base for micronutrients.

Report from Muhimbili Report on Evaluation of Implementation of WHO’s 10 Key Eye Health Activities in Dar es Salaam Milka Mafwiri Muhimbili university, Dar es Salaam, Tanzania

In September 2010, following completion of my coursework and dissertation, I finished my MSc in Community Eye Health (CEH) at the London School of Hygiene and Tropical Medicine. I would like to take this opportunity to sincerely thank my sponsors, who enabled me to attend the course and undertake my dissertation work. I have returned to Tanzania, assuming my responsibilities as a lecturer at Muhimbili university and an ophthalmologist at Muhimbili National Hospital. I also coordinate the Childhood Blindness Prevention Initiative at Muhimbili, and the Vision 2020 links program between Muhimbili and Guys-St Thomas Hospital, uK. Knowledge and practices My dissertation topic was “The evaluation of WHO’s 10 Key Eye Health Activities for prevention of blindness in children among reproductive and child health (RCH) staff in Dar es Salaam.” The study involved an assessment of the knowledge and practices of primary level staff in RCH clinics before and after training, and the provision of educational materials. Sight and Life supported the production of training materials (including posters and manuals) for this work. Due to time constraints, a post-training assessment was only carried out three weeks after training. As this period of time was too short for firm conclusions to be drawn about changes in knowledge and practices attributed to the training provided, a follow-up study was planned.

Project workers at a training session supported by Sight and Life.

“Thirty newly recruited RCH workers from 15 RCH clinics underwent a pre-training assessment, and have already been trained in and provided with educational materials on 10 Key Eye Health Activities”

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REPORT FROM MuHIMBILI

“In this preliminary report, I would like to express my gratitude to Sight and Life for their grant, which has enabled me to conduct this study”

The project team after training with posters of WHO’s 10 Key Eye Health Activities.

Sight and Life again contributed towards the completion of this follow-up study, depositing the funds in the Childhood Blindness account in March 2011. The study involved a post-training assessment of the knowledge and practices of the initial 15 RCH workers, eight months after training. An additional 30 newly recruited RCH workers from 15 RCH clinics underwent a pre-training assessment, and have already been trained in and provided with educational materials on 10 Key Eye Health Activities. Implementation strategies The results of this pilot study will be used by eye care stakeholders to plan strategies for the prevention of blindness in this country’s children. The poster from this work has already been accepted by the Ministry of Health and Social Welfare for use in all RCH clinics. At the end of the study, a report will be shared between the London School of Hygiene and Tropical Medicine, Sight and Life and Sightsavers.

The project team holding 10 Key Eye Health Activities manuals after training at Muhimbili University of Health and Allied sciences, Tanzania.

In this preliminary report, I would like to express my gratitude to Sight and Life for their grant, which has enabled me to conduct this study. I also appreciate the continued support of my supervisor, Prof. Clare Gilbert, and her team. I would like to share my enthusiasm for my work on RCHs. It is my wish to pursue this, in the hope that a number of children with potentially blinding conditions will be prevented from becoming blind.

Correspondence: Dr Milka Mafwiri, Muhimbili University of Health and Allied Sciences, Childhood Blindness Prevention Initiative, PO Box 65000, Dar Es Salaam 65405, United Republic of Tanzania E-mail: mmafwiri@yahoo.com

REPORT FROM BuRKINA FASO

Report from Burkina Faso The Healthy Eyes Activity Book Helps Spread the Word on Malnutrition and Hygiene Maxime Wysocki FuDOS, Ouagadougou, Burkina Faso

After taking my diploma in tourism, I decided to travel to Burkina Faso in order to build a sustainable tourism agency, which could create income in this very poor country. While I was preparing for my travels, I asked the library in my village to donate some books. In the meantime, I met the team from Sight and Life and asked them if they could help me to donate some educational materials to primary schools in Burkina Faso. Team spirit After spending two months traveling through Spain, Morocco, Mauritania, Senegal and Mali, I met up with Pascal, the president of a non-governmental organization (NGO) called Frères unis pour le Développement et les Œuvres Sociales (FuDOS). Pascal was to work with me on my project in Ouagadougou. We travelled further south in Konnékongo, where I started up a little library in the primary school. In Ouagadougou, I gave some English lessons and tried to help some schoolchildren with their work. After meeting with many school teachers, I began to distribute the Healthy Eyes Activity Book (HEAB). I did this with the support of the association and other NGOs, as I had no transport back-up, and experienced for myself the team spirit which is the key to living in this country. My work met with a great deal of interest from the city’s schools, as well as those in the South. After reading the HEAB, Jérôme Kaboré, president of the Association Nationale des Enseignants du Primaire (ANEP) was enthusiastic and proposed his help. Thanks to this new collaboration, I reached 13 regions, handing out just one book per teacher. As a result, the message about malnutrition and hygiene was spread across the country. I continued to contact many people in order to create an itinerary for tourists, with the remuneration for the night stays being paid directly to the NGOs in various little villages.

In Konnekongo the schoolchildren await the distribution of the Healthy Eye’s Activity Book.

Sustainable travel During this six-month-long trip, I experienced the team spirit of the Burkinabés. I met up with many people who were interested in helping to spread Sight and Life’s messages, in addition to being prepared to help me build a new sustainable travel agency and thus permit villages to receive an income. I would like to thank Sight and Life very much for providing me with educational materials and hope to return there very soon in order to develop our relationship further.

