Food and Nutrition Bulletin

Processed complementary foods have the potential to play an important role in the diets of infants and toddlers in Latin America. Both feeding frequency and nutrient density need to be considered when formulating recommendations on appropriate feeding practices and composition of processed foods. Unfortunately, empirical data are not yet available on the relationships among feeding practices, feeding frequency, energy density, energy intake, and intake from breastmilk that would permit appropriate public health recommendations to be made. Analyses of nutrient requirements and the nutrient contents of typical toddler foods show that it is virtually impossible to satisfy iron requirements without fortification unless there is a substantial intake of animal products. Zinc and calcium have also been identified as problem nutrients. The optimal characteristics of processed complementary foods include adequate energy density, appropriate micronutrient:energy ratios, suitably low renal solute load, appropriate viscosity for age, desirable sensory properties, resistance to microbial contamination, simple preparation techniques, and low cost.

The principal aim of this paper is to describe the socio-economic context in which the topic of processed complementary feeding in Latin America should be examined. Data from CEPAL (Comisión Económica para América Latina y el Caribe) and from the Demographic Health Surveys (DHS) are used to review global trends in urban poverty and malnutrition in the region. The phenomena that are unique to urban life and that are likely to have an impact on child-care and feeding practices are reviewed using data from DHS for six Latin American countries. The issues examined include the higher levels of education and of labour force participation of urban women, the larger percentage of women who head households, and the potentially different family structure and social networks, which may affect the availability of substitute child care. Urban and rural differences in breastfeeding and complementary feeding patterns are also examined to improve our understanding of the potential constraints and opportunities for the promotion of processed complementary foods in Latin America. Programmatic issues that need to be considered in designing and targeting such interventions in largely urbanized Latin America are also discussed.

The principal international instruments regulating the composition and marketing of processed complementary foods are the International Code of Marketing of Breast-Milk Substitutes, adopted by the World Health Assembly in 1981, subsequent relevant World Health Assembly Resolutions, and the Codex Alimentarius Standards for Canned Baby Foods and for Processed Cereal-Based Foods for Infants and Children. The Code and Resolutions emphasize the use of a variety of locally available foods in addition to breastmilk in ensuring a balanced diet for infants from around the age of six months. Complementary foods should not be marketed in ways that interfere with breastfeeding, and governments should support education for parents in the appropriate feeding of infants.

The objective of this study was to develop supplements for nutritional support of children less than two years old and for pregnant and lactating women under a multidisciplinary Programme of Education, Health, and Nutrition (PROGRESA) that the Mexican Government is implementing for populations in extreme poverty. Nutrient composition, physicochemical properties, and feasibility of production and utilization were considered in designing the supplements. The nutrient composition took into account the dietary patterns and nutritional status of the target populations. The ingredients and processing methods were selected considering local availability and production at a relatively low cost while maintaining a supplement of a high quality that would be widely accepted by the target population. The final products were initially evaluated for acceptability by 40 children, 52 pregnant women, and 62 lactating women. Nine products were developed: six for children and three for women. The children's products were three powders that were used to prepare a beverage with chocolate, vanilla, and banana flavours and three powders that were used to prepare a more viscous solution in the form of pap with the same three flavours. After the acceptance test, the use of the pap supplements was recommended for children four months to two years of age. The supplements for women were also powders used to prepare a beverage with vanilla or banana flavour or with no flavour. The products were widely accepted in sensory evaluation tests. For the children's products, the average scores were 4.11 to 4.29 for the beverage and 3.98 to 4.15 for the viscous mixture (range, 1 to 5). The women's products received average scores of 4.75 to 5.70 from pregnant women and 4.80 to 5.40 from lactating women (range, 1 to 7). Evaluation in the community demonstrated that the supplements were widely acceptable and well consumed. Today more than three million rations of supplements are consumed every day, and an evaluation of their potential benefits is being carried out.

