Food and Nutrition Bulletin

To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified.

Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia.

Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries.

Between 1990–2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation.

In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.

The prevalence of stunting, underweight, and micronutrient deficiencies are persistently high in young children in the Philippines, and among other factors, suboptimal infant and young child feeding behavior may contribute to these forms of malnutrition.

To improve the understanding of contributors associated with the nutritional status of children 6 to 23 months of age living in urban areas of the Philippines.

A cross-sectional survey was conducted covering five urban centers in the Philippines. Data on infant and young child feeding and nutritional status (including wasting, stunting, underweight, anemia, iron deficiency, and vitamin A deficiency) were collected for 1,784 children.

Among children from urban and predominantly poor and very poor households, 26% were stunted, 18% were underweight, and 5% were wasted. Forty-two percent were anemic, 28% were iron deficient, and 3% were vitamin A deficient. About half of the children were breastfed within an hour after birth, were breastfed at the time of the survey, and had been continuously breastfed up to 1 year of age. Of the factors investigated, low socio-economic status, use of cheaper cooking fuel, and nonuse of multivitamins were all independently associated with stunting. The prevalence of anemia, iron deficiency, and vitamin A deficiency were independently associated with the same factors and poorer sanitation facilities, lower maternal education, current unemployment, and inflammation.

These factors merit attention in future programming, and interventions may include promotion of the timely introduction of appropriate fortified complementary foods, the use of affordable multiple micronutrient preparations, and measures to reduce infections.

The Minimum Cost of a Nutritious Diet (MCNut) is the cost of a theoretical diet satisfying all nutrient requirements of a family at the lowest possible cost, based on availability, price, and nutrient content of local foods. A comparison with household expenditure shows the proportion of households that would be able to afford a nutritious diet.

To explore using the Cost of Diet (CoD) tool for policy dialogue on food and nutrition security in Indonesia.

From October 2011 to June 2012, market surveys collected data on food commodity availability and pricing in four provinces. Household composition and expenditure data were obtained from secondary data (SUSENAS 2010). Focus group discussions were conducted to better understand food consumption practices. Different types of fortified foods and distribution mechanisms were also modeled.

Stark differences were found among the four areas: in Timor Tengah Selatan, only 25% of households could afford to meet the nutrient requirements, whereas in urban Surabaya, 80% could. The prevalence rates of underweight and stunting among children under 5 years of age in the four areas were inversely correlated with the proportion of households that could afford a nutritious diet. The highest reduction in the cost of the child's diet was achieved by modeling provision of fortified blended food through Social Safety Nets. Rice fortification, subsidized or at commercial price, can greatly improve nutrient affordability for households.

The CoD analysis is a useful entry point for discussions on constraints on achieving adequate nutrition in different areas and on possible ways to improve nutrition, including the use of special foods and different distribution strategies.

Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs.

To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia.

A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time.

The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fortification went down significantly compared with prices they would have been offered had they ordered vitamin A individually. In Indonesia, this consolidated procurement approach has allowed a 14.5% decrease in the unit price of vitamin A.

The GAIN Premix Facility demonstrated its effectiveness in acting as a global procurement platform by aggregating demand across different customers and leveraging improved prices through increased volumes. Building on the success of this effort, the GAIN Premix Facility is replicating this global approach for procurement of other standard items being procured across fortification programs worldwide.

Food fortification is a viable strategy to improve the nutritional status of populations. In South-east Asia, recent growth and consolidation of the food industry provides an opportunity to explore whether certain widely consumed processed foods could contribute to micronutrient status if they are made with adequately fortified staples and condiments.

To estimate the potential contribution certain processed foods can make to micronutrient intake in Southeast Asia if they are made with fortified staples and condiments; e.g., via the inclusion of iodized salt in various processed foods in the Philippines, fortified wheat flour in instant noodles in Indonesia, and fortified vegetable oil in biscuits in Vietnam.

For Indonesia, the Philippines, and Vietnam, a review of consumption trends, relevant policies, and industry practices was conducted using publicly available sources, food industry market data and research reports, and oral communication. These informed the estimates of the proportion of the Recommended Nutrient Intake (RNI) that could be delivered via select processed foods.

In the Philippines, Indonesia, and Vietnam, the processed food industry is not always required to use fortified staples and condiments. In the Philippines, dried salted fish with iodized salt would provide 64% to 85% of the iodine RNI for women of reproductive age and 107% to 141% of the iodine RNI for children 1 to 6 years of age. In Indonesia, a 75-g pack of instant noodles (a highly consumed product) with fortified wheat flour would provide 45% to 51% of the iron RNI for children 4 to 6 years of age and 10% to 11% of the iron RNI for women of reproductive age. In Vietnam, biscuits containing vegetable oil are increasingly popular. One 35-g biscuit serving with fortified vegetable oil would provide 13% to 18% of the vitamin A RNI for children 4 to 6 years of age and 12% to 17% of the vitamin A RNI for women of reproductive age.

Ensuring that fortified staples and condiments such as flour, salt, and vegetable oil are used in widely consumed processed foods would ensure that these foods contribute to improvement in micronutrient intake among populations in Southeast Asia, particularly as the consumption of these foods is increasing. Policymakers and nutrition program managers should consider the contribution to nutritional intake that fortified staples and condiments can provide through processed foods, in addition to being used for cooking in the home, and ensure that the food industry is required to use these fortified staples and condiments rather than nonfortified foods.

The prevalence of micronutrient deficiencies in Cambodia is among the highest in Southeast Asia. Fortification of staple foods and condiments is considered to be one of the most cost-effective strategies for addressing micronutrient deficiencies at the population level. The Government of Cambodia has recognized the importance of food fortification as one strategy for improving the nutrition security of its population.

This paper describes efforts under way in Cambodia for the fortification of fish sauce, soy sauce, and vegetable oil.

Data were compiled from a stability test of Cambodian fish sauces fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA); analysis of fortified vegetable oils in the Cambodian market; a Knowledge, Attitudes, and Practices (KAP) study of fortified products; and food fortification program monitoring documents.

At different levels of fortification of fish sauce with NaFeEDTA, sedimentation and precipitation were observed. This was taken into consideration in the government-issued standards for the fortification of fish sauce. All major brands of vegetable oil found in markets at the village and provincial levels are imported, and most are nonfortified.

Fish sauce, soy sauce, and vegetable oil are widely consumed throughout Cambodia and are readily available in provincial and village markets. Together with an effective regulatory monitoring system, the government can guarantee that these commodities, whether locally produced or imported, are adequately fortified. A communications campaign would be worth-while, once fortified commodities are available, as the KAP study found that Cambodians had a positive perception of fortified sauces.

Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake.

To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported .

Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil.

Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Average Requirement (EAR) for an Ethiopian woman, 30.9% and 46.9% of the EAR for a Bangladeshi child and woman, respectively, and 17.5% of the EAR for a Cambodian woman. Although concerns about obesity are valid, fortification of existing vegetable oil supplies does not promote overconsumption of oil but rather promotes consumption of vegetable oil of higher nutrient quality.

Fortifying vegetable oil on a large scale in Malaysia and Indonesia can reach millions of people globally, including children less than 5 years old. The levels of fortification used are far from reaching the Tolerable Upper Intake Level (UL). Vegetable oil fortification has the potential to become a global public health intervention strategy.

Vitamin D is vital for bone health and has important roles in nonskeletal health and organ function. Most vitamin D is generated in the body by exposure to sunlight, with limited amounts added by the diet. Despite the presence of regular sunshine in Southeast Asia, vitamin D deficiency or insufficiency is being found there more commonly, primarily due to reduction of sunlight exposure as a result of lifestyle changes. Some of these lifestyle changes are unlikely to be reversed, and foods naturally containing vitamin D are not widely consumed, so fortification of foods with vitamin D may raise vitamin D status.

The literature database was searched for studies of vitamin D fortification, and we estimated potential vitamin D intakes from fortified vegetable oil.

Almost all of the studies showed that circulating vitamin D (25-hydroxyvitamin D [(25OHD]) increased in a dose-dependent manner with increased intake of vitamin D–fortified foods. However, in a number of studies the additional intake was insufficient to increase vitamin D levels to 50 nmol/L. Vegetable oil fortified with vitamin D at a level of 10 μg/100 g could provide 3.9% to 21% of the Institute of Medicine Estimated Average Requirement (EAR) of vitamin D for adults in Southeast Asia.

Fortification of widely consumed foods, such as edible oil, with vitamin D could contribute to improved vitamin D status in Southeast Asian countries. Intake modeling studies should be conducted to calculate the resulting additional intakes, and fortification of additional foods should be considered. More nationally representative studies of vitamin D status in the region are urgently needed.

Iron and zinc deficiency are major public health problems affecting many parts of the world, including Southeast Asia. Infants, young children, and women of reproductive age are particularly vulnerable due to their high requirements. Even though iron and zinc are present in significant amounts in the plant-based diets typically consumed in developing countries, their bioavailability is low due to high levels of absorption inhibitors such as phytate. Phytase has been used in animal nutrition for decades to improve the bioavailability of certain minerals in feed.

To show the effect of phytase in human nutrition based on evidence from human studies. Phytase can be used either during processing or as an active food ingredient degrading dietary phytate during stomach transit time.

Evidence from human studies testing the effect of phytase on iron and zinc bioavailability using stable isotopes was reviewed.

Twelve studies tested the effect of phytase on iron and five tested its effect on zinc bioavailability. Most of these studies used a phytase derived from Aspergillus niger. They found a beneficial effect unless phytate concentrations were too low or levels of inhibitors or enhancers of iron absorption were too high. Twenty to 320 phytase units per 100 g of flour significantly improved iron absorption, even though higher levels might further increase iron bioavailability. For zinc, not enough information is available to determine optimal activities.

Phytase clearly has a beneficial effect on iron and zinc absorption from phytate-rich foods. It also has the potential to increase the absorption of magnesium, calcium, and phosphorus in areas such as Southeast Asia where mineral deficiencies are widespread.

Considerable efforts have been made over the past decade to address vitamin and mineral deficiencies. An increasing number of countries in the Association of Southeast Asian Nations (ASEAN) are adopting mandatory food fortification as one of the primary strategies to overcome these deficiencies. Experience shows that fortified foods can reach large parts of the population, including the poor, if the fortification is done on a mandatory rather than a voluntary basis and if the food vehicle is widely consumed.

To review the importance of regulatory monitoring as an essential component of food fortification efforts in selected ASEAN countries, with special focus on the available information on regulatory monitoring systems for iodized salt and fortified wheat flour.

The role of regulatory monitoring in strengthening food fortification programs was discussed during a joint regional meeting of the World Health Organization, UNICEF, the Flour Fortification Initiative, the Global Alliance for Improved Nutrition, the Micronutrient Initiative, and the World Bank on regulatory monitoring of salt and wheat flour fortification programs in Asia, which took place in Manila, Philippines, on 27–29 September 2011. This paper reviews the regulatory monitoring systems of selected ASEAN countries that participated in this meeting.

Problems and challenges in regulatory monitoring systems for iodized salt and fortified wheat flour in selected ASEAN countries are identified, and a description of the role of regulatory monitoring in strengthening food fortification initiatives, particularly of salt and flour, and highlights of areas for improvement are presented.

Regulatory monitoring consists of monitoring activities conducted at the production level, at customs warehouses, and at retail stores by concerned regulatory authorities, and at the production level by producers themselves, as part of quality control and assurance efforts. Unless there are appropriate enforcement and quality assurance mechanisms in place to stimulate compliance by food producers, i.e., regulatory monitoring, having national legislation will not necessarily lead to increased coverage of fortified products and associated outcomes.

Food fortification is a cost-effective, powerful, and sustainable strategy to combat micronutrient deficiency, with the potential to reach large sections of the population with minimal cost and effort. However, the implementation of food fortification on a systematic and large scale, for instance in national programs, has often been challenging.

This paper takes a closer look at food fortification efforts and legislation mechanisms in Vietnam and Indonesia in order to determine specific factors and components in the legal framework that are crucial to the success of fortification programs.