Correspondence: Maxime Wysocki, FUDOS, Ouagadougou, Burkina Faso E-mail: maxime.wysocki@gmail.com

REPORT FROM THE DOMINICAN REPuBLIC

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Report from the Dominican Republic Fighting Preventable Blindness Faith A Hayden EyeWorld, uSA

Over the past decade, Dr Kosoko-Lasaki, professor of ophthalmology surgery and glaucoma specialist, Creighton university, uSA, has traveled to the Dominican Republic (DR) to address vitamin A deficiency (VAD) and glaucoma, two major areas of public health concern. Creighton university has a medical mission program based in both Omaha, uS, and the DR called ILAC, or the Institute for Latin American Concern, which began in 1973. When Dr Kosoko-Lasaki heard of villagers with night blindness, an early sign of VAD, she knew she had to act. With the help of numerous organizations, including ILAC, the World Health Organization, and Sight and Life, she traveled to the DR in the early 2000s for her first vitamin A intervention. During VAD interventions, Dr Kosoko-Lasaki administers vitamin A, donated by Sight and Life, to children between the ages of three and 10, as well as lactating mothers and pregnant women in the second and third trimester. In recent years, Dr Kosoko-Lasaki has expanded her charity work in the DR to encompass glaucoma screening and surgery, as well. Dr Kosoko-Lasaki’s last trip to the Dominican was in March 2011, for six days, four of which were dedicated to glaucoma sur-

gery. She brought with her Rebecca Batt, a certified ophthalmic assistant, who took patient pressures and performed reading exams, and Brett Briggs, a Creighton student, who coordinated the glaucoma screening process, visual field, and visual acuity. An underserved nation “We saw upward of 250 people,” said Mr Briggs. “People hear there’s an American doctor coming and they travel from far and wide. The DR is very underserved. People just don’t have the money to see an ophthalmologist. A lot of these patients are risking losing their jobs by taking time off work to see a doctor.” The team was able to cover a tremendous amount of ground. It performed 120 adult eye exams and found 41 existing cases of glaucoma, seven new cases of glaucoma, and 13 instances of other ocular diseases. It administrated vitamin A to 117 children, educated 30 cooperadores in vitamin A and ocular health, and performed 12 laser glaucoma surgeries and one trabeculectomy.

“Awareness is what is needed for glaucoma. When people are aware, they want to be treated” Dr Kosoko-Lasaki plans on continuing to donate her time in the DR, saying that she has seen improvements in the country’s glaucoma care over the years. “Patients are aware, and the clinic is very busy,” she said. “Awareness is what is needed for glaucoma. When people are aware, they want to be treated.”

Dr Kosoko-Lasaki demonstrates correct eye examination technique to a group of “cooperadores” in the Dominican Republic, March 2011.

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REPORT FROM THE DOMINICAN REPuBLIC

Dr Leopoldo Carretero administers a dose of vitamin A to a malnourished child in the Dominican Republic, March 2011.

She would like to see doctors focus more of their volunteering on glaucoma, however, noting that it is the second most common cause of blindness in the world. ”Attention hasn't been directed to that area because of the difficulty of managing the disease,” she said. “The medications are expensive. Patients in the DR have access to medications, but if someone gives it out for free one or two times – a medication that patients are supposed to take for the rest of their life – at what point do they stop giving it for free? That’s the challenge.”

Editor’s note: This is an abridged version of an interview published in EyeWorld, the Newsmagazine of the American Society of Cataract and Refractive Surgery. The full version can be downloaded at www.eyeworld.org/ article-fighting-preventable-blindness-in-the-dominican-republic Correspondence: Sade Kosoko-Lasaki, Creighton University, 2500 California Plaza, Omaha, Nebraska 68178, USA E-mail: SadeKosoko-Lasaki@creighton.edu

Promoting partnerships and capacity building.

REMEMBERING LOIS ENGLBERGER

Remembering

Lois Englberger (1949 – 2011) Harriet Kuhnlein Centre for Indigenous Peoples’ Nutrition and Environment and School of Dietetics and Human Nutrition, McGill university, Montreal, Canada

Following her death in September 2011, Dr Lois Englberger has been sorely missed by the many who appreciated her excellent work and community perspective and commitment. Since 1977, Lois lived in Pohnpei, the Federated States of Micronesia (FSM). She was a guiding light for the Island Food Community of Pohnpei (IFCP), a community organization with local leaders that promotes the use of local, indigenous food. During her career, Lois was a consultant with the Food and Agriculture Organization of the united Nations (FAO), the Asian Development Bank and the university of Hawaii’s Department of Food Science and Human Nutrition. She worked in India, the Kingdom of Tonga, Colombia, yemen and several Pacific island nations. She served as a supervisor for many local Micronesian students and graduate students from uS and Canadian universities. She was a champion of local food research and promotion. Pacific island food research Lois’s doctoral work stimulated her journeys into the realm of local Pacific island foods with research on their nutrition composition and potential to improve micronutrient nutrition. Probably her best known work was with the Karat banana and numerous other local banana cultivars in the Pacific. She was a scientist of the first order, making meticulous sampling and analyses strategies, and carefully crafted manuscripts describing the scientific qualities of unique island foods. She and IFCP colleagues worked with the Centre for Indigenous Peoples’ Nutrition and Environment (CINE) to demonstrate the rich biodiversity in more than 380 food species on the Island of Pohnpei. Her scholarship was recognized and sought by many journals and other publications and collaborators. Lois was a long-term collaborator with Sight and Life. In addition to grants for nutrition education programs in Micronesia, and facilitating food analyses that resulted in a number of joint

publications, Sight and Life sponsored a video, “Going yellow.” In 2006, Sight and Life visited Pohnpei to produce a film entitled “Battling the double burden of malnutrition.” The film highlights the concurrent public health scourge of infectious disease and vitamin A deficiency and upsurge in chronic disease, such as diabetes, from obesity and overweight in the Pacific. Without Lois’s tireless support, this project would have never been completed. Her work with local leaders and partners within the IFCP has been internationally celebrated. Her wizardry in networking within the FSM, as well as the health community throughout the Pacific, resulted in the famous “Let’s Go Local” slogan, and the culture, health, environment, economy, food security (CHEEF) benefits of local foods. A tireless advocate Lois was gentle, modest and kind, but also energetic, enthusiastic and determined when she believed a cause was just. She was a tireless network promoter and advocate. Her work has influenced many decision-makers and policy advocates worldwide for public health nutrition interventions that build on local nutrient-rich foods. Lois was noted in 2006 and 2007 by Pacific Magazine as among the Pacific Leaders. It was her wish to encourage continued support for the outstanding work of the Island Food Community of Pohnpei.

