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Département de Nutrition et Sciences Alimentaires, Faculté des Sciences Agronomiques, Université Nationale du Bénin, BP 526 Cotonou, République du Bénin and the
Division of Human Nutrition and Epidemiology, Wageningen University, 6700 EV Wageningen, The Netherlands
*
2To whom correspondence should be addressed. E-mail: ansromarc{at}yahoo.fr
ABSTRACT
In developing countries, low food intake is often reported in children < 5 y old. Reduced appetite may be a contributing factor. We investigated whether a combination of a multivitamin-multimineral supplement and additional iron treatment improved appetite and growth of 18- to 30-mo-old stunted and anemic Beninese children. The study was placebo-controlled using VITALIA tablets (11 vitamins and 10 minerals) and ferrous fumarate tablets (66 mg of iron). One hundred fifty stunted (height-for-age Z score < -2) and anemic children (hemoglobin < 110 g/L) were randomly assigned to one of four groups: group 1, multivitamin-multimineral plus iron; group 2, multivitamin-multimineral plus placebo; group 3, placebo plus placebo; and group 4, placebo plus iron. Supplementation was daily and supervised for 6 wk. Appetite, knee-heel length, dietary intakes and morbidity were assessed before and after supplementation. Length, weight, arm circumference and hemoglobin concentration were assessed before, just after supplementation and 4 mo after the intervention. Appetite was assessed by means of an appetite test using a test food, riz-au-gras, eaten ad libitum after an overnight fast. Dietary intakes were assessed during three consecutive days in a subsample by means of the observed weighed record method. Energy intake from the habitual breakfast was significantly correlated with that from the test food (r = 0.49, n = 38, P = 0.002). There were no differences among groups in changes in appetite and growth performance. The habitual diet of the children was monotonous and contained only small amounts of animal products. The morbidity status of the children was comparable in all study groups, before as well as after supplementation. We conclude that the 6-wk multivitamin-multimineral supplementation with additional iron treatment failed to improve the appetite and growth of the children.
KEY WORDS: • appetite • growth • young children • micronutrient supplementation • deworming
In most developing countries, especially in poor areas, the high
prevalence of stunting in young children is often ascribed to
inadequate dietary intakes, infections and the mother-infant
interaction (1
). Reduced appetite due to several factors
may play an important role in this phenomenon (1
–4
).
Therefore, an improvement of appetite in stunted children, if possible,
may contribute to the improvement of their linear growth.
The effect of micronutrients on appetite and growth of children in less
developed countries is of great interest. It was reported that iron
supplementation improved appetite and growth in anemic Kenyan primary
school children (5
). It was also suggested that a
deficiency of the so-called type II nutrients may affect appetite
and linear growth of young children and that these will be restored as
soon as the missing nutrients are supplied (3
, 4
). To our
knowledge, there are few intervention studies in young stunted children
that support this statement. In fact, stunted young children are those
who are very likely to suffer from multiple micronutrient deficiency
and also those who are likely to have a poor appetite because of
infections, malnutrition and monotonous diet. This might be the case of
young children in Zè, an area situated in the south of Benin.
Indeed in the Zè area, >40% of young children have a
height-for-age Z score below -2 and most of these stunted children
(
63%) are anemic (hemoglobin < 110 g/L). Previous studies in
the south of Benin (6
, 7
) revealed that iron deficiency is
the main cause of anemia in the population. It has also been
established that parasitic infections are highly prevalent in young
children in the south of Benin. Indeed, preschool children were
infected mainly by Ascaris lumbricoides (53%),
Trichuris trichiura (51%) and hookworms (12%)
(8
). This situation is likely to generate iron deficiency
and decrease appetite in most children. In the present study, we
assessed whether a combination of micronutrient and iron
supplementation with anthelminthic treatment can improve the appetite
of young stunted and anemic children.
MATERIALS AND METHODS
Study area.
The study was carried out in Zè, a rural area situated 50 km
from Cotonou, the economic capital of the Republic of Benin. The main
income-generating activities in this area are subsistence farming,
small-scale food processing and traditional rearing of animals,
mainly pigs, chicken and goats. Most households in the study area have
poor living conditions and low purchasing power.
Subjects and sampling.
The present intervention study involved young stunted and anemic
children. The recruitment period lasted 6 mo followed by the baseline
measurements. A list of young children 18–30 mo old living in the
study area was obtained from the maternity hospitals. Weight and length
were measured in a total of 566 children and their height-for-age Z
scores were calculated. A total of 272 children were stunted
(height-for-age Z score below -2). Four with height-for-age Z scores
below -5 were excluded. A questionnaire was administrated to mothers
about breastfeeding, breakfast habits of the children and the
consumption of and preference for rice. Based on this questionnaire, 22
children were excluded because, according to the mothers, they were not
used to eating rice or did not like rice. Blood hemoglobin was measured
in the remaining 246 children. Stunted children with blood hemoglobin
below 110 g/L (n = 154) were invited to join the
study because their mothers had certified that they like riz-au-gras,
which was used as the test food. Riz-au-gras is rice prepared based on
a standard recipe. Rice is cooked in a boiling sauce containing tomato,
onion, garlic, black pepper, salt, vegetable oil and water. Informed
consent to participate in the study was obtained from the parents. At
the beginning, 154 stunted and anemic children were involved in the
study (Fig. 1
). Due to loss to follow-up, complete datasets were available for
150 children. Approximately one-half of these children were
reported by mothers to be still breastfed and the proportion of
breastfed children was similar among treatment groups. However, at
18–30 mo old, the frequency of breastfeeding was low and the
contribution of breast milk to the daily diet of the children was
assumed to be negligible. At baseline, most of the children showed a
pronounced trend to