Fortification efforts in Indonesia and Vietnam are evaluated using published data as well as unpublished data from detailed evaluation reports, and compared with respect to the specific circumstances, constraints, objectives and results in each country.

The legal framework is a crucial factor for the success of food fortification programs, as it shapes to a large extent the implementation of food fortification. The legal framework is instrumental to ensure the quality, safety, availability, cost-effectiveness, and sustainability of food fortification. In the first place, the legal framework should specify the fortificants and fortification levels, as well as the food vehicles and the fortification procedures. In addition, it should ensure the commitment of policy makers and producers to fortification, regulate the costing, describe and ensure information and communication such as product labeling, integrate social marketing into the implementation, and provide the means to monitor and enforce fortification. A clear public health objective, together with careful consideration of the choices and restrictions dictated by the specific national environments, will help to develop legal frameworks that optimize the potential success of food fortification strategies.

The lessons from these experiences show that a mandatory approach to fortification, with costing, monitoring and enforcement, and social marketing clearly defined and well embedded in the legal framework and in the implementation structures, is the best foundation for an effective, sustainable, and feasible food fortification program.

In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the industrial level are fortified with iron. Unfortunately, the food producers and regulatory agencies implementing fortification programs do not always have the capacity to monitor the programs on an ongoing basis.

To assess a new portable device for the quantitative measurement of iron content of fortified sauces that could be used to control fortification levels.

The linearity, detection limits, and inter- and intraassay variability of this device were assessed on fish sauce and soy sauce fortified with ferrous sulfate, ferrous fumarate, and sodium iron ethylenediaminetetraacetate (NaFeEDTA); the accuracy of the results was determined by comparing them with the results obtained by atomic absorption spectrophotometry.

Measurements required a minimum incubation time of 1 hour for iron sulfate or iron fumarate and 24 hours for NaFeEDTA. Linearity of the results ranged from 2 to 10 mg iron/L for ferrous sulfate or ferrous fumarate and from 1 to 10 mg iron/L for NaFeEDTA, implying the need for proper dilution, as the iron contents of fortified sauce are usually in the range of 150 to 1,000 mg/L. Depending on incubation time, iron compounds, and sauces, the coefficient of variation (CV) of intraassay precision was between 1.5% and 7.6% and the CV of interassay precision was between 2.9% and 7.4%. Comparison with results from atomic absorption spectrophotometry showed high agreement between both methods, with R = 0.926 and R = 0.935 for incubation times of 1 hour and 24 hours, respectively. The Bland—Altman plots showed limits of agreement between the two methods of ± 70 mg/L in the range of fortification levels tested (100 to 500 mg/L).

This device offers a viable method for field monitoring of iron fortification of soy and fish sauces after incubation times of 1 hour for ferrous sulfate or ferrous fumarate and 24 hours for NaFeEDTA.

The “Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia” project (SMILING), funded by the European Commission, is a transnational collaboration of research institutions and implementation agencies in five Southeast Asian countries—Cambodia, Indonesia, Laos PDR, Thailand, and Vietnam—with European partners, to support the application of state-of-the art knowledge to alleviate micronutrient malnutrition in Southeast Asia.

The major expected outcomes are to improve micronutrient status on a large scale, to identify priority interventions in each Southeast Asian country, and to develop a road map for decision makers and donors for inclusion of these priority interventions into the national policy.

SMILING has been built around a strong project consortium that works on a constant and proactive exchange of data and analyses between partners and allows for the differences in contexts and development stages of the countries, as well as a strong North—South—South collaboration and colearning.

The selection of Southeast Asian countries considered the range of social and economic development, the extent of micronutrient malnutrition, and capacity and past success in nutrition improvement efforts. SMILING is applying innovative tools that support nutrition policy-making and programming. The mathematical modeling technique combined with linear programming will provide insight into which food-based strategies have the potential to provide essential (micro) nutrients for women and young children. Multicriteria mapping will offer a flexible decision-aiding tool taking into account the variability and uncertainty of opinions from key stakeholders. The lessons learned throughout the project will be widely disseminated.