Mexico has implemented a number of food and nutrition programmes and policies since 1950. However, these initiatives have been largely ineffective. A new social programme targeted to poor families has been implemented. It now covers almost 2 million families and is expected eventually to cover 4.2 million families. The programme facilitates access of beneficiaries to health and education services, and includes monetary transfers and a nutrition component targeted to the critical development period between gestation and the age of two years. Pregnant and lactating women and children under two years of age receive food supplements fortified with key micronutrients. After decades of food and nutrition interventions that were not carefully evaluated, the programme performance and its nutritional impact will be evaluated. A baseline survey was conducted in 1998 on a random sample of communities selected as beneficiaries of the programme and on a sample of similar communities that will participate in the programme after the end of the evaluation. Additional surveys will be conducted in 1999 and 2000. Each survey will include a cross-sectional evaluation of children and women and a cohort of children zero to 12 months of age at baseline who will be followed. Preliminary results from the baseline survey of beneficiaries are presented and discussed.

Alli Alimentu, a processed complementary food, is currently consumed by 50,000 children per day in Peru. The food, developed by the Instituto de Investigación Nutricional, is produced and distributed by the private sector in programmes funded by the government. In this paper, the development of the food is described, and issues related to financing, cost, production, and distribution are discussed. Monitoring and evaluation has focused on three activities: operational processes, communication and training, and impact. The impact evaluation showed that the consumption of energy, protein, iron, vitamin A, and calcium increased and the prevalence of anaemia and vitamin A deficiency decreased among targeted children. Surprisingly, the project did not affect child growth, suggesting that stunting is associated with multiple factors (genetic, environmental, and infectious) that the project did not modify.

Incaparina is a high-quality protein vegetable food used in Guatemala. It was developed in the 1960s for children and other population groups with nutritional deficiencies. The original formula is still used as a commercial product, but both its ingredients and its micronutrient composition needed to be improved. Protein quality was improved, vitamin A content was reduced, and the contents of iron, B vitamins, zinc, and calcium were increased. The price of new Incaparina is still very competitive. In order to ensure the quality of this commercial product, a Seal of Nutritional Excellence was developed and is expected to be used by private firms.

This paper describes the development of processed complementary foods in Colombia and the composition of currently available foods. The main product, Bienestarina, has been produced by the Instituto Colombiano de Bienestar Familiar since 1976. The total annual production of the product exceeds 300,000 tons. In 1999 nearly 27,000 tons were produced and served to over 4.2 million beneficiaries. Both the government and the private sector are involved in the production of these foods. Bienestarina and other complementary foods appear to be widely accepted by the low-income population. Their nutritional impact has not been evaluated, and their composition reflects former concerns about protein rather than micronutrient adequacy and bioavailability.

The World Food Programme (WFP) distributes approximately 125,000 metric tons per year of processed complementary foods in maternal and child health and school feeding programmes and for use in refugee and emergency projects. In formulating the foods, WFP seeks the highest nutritional quality for the best cost. Safety is never compromised. The cost of WFP foods is about US$360 per metric ton. The United States Agency for International Development provides half of WFP's demand, and the local manufacturers provide the rest. WFP has had a very successful experience in working with the private sector.

This article addresses the policy, programme, and food-commodity aspects of United States non-emergency food assistance programmes in the Latin American and Caribbean region since the end of the Cold War. The article contains an analysis of the cost, composition, and quality-control improvements of United States Public Law 480 (P.L.480) Title II foods, which reach over one-half million recipients each year through 16 maternal and child health programmes in 6 countries. After a description of the changes in maternal and child health programmes in the 1990s, the author concludes that further improvement in the nutritional status of young children in Latin America will take place more readily from the transformation of food distribution programmes into food and nutrition security programmes than from isolated acts of supplying complementary foods of improved quality.

We know from past experience that nutritional status can be improved by improving practices without the use of processed food. The question should be: Can food alone, in the absence of improved practices, improve nutritional status outside a rehabilitative, structured feeding situation? Projects discussed in this paper demonstrate that there can be biological impacts from improved practices. Helping families use their own resources better is an important first step, not a last step, in programme development. The lessons that have been learned over the years for improving young child feeding are as follows: science is not enough; knowledge is not enough; the focus should be on improving practices; mothers are not a homogeneous group; and the solution is seldom singular. Processed complementary food is really a small piece of a larger picture that needs to be thought about strategically on the basis of practices and the barriers to improving them. It is important to work with governments to help them formulate and think through the options that present themselves to improve the nutritional intake of young children. Rather than using a zoom lens, which often magnifies the food component, we need to use a panoramic lens to see other options when helping countries.