Correspondence: Harriet Kuhnlein, Centre for Indigenous Peoples’ Nutrition and Environment and School of Dietetics and Human Nutrition, McGill University, Montreal, 1204 6th Street, Anacortes WA, 98221, Canada E-mail: harriet.kuhnlein@mcgill.ca

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“ It was Lois’s wish to encourage conti nued support for the outst anding work of the Isl and Food Community of Pohnpei ”

Lois Englberger (1949 – 2011)

THE PHIL MuSGROVE LEGACy FuND

The Phil Musgrove Legacy Fund

A Drive to Increase Access to the Legacy of Philip Musgrove George Alleyne, Robert Hecht, Anthony Measham, Elinor Schwartz, Ricardo Bitrán Steering Committee Members, Philip Musgrove Legacy Fund

Philip C Musgrove (1941 – 2011)

Phil’s impressive accomplishments helped to shape the field of health economics through his work at the Pan American Health Organization, the World Bank, and the World Health Organization. As an editor at Health Affairs, and for the Disease Control Priorities Project, his contributions to substance and style added greatly to his stellar reputation as an author. Phil lectured around the world, brilliantly conveying his insights on key health policy issues. Teaching at Johns Hopkins and elsewhere, his clear expression of complex concepts inspired a generation of graduate students to enter the field.

“Phil lectured around the world, brilliantly conveying his insights on key health policy issues”

An intellectual legacy The Philip Musgrove Legacy Fund will complement several efforts to honor Phil’s memory and increase access to his intellectual legacy. The World Bank has agreed to co-sponsor an annual lecture and an award in Phil’s name, with matching support from the Fund. The Fund will be used to translate his book, Health Economics in Development, into Spanish and Portuguese, and to assist a Brazilian group collecting Phil’s unpublished writings and speeches for a book on health economics in Brazil. The Fund will establish a website to post Phil’s biography, bibliography, links to his writings and notices of events in his name. Its steering committee would therefore be grateful for contributions to make these efforts possible, and can be contacted via the Results for Development Institute for further information.

Editor’s note: Sight and Life published the obituary of Philip Musgrove in its 02/2011 issue. Published at the request of the Results for Development Institute, this is an abridged version of a letter sent to Sight and Life in November 2011, which can be accessed at www.resultsfordevelopment.org

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WHAT’S NEW

Harnessing Innovation to Provide Solutions The White House recently hosted an event to explore how government and the private sector jointly promote science and technology innovations to advance global development. One of the projects to be recognized was a partnership between Scientists Without Borders, DSM and Sight and Life. The partnership has issued a challenge to find innovative ideas for more sustainable packaging for micronutrient powders (MNPs), which is one of the most widely distributed and cost-effective nutrition interventions in resource-poor settings. Given that two thirds of the current cost of production of MNPs is attributable to their packaging, and that 200 to 300 million MNPs are distributed a year, the current foil packaging creates significant waste. A new delivery mechanism could dramatically reduce waste and make MNPs more cost effective, thus potentially increasing their availability to the world’s poor. Scientists Without Borders, the Sackler Institute for Nutrition Sciences at the New York Academy of Sciences, DSM and Sight and Life will sponsor a prize of at least $25,000 (US) for the most innovative ideas. Dr Klaus Kraemer, Director of

Sight and Life, said: “We are excited to work towards more innovative and sustainable approaches to tackling malnutrition. We hope to eventually better reach millions of people with MNPs which will not only improve their lives but will also have a less detrimental effect on the environment.”

Scientists Without Borders: Scientists Without Borders is a public-private partnership led by the New York Academy of Sciences. This web-based collaborative community generates and advances innovative and effective science and technology-based solutions to the world’s most pressing global development challenges. Its unique model leverages a free online platform to connect a worldwide group of cross-disciplinary, multi-sector users to develop and openly share concrete and effective solutions to these challenges. For more information, please visit: www.scientistswithoutborders.org

Gates Views Both Nutrition Security and Food Security as Key

Every year, Bill Gates, the Chairman of the Bill and Melinda Gates Foundation, writes an open letter, in which he examines issues that he believes need to be addressed in plans, projects and programs relevant to the work of the Foundation. The Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and on giving them the chance to lift themselves out of hunger and extreme poverty. Agricultural investment as a way of addressing poverty and food security is a topic of

discussion in almost all forums. It is therefore not surprising that his 2012 letter has a strong focus on the need for innovation in agriculture – especially at the “small farmer” level. Mr Gates uses the story of a Tanzanian farmer, Christina Mwinjipe, to make his message clear. The good news is that nutrition security is also recognized: “The lack of adequate nutrition is a key reason why poor children so often die of diseases like diarrhea, that richer and better-fed children are able to fight off. Poor nutrition in childhood also prevents the develop-

WHAT’S NEW

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ment of both the brain and the body, severely and irreversibly limiting children’s ability to grow, learn, and become healthy, productive adults.” The world is beginning to recognize that food security and nutrition security have to go hand in hand if we are to truly improve the lives of the most vulnerable.

To read the full letter, go to: www.gatesfoundation.org/annual-letter/2012/Pages /home-en.aspx

Australia Salutes a Global Nutrition Champion

Ian Darnton-Hill: Recognized for his distinguished service to the international community.

Ian Darnton-Hill, a well-known figure in global child health and nutrition, was recently made an Officer in the General Division of the Order of Australia. This highly deserved acknowledgement rewards Ian’s distinguished service to the international community, particularly in the areas of public health and nutrition, towards disease prevention and health promotion and as a physician, academic and educator. For many in the nutrition field, Ian is best known for his nu-

merous leadership roles within UNICEF. However, he has also served on numerous committees, panels, expert groups and editorial boards, and has published widely. His most recent publications are as co-author of “Maternal and young child nutrition adversely affected by external shocks such as increasing food prices” in the 2010 Journal of Nutrition, co-author of “Maternal and child undernutrition: effective action at national level” in the 2008 Lancet series on Maternal and Child Undernutrition and as co-author of a chapter entitled “Global perspectives towards accelerating progress on preventing and controlling nutritional anemia” in Nutritional Anemia, published by Sight and Life.

Sight and Life would like to take this opportunity to congratulate Ian on this recognition and to thank him for his contributions, not only to the work of Sight and Life but also to global nutrition and public health.

World Food Programme Appoints New Executive Director The World Food Programme (WFP) has announced that, in April 2012, Executive Director Josette Sheeran is leaving at the end of her term of office to take up the position of Vice Chair of the World Economic Forum (WEF), where we hope she will continue to serve as an esteemed advocate for nutrition. Her post will be filled by Ertharin Cousin of the United States. Ms Cousin has over 25 years of national and international corporate, non-profit and government leadership experience, and is currently the US Representative to the UN agencies that

have food and agriculture mandates (the Food and Agriculture Organization, or FAO, and the WFP). Ms Sheeran has ably steered the WFP in its transformation from a food aid to a food assistance agency, with a clear focus not only on filling hungry bellies but also on ensuring that the right nutrients are part of the equation. She has been using a red cup as a visual tool to emphasize that it is important not just to fill the cup with food, but to make sure that it contains the right kind of nutrients for a child to

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live and thrive. “Leading WFP is a great honor and a critical link to the world’s most vulnerable,” she said, following the announcement of the new appointment. We, as the global nutrition community, look forward to welcoming Ms Cousin and continuing the journey towards the global eradication of hunger and malnutrition.

Ertharin Cousin, who replaced Josette sheeran as Executive Director of WFP in April of this year.

New FAO Chief Begins His Term

José Graziano da silva, eighth Director-General of the Food and Agricultural Organization of the United Nations (FAO), at the “Ensuring Food security” session at the Annual Meeting of the World Economic Forum, Davos on January 26 2012.

January 2012 saw José Graziano da Silva take over the reins of the Food and Agricultural Organization of the United Nations (FAO). Da Silva is a former Brazilian minister and steered the acclaimed Zero Hunger program in his home country. The program helped lift 24 million Brazilians out of extreme poverty over a span of five years, and also helped reduce malnutrition by 25%. If his success in Brazil is anything to go by, we can look forward to a time of focus and action. At Sight and Life, we appreciate his dedication to issues related to rural development and fighting hunger at various levels, including academia, politics and organized labor, and his commitment to further governance reform and decentra-

lization at FAO and more “South-South cooperation” between emerging economies. At the WEF in Davos in January 2012, da Silva was a panelist in a session entitled “Ensuring Food Security.” He highlighted a key challenge for the world going forward as being how to combine the two agendas of climate change and food security. We applaud his desire to move from talk to a phase of action, which includes all levels, from civil society to governments, and the need to ensure synergy between different programs – the breaking down of the traditional silos that we have worked in. We look forward to his energy, dynamism and understanding of the important role of nutrition, bringing food and nutrition security together.

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Scaling Up Rice Fortification in Asia

A field of rice. DsM’s additional $1 million donation to the WFP supports rice fortification activities in southeast Asia.

As the issue of nutrition and the need to scale up successful interventions was being discussed at the WEF in Davos, DSM announced an additional $1 million donation to the WFP to support rice fortification activities in Southeast Asia. This donation will help to lay the foundations for introducing fortified rice into WFP’s food basket, with the aim of improving

the nutrition of 4 million people. Feike Sijbesma, Chairman of the Managing Board of DSM, stated that “this represents another step forward in our partnership with WFP and by joining forces, and focusing on cost-effective, sustainable solutions, together we can make a real difference in tackling the global nutrition challenge and improving lives.” Josette Sheeran, Executive Director of the WFP, noted that: “DSM’s philanthropic vision of enhancing nutrition for the hungry poor is inspiring and we are proud to work with a partner that continues to bring such innovation into the fight against hunger. With almost one billion people going to bed hungry every night, it is more important than ever before that we leverage private sector expertise to provide vulnerable populations with the right food at the right time.” Ms Sheeran’s comment highlights the importance of finding ways for the private sector and UN agencies to work together. The donation, which will support rice fortification policy and program development, will also include an in-kind donation of NutriRice™, a fortified rice kernel containing essential micronutrients, which can be mixed in with regular rice, with no change to taste or color.

Feeding the World – the 9 Billion People Question You know that nutrition is on the radar when it is featured in distinguished publications such as The Economist. This is what happened in the February issue of the magazine, in the shape of a feature entitled “The Nutrition Puzzle: Why do so many people in poor countries eat so badly –and what can be done about it?” (www.economist.com/node/21547771). The feature formed part of The Economist’s “Feeding the World: The 9 billion question” focus in 2012, which was launched with an inaugural summit in Geneva attended by 200 senior executives from 25 countries and all continents. This year, discussions are to continue with events in different regions around the world. The aim is to deliver fresh insights into solving the critical food challenges, by providing a platform for

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the views and experiences of progressive experts from the fields of agribusiness, policy, international agencies, science and the non-governmental organization (NGO) community. Some of the key discussions at the Geneva summit centered on the role of public-private partnerships as a key mechanism for advancing agriculture in order to meet global challenges in food security. However, it is increasingly being acknowledged that, without also addressing nutrition security, food security will do little to truly solve the hunger problem or the challenge we face of feeding the 9 billion people who are expected to make up the world’s population by 2050.

It is critical that the nutrition community keeps reminding the world of the vital role that nutrition plays, when it comes to addressing many of the development and poverty challenges. Now is our moment! Those living and working in Africa should note in their diaries that the next event in the Feeding the World series will take place in Johannesburg, on November 15 and 16 this year.

More on the Geneva Summit can be found at: http://cemea.economistconferences.com/event/feeding-world

Online Resources

Interactive 1,000 Days map.

Many of us working in the field of public health nutrition are constantly on the look-out for the latest resources and research, so that we can use them as a source of information and tools to convince others as we work towards a world free from hunger. In the last few years, the issue of child malnutrition has garnered increased attention across the global health and development sectors. This has led to a growing body of evidence that makes the case that investing in better nutrition during the 1,000 day window can save lives, improve health and drive long-term economic growth. The 1,000 Days: Change a Life, Change the Future initiative has a website that is worth saving as a favorite and revisiting often. The initiative also recently launched two new online tools. The first is a resources library, which is designed as a

“one-stop-shop” for advocates, policy-makers, opinion leaders and, indeed, anyone interested in learning more about the power of 1,000 days. The library is a collection of must-have and must-read research papers, publications, presentations and info-graphics from cross-cutting fields. The second is an interactive 1,000 Days map, entitled “Mapping the Window of Opportunity.” The map explores the global challenge of child undernutrition, and opportunities to address it at scale, by providing a snapshot of how major USbased NGOs are working to improve nutrition during the critical 1,000 day window. Over 300 projects are featured in the map, concentrated in the 27 high-burden countries where the US government has targeted many of its nutrition investments. The map focuses on 16 key nutrition interventions, including those identified by The Lancet and the World Bank. Although the map only represents a small subset of the work being done to improve maternal and child nutrition, and only covers the work of US-based NGOs, it is informative and valuable. It can help identify gaps between existing programs and areas of need, and highlight opportunities for future investments.

To find out more, visit: www.thousanddays.org and click on Resources

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UN Secretary General Includes Nutrition in his New Five-Year Action Agenda: “The Future We Want”

Ban Ki-moon, United Nations secretary General, has ambitious goals for nutrition.

The best news for nutrition so far in 2012 has to be the strong support for nutrition from United Nations Secretary General Ban Ki-moon, as part of the action agenda for his second term of office. Ban Ki-moon has committed to five laudable action areas, namely: sustainable development; the prevention of conflicts and disasters, human rights abuses and development setbacks; building a safer and more secure world, which includes standing strong on fundamental principles of democracy and human rights; supporting nations in transition; and working for women and young people. With regard to the last action area, working for women and young people, he stated: “We are preparing to unlock the potential of current and future generations by ending the hidden disgrace of stunting that affects more than 170 million children under five years old – that is, one child in every four.” The Secretary General’s goals are ambitious. However, certainly with regard to stunting, all agree that they are achievable, albeit only if the power of partnerships can be harnessed. He himself stated that the power of partnerships will be one of the forces that will make a difference: “Initiatives such as Sustainable Energy for All, Every Woman Every Child, the Global Compact, Scale Up Nutrition and the Global Fund to Fight AIDS, Tuberculosis and Malaria are showing

what is possible.” At Sight and Life, we believe that the next four years will be critical for the nutrition community, in order to turn talk of what works into scaled-up programs, to stop debating the need for partnerships, instead putting them into practice, and to hold all stakeholders accountable and measure the impacts. This is the only way that we will see if we can make a difference. We are unlikely to get another chance!

For the full speech, please go to: http://www.everywomaneverychild.org/component/content/ article/10-media/235-remarks-remarks-to-the-general-assemblyon-five-year-action-agenda-qthe-future-we-wantq

A Letter from Kenya: The Road to Becoming a Master of Public Health Josiah Osiri Kisumu, Kenya

The road to gaining my Master of Public Health (MPH) degree has been the longest and most challenging that I have ever experienced. Its main barriers were financial, coupled with family responsibilities. However, I had a strong feeling that one day I would graduate with an MPH degree from a distinguished university and contribute to the improvement of public health – especially that of the deprived population. I found myself taking up a number of public health courses, both locally and internationally, all of which whetted my appetite for the MPH. However, it was not until 2009, when I came across an organization known as Sight and Life, that my life’s dream could come true. A rural set-up My desire to pursue a Master of Public Health degree dates back to when I was posted to my first working station, after completing a three-and-a-half-year course in Community Health Nursing. My working station was a rural set-up, and I realized that life in a rural area was very different from the urban environment where I had been brought up and trained. The rural population lived by the grace of God. Premature maternal and child mortality were common events; people waiting for illness to take its natural course and open defecation were both seen as normal. These experiences prompted me to consider the origin of disease, the meaning of life and the role of government and communities in attaining better health and God’s intended purpose of life. I wanted to do something that would alleviate suffering, preserve life and make it meaningful. I did what I could with the resources that were available. I went back to college on a number of occasions in order to acquire specialized skills, such as maternal child health and family planning (MCH/FP), management of MCH/FP clinics, mental health, primary health care (PHC), training of trainers (TOT), communitybased health financing, water, sanitation and hygiene promotion, among many others. These courses added significant value to

Josiah Osiri at University of sheffield.

“My goal was to earn an MPH degree and acquire the quantitative, analytical and communication skills necessary to work in public health”

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my work in various communities and organizations. My ultimate goal was to earn a MPH degree and acquire the full range of quantitative, analytical and communication skills necessary to work in the cross-cutting domain of public health. A window of hope For 10 years, I routinely sought admission to leading Western universities. When I got involved in a partnership project between DSM and the United Nations World Food Programme, in an effort to fight hidden hunger in one of the refugee camps in Kenya, I saw a window of hope. In 2009, I applied to the University of Westminster, London, to study for a master’s degree in Public Health, Nutrition and Physical Activity. I appealed to potential sponsors; only Sight and Life responded positively, requesting however that admission be deferred to 2010. Unfortunately, early in 2010, the university decided to discontinue the Master of Public Health, Nutrition and Physical Activity program in the next academic year, suggesting an alternative program which I did not like. I launched a fresh search, this time settling for the University of Sheffield, which ranked highly both in the UK and globally, and had one of the best public health schools. The change from Westminster to Sheffield had budgetary implications. Tuition fees were 50% higher than Westminster, which entailed going back to Sight and Life to renegotiate their gift. Although they did not give me the full amount, they were able to increase their contribution. I want to thank Sight and Life for this gift, which enabled me to secure a UK visa and participate in the MPH program as a full-time student … something I had sought for over a decade.

“The road to gaining an MPH was not a bed of roses, but I’m glad that I made it” Ready for challenges Pursuing my dream motivated me to work hard and do my best. Given the public health challenges of the 21st century, selecting study modules was not difficult. I picked 10 modules. Covering these successfully was not easy. I did not have any free time, as I had to take up a part-time job to cover the budget deficit and support my family and mother in Kenya. I also attended Public Health Society activities, as its Vice President, and never failed to attend church services on Sundays. The road to gaining my MPH was no bed of roses, but I’m glad I made it, against all the odds – and the extreme cold weather! It was an incredible experience. I enjoyed each and every bit of my studies. The courses met my expectations. The lecturers were accessible, knowledgeable

letters to the editor

and experienced. They encouraged students to read widely and share their thoughts and experiences, allowing critical thinking and innovativeness. They were interested in everyone, even engaging in students’ extra-curricular activities. The students were equally diverse. Having obtained my MPH degree, I now feel confident and ready to tackle current public health challenges and the plight of the displaced population, and to make the Millennium Development Goals happen. My next step is to earn a PhD and, eventually, become a university lecturer, involved in research that informs health policies and the transfer of skills to the next generation. Sight and Life has touched my life, removing the barrier that stopped me achieving my academic goal. I now have “sight” to see beyond the horizon and “life” to share with the deprived population. I wish to express my immeasurable gratitude to Sight and Life for their educational gift, and to thank Klaus Kraemer for his sincerity, inspiration and keeping our communication alive to this date, and Jee-Hyun Rah and Anne-Catherine Frey for their insights and help.

Correspondence: Josiah O Osiri, P.O. BOX 7117, code 40100, Kisumu, Kenya E-mail: josiah.osiri@rocketmail.com Editor’s note: This is an abridged version of an open letter that was sent to Sight and Life by Josiah Osiri in March 2012.

Editor’s note: Sight and Life reviews recent publications which may be of particular interest to our readers. However, no publications other than Sight and Life publications are available from us, nor do we have any privileged access to them.

The Vitamines When Casimir Funk published the second edition of The Vitamines (1922), the world was still reeling from the devastating effects of the Great War. Funk’s revised and updated book had been delayed by the conflict, but it gave him time and reason to reflect upon the lessons of the war. He noted that, in times of peace and prosperity, “it is easy to see that no knowledge of vitamines is necessary to keep those people in good health.” The upheaval had delivered some poignant lessons about nutritional deprivation. “The knowledge of centuries suddenly becomes useless to the people … untold hardships are endured … the population functioning similar to experimental animals, used to establish the value of new foodstuffs.” The paramount importance of vitamins was readily becoming apparent, through laboratory work and clinical observations. During the war, young children living on skimmed milk and margarine were afflicted with xerophthalmia and high mortality in Denmark, rickets was rampant among children in Vienna, laborers were dropping dead with beriberi in South East Asia and pellagra killed countless mill workers in the southern US. Emerging insights on vitamins had helped to save hundreds of thousands of lives. Funk noted: “… it is a source of great pleasure to witness the great progress that has been made in vitamine research. In our opinion, the name “Vitamine”, proposed by us in 1912, contributed in no small measure to the dissemination of these ideas. The word, “Vitamine”, served as a catchword which meant something even to the uninitiated, and it was not by mere accident that just at that time, research developed so markedly in this direction.” An enduring legacy The Vitamines gives a detailed picture of the state of knowledge regarding vitamins by the early 1920s. Funk began the book with a short historical survey of animal research and clinical observations that preceded the more modern period of “vitamine research” that he recognized, not coincidentally,

as starting in 1912. The book is organized into three parts: (1) vitamin requirements of plants and animals, (2) chemistry, physiology and pharmacology of the vitamins, and (3) human vitamin deficiencies. Funk designated names for the three known vitamins of the time: “vitamine B for the antiberiberi vitamine, vitamine A for the antirachitic vitamine, and vitamine C for the antiscorbutic vitamine.” Vitamin D had yet to be discovered, thus vitamin A was thought to be the cure for both xerophthalmia and rickets. It is interesting to note that Funk recognized at this early time that a deficiency of vitamins “lowers the resistance towards infections.” Funk’s research and writing were uneven and marked by exaggerated claims (such as isolating “vitamine B” from rice polishings in 1911 – work that was never confirmed by others) and sheer stubbornness. For example, the English biochemist Jack Cecil Drummond proposed that the “e” be dropped from “vitamine”, since the substances were not all chemical amines. But Funk objected: “I cannot agree to this change since I still believe in the nitrogenous nature of these substances.” In the end, the main enduring legacy of Funk’s work was his clever naming of “vitamine”, later passed on through generations as our present-day “vitamin.”

Reviewed by: Richard D Semba, The Johns Hopkins University School of Medicine, Baltimore, USA E-mail: rdsemba@jhmi.edu

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“ Funk recognized at this early

ti me that a defi ciency of vitamins ‘lowers the resist ance towards infect ions ’”

Casimir Funk

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A Life Free from Hunger: Tackling Child Malnutrition With programs in more than 120 countries, Save the Children is one of the leading non-profit organizations in the world to promote children’s rights, provide relief and help support children in need. Their new report, entitled “A Life Free from Hunger: Tackling child malnutrition”, was released soon after United Nations Secretary-General Ban Ki-moon’s announcement that his new five-year action agenda would include putting an end to the hidden tragedy of the stunting of almost 200 million children, by mobilizing financial, human and political resources commensurate with the challenge. Progress on reducing child malnutrition has been pitifully slow for a generation. Even the meager gains that are being made are at risk due to on-going economic instability, fluctuating global food prices, climate change, and demographic changes. While the world is experiencing years of financial turmoil, pervasive long-term malnutrition is eroding the foundations of the global economy by destroying the potential of millions of children. This new and comprehensive report explores the causes of chronic malnutrition and stunting in children, identifies solutions and provides key recommendations to help give every child a life free from hunger. The report begins by scoping the scale of the malnutrition crisis and the causes and consequences of malnutrition, examining the relationship between nutrition and economic growth. Nutrition experts have agreed on 13 low-cost nutrition interventions that, if scaled-up to increase coverage, could reduce stunting by 36% and child deaths by 25%, saving the lives of two million children. The report considers how these interventions – including exclusive breastfeeding, micronutrient supplementation and fortification – can improve the quality of children’s health and well-being. Growing evidence shows that social protection and changes to agricultural policy and practice have the real potential to improve the diets of pregnant women and young children. The report examines how social protection schemes, such as cash transfers, can ensure that families are better able to afford healthy food and health services, such as children’s health checks and medicines. In other words, it looks at how to make more money available for nutrition and then, importantly, at how to get more nutrition for that money. It argues that agricultural policies are not working for the poorest and

investigates how agricultural production can be adapted to be more suited to meet the nutritional needs of children. Increasingly global leaders are committing to new nutrition initiatives to enhance investment in proven solutions and so it is appropriate that the report examines the political factors that contribute to the global burden of hunger and malnutrition, and recommends how governments, multilateral agencies, business and individuals can play their part in tackling the problem.

“This report provides the why, how, when and who for tackling childhood malnutrition at a time when it is vital to ‘get it right’” This report provides the why, how, when and who for tackling childhood malnutrition at a time when it is vital to “get it right.” The reality is that, by April 2013, it will already be too late to make a difference to the last generation of children to reach their second birthday in 2015 – the end point of the MDG targets.

For more information, please visit http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/ b.7980641/k.C98/Nutrition_Report_2012.htm

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HUNGaMA: Fighting Hunger & Malnutrition The HUNGaMA Survey Report 2011 “The problem of malnutrition is a matter of national shame. Despite impressive growth in our GDP, the level of undernutrition in the country is unacceptably high,” said Prime Minster of India Dr Manmohan Singh at the release of the HUNGaMA survey. In Hindi, hungama means “a stir” or “a ruckus.” This is exactly what the Citizens’ Alliance Against Malnutrition (consisting of young parliamentarians, artists, directors, social activists and policy-makers) hopes the survey will create, in order to stir the Indian nation to fight against unacceptably high levels of child hunger and malnutrition. Conducted by the Naandi Foundation, it bridges a gap in current data and knowledge on childhood malnutrition, and is an important first step in raising the profile of India’s childhood malnutrition. Conducted in 112 rural districts of India in 2011, the survey provides reliable estimates of child nutrition, covering almost 20% of Indian children. It presents district-level data on underweight, wasting and stunting, collected from 109,093 children under the age of five. It provides updated information and a point of comparison for existing data,

as well as a unique and unprecedented set of information on the basic knowledge, attitudes and practices critical to child nutrition outcomes from the perspective of the 74,020 mothers interviewed. The resources available in the Anganwadi Centres (AWC) and the knowledge of the Anganwadi Workers (AWW) are also surveyed. Although it reports a 20% decrease in childhood underweight over the last seven years (an annual reduction of 2.9%), childhood malnutrition in India remains widespread and unacceptably high, with close to 60% of children being stunted in the 100 focus districts (the worst performers on the child development district index developed for UNICEF India). This highlights the need to focus on long-term social impact programs that address stunting. The data shows that child malnutrition starts very early in life, with high rates of stunting and underweight by the age of 24 months, and low birth weight (under 2.5 kg) associated with higher incidence of both underweight and stunting. More than half of the mothers interviewed did not give their newborns colostrum, nor did they breastfeed exclusively in the first six months of life. There is no doubt that there is a need for greater support of mothers in the first 1,000 days of their child’s life and for strengthening of the Anganwadi services’ outreach and counseling component. The prevalence of malnutrition was also significantly higher among children from low-income families, Muslim households and Scheduled Castes or Tribes, as well as children born to mothers with a low level of education.

“While signs of progress are promising, a great deal of work is still to be done” The survey concludes that, while signs of progress are promising, a great deal of work is still to be done. Concerted efforts are vital for those identified as the most vulnerable children: the youngest, the poorest and the excluded.

For more information, please visit http://www.naandi.org/1008569_Hungama_Bk.pdf

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Reshaping Agriculture for Nutrition and Health In the preface to this timely publication, the authors state: “What happens in the agriculture sector – a supplier of food and essential nutrients, a source of income and employment, and an engine of growth – has important implications for nutrition and health.” This is true, and one of the key reasons why we need to break down the silos that nutrition and agriculture have traditionally worked in. We need to see the entire value chain, from farm to fork to fortification and even supplementation, as being interlinked and interdependent. This book’s intention is to identify knowledge gaps, foster new thinking and stimulate concrete actions on leveraging agriculture to improve nutrition and health. It serves a variety of readers, from scholars, academics, students and researchers to practitioners working on the ground and decisionmakers devising policies that successfully connect agriculture, nutrition and health at local, regional and global levels. It is founded on papers by a wide range of experts, given at the International Food Policy Research Institute (IFPRI) conference, “Leveraging Agriculture for Improving Nutrition and Health”, in New Delhi in February 2011. Unexpectedly, market prices do not provide an adequate incentive to produce nutritious food. Even if prices were to reflect the nutritional value of food, they could put nutritious foods out of the reach of poor people. Thus, public interventions are needed to correct market failures (when prices do not reflect the nutritional value of foods) or to improve affordability (for poor people). While some people are getting too little food, others are getting too much of the wrong food and the double burden of malnutrition is on the increase.

“Most people would say agriculture is about growing food; they are right. The purpose of agriculture, however, does not stop there – at a deeper level, agriculture is also about growing healthy, well-nourished people”

Complex links The links between agriculture, nutrition and health are numerous and complex. However, this publication sets them out in an easy-to read and logical sequence. The broad themes addressed include: the conceptualization of the links between the three sectors; looking at the food system and the interaction with nutrition, as well as the disconnects; the need to turn economic growth into nutrition-sensitive growth; and issues of gender and farm laborers. All of these are relevant and all need to be considered as we move forwards in truly addressing both poverty and malnutrition. There is no doubt that achieving the goal of nourishing the world’s population sustainably, so that all people can lead healthy, productive lives, requires closer collaboration. It needs to be ensured that the agriculture, nutrition, and health sectors do not work at cross-purposes and instead seek out and scale up innovations and successes, and create an environment for cooperation. This publication is highly recommended. It is essential reading for everyone working in public health nutrition, looking as it does at both challenges and solutions from a holistic viewpoint.

To find out more, please visit http://www.ifpri.org/publication/reshaping-agriculturenutrition-and-health

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Accelerating Action: New WFP Policy Published World Food Programme (WFP) Executive Board First Regular Session Rome, February 13 – 15, 2012 Policy Issues, Agenda, Item 5: WFP Nutrition Policy In February 2012, the Executive Board of the World Food Programme (WFP) approved a new Nutrition policy, which is available on the WFP’s website. Action on nutrition is accelerating in different sectors, nationally and globally, involving governments, United Nations agencies, non-governmental organizations, civil society and the private sector. The Lancet medical journal has indicated that if undernutrition can be overcome – especially during the first 1,000 days – not only can lives be saved, but children can also grow up to realize their full potential and entire economies will benefit from a healthier and more productive workforce.

This policy paper presents WFP’s vision of how to contribute to this global movement and defines a mission and policy framework for doing so. WFP’s mission in nutrition is focused on its comparative strengths related to food: “… to work with partners to fight undernutrition by ensuring physical and economic access to a nutritious and ageappropriate diet for those who lack it and to support households and communities in utilizing food adequately. WFP ensures access to the right food, at the right place, at the right time.” The new policy notes that undernutrition has many causes. Thus, efforts to tackle it must be multi-disciplinary, engaging diverse stakeholders in line with national priorities. Based on its mandate and comparative advantage, WFP ensures physical and economic access to a nutritious, acceptable and ageappropriate diet for those who lack it. While reaching more than 90 million beneficiaries every year – many of them children – and meeting both their caloric and nutrient needs, WFP can also have an indirect impact on the lives of many more people by advocating for comprehensive solutions and developing the capacity of governments and other partners to include food-based components in their strategies for tackling undernutrition. WFP will strive to accomplish this mission by designing and supporting the implementation of programs and operations in the five areas covered by its policy framework: 1. Treating moderate acute malnutrition – wasting 2. Preventing acute malnutrition – wasting 3. Preventing chronic malnutrition – stunting 4. Addressing micronutrient deficiencies. Among vulnerable groups, the focus is on saving lives during emergencies. For the general population, the focus is on food fortification 5. Strengthening the focus on nutrition in programs without a primary nutrition objective and, where possible, linking vulnerable groups to these programs

“Undernutrition is a complex, multi-faceted problem, and responses need to include many diverse actors”

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Continued improvement WFP will continue to improve its internal processes and capacity to support food-based solutions where appropriate. The organization is committed to work ever closer with governments, civil society and academia, as well as with the private sector, to ensure that proper situation analysis informs tailored, but comprehensive, multisectoral solutions. WFP will leverage its expanded toolbox, which now includes a greater variety of specially formulated, nutritious food products, and cash and voucher distribution, ensuring that all tools contribute to the achievement of nutrition objectives. WFP will also expand its focus on research, assist partners in developing improved and more cost-effective products, and ensure an adequate

supply to meet growing demand for these products. Undernutrition is a complex, multi-faceted problem, and responses need to include many diverse actors. WFPâ&#x20AC;&#x2122;s contribution is essential: In a context of poverty, the right food, at the right place, at the right time, is a prerequisite for a successful response.

This is an abridged version of the executive summary of the new World Food Programme nutrition policy. The full version of this policy paper is available at: http://documents.wfp.org/stellent/groups/public/documents/eb/ wfpdoc061668.pdf

New WFP Nutrition Policy with five main pillars WFP Nutrition Strategy

1 Nutrition activities focused on vulnerable groups including young children, pregnant & lactating women, and people living with HIV

2 Treatment of moderate acute malnutrition

3 Prevention of acute malnutrition

Prevention of chronic malnutrition

4 Addressing micronutrient deficiencies. Among vulnerable groups, the focus is on saving lives during emergencies. For the general population, the focus is on food fortification.

5 Ensure other programs contribute to improved nutrition outcomes General food distribution

school feeding

Food for work / asset / training

Enabling environment: Technical assistance and advocacy with governments and other stakeholders

Others

Advocating better nutrition for brighter futures.

IMPRINT

Imprint Sight and Life Magazine Incorporating the Xerophthalmia Club Bulletin and the Nutriview Newsletter

Design concept, layout and graphics: S1 Communication Design, Augsburg

Publisher: Sight and Life Editor: Klaus Kraemer Editorial team: Anne-Catherine Frey, Svenia Sayer-Ruehmann, Jane Badham

Printer: Burger Druck, Waldkirch

Communication consultancy and text writing: The Corporate Story

Language services: transparent, Berlin Opinions, compilations and figures contained in the signed articles do not necessarily represent the point of view of Sight and Life and are solely the responsibility of the authors.

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Photo credits Cover: Mike Bloem Photography Page 4 /5, 19, 29: Mike Bloem Photography Page 76: Remy Steinegger

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sIGHT AND LIFE | Vol. 26 (1) | 2012

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We care about the worldâ&#x20AC;&#x2122;s most vulnerable populations and exist to help improve their nutritional status. acting as their advocates, we guide original nutrition research, disseminate its findings and facilitate dialog to bring about positive change.

SIGHT AND LIFE | VOL. 26 (1) | 2012

Building bridges for better nutrition.