In urban Kenya the rates of exclusive breastfeeding are low, and complementary feeding practices result in inadequate intake of energy and nutrients by young children. Although information on appropriate feeding of young children has been widely promoted through the health system for years, and mothers are knowledgeable about recommendations, inadequate feeding practices still result in high rates of malnutrition. Processed cereal blends are used by some urban mothers for infant feeding, and their cost is similar to that of porridges enriched in the home by the addition of milk, margarine, or soya flour. However, little has been done to ensure that these products are nutritionally adequate or to ensure that labelling instructions are appropriate and that they promote exclusive breastfeeding from four to six months of age. Social marketing to low-income families of fortified cereal blends that would address these concerns could be a sustainable means of improving infant-feeding practices.

The use of a processed weaning food in a public health programme should never proceed without an effective programme of communication for behavioural change. There is a long and largely unsuccessful history of public health-oriented weaning foods. Most of the problems have been due to the lack of attention to behaviour, which is not a priority for most nutritionists. Food consumes programmes and consequently uses most of the economic and human resources devoted to the programme. A food programme is not a nutrition programme, and processed weaning foods are not always necessary and are not a priori the best food. The trade-offs between promoting processed foods versus promoting local foods must be considered. It is important not to let the scientifically perfect weaning food stand in the way of practical, sustainable solutions for improving the nutrition of infants and toddlers.

In most countries, processed complementary foods have been developed to be used in free or highly subsidized food distribution programmes, but little effort has been made to introduce them in the regular market. They have been positioned as “food for the poor” and, as such, carry a stigma. If nutritionally improved complementary foods were made commercially available at affordable prices, their coverage and contribution to improve nutrition would be more significant and sustainable at lower cost to governments. The question is whether a market-oriented approach is feasible, that is, whether the food industry would be willing to produce and market such foods and whether a demand for them can be created. A number of issues along these lines are briefly discussed, including the available evidence for the effectiveness of processed foods in improving nutritional status, the role of nutrition education and social marketing, and the need and rationale for a market-oriented approach.

Any evaluation should start with the question: “Who will use the information and for what purpose?” This question implies that one must consider not only the facts presented in the evaluation, but also whether the person who receives the information is motivated and has the authority and resources to implement changes that emerge from the evaluation. The similarities and differences among summative, formative, and process evaluations are discussed. Particular attention is given to stakeholder participation, choosing the appropriate level of statistical significance, and separating issues relevant to public-sector versus private-sector investment as they relate to evaluating the targeting and effect of processed complementary foods.

Social marketing is the use of marketing techniques to achieve a public health goal. In the context of developing countries, social marketing has often been coupled with the availability of health products, allowing the use of other elements of the marketing mix: product, price, and distribution. The strength of social marketing, within a larger strategy, is its ability to harness existing private-sector infrastructure to create access to information and products. In this paper, issues related to targeting, pricing, and how to develop a social marketing programme for processed complementary foods are discussed.

The cost of feeding Latin America's children is high, when viewed in the context of public expenditures on food. The need to increase the cost-effectiveness of such expenditures, coupled with the growing interest in partnerships between the public and private sectors and increases in urbanization, female employment, and household food expenditures, suggests a potential role for processed complementary food in the prevention of malnutrition. The nutritional characteristics of the various foods currently used in nutrition and health programmes are variable, depending on the scientific information available when the food was formulated. A growing interest in the role of the private sector in public health interventions is evidenced by the number of programmes in which such a collaboration exists. The cost of production per 100 g of dry product varies from US$0.04 for World Food Programme blended foods to approximately US$0.20 for recently formulated foods with a significantly higher fat content for national programmes in Mexico and Peru. The constraints and challenges for harnessing the potential of processed complementary foods to improve infant and child nutritional status are numerous. However, the multifactorial causation of child malnutrition points to the importance not only of ensuring access to the appropriate mix of foods, but also of promoting optimal breastfeeding and complementary feeding practices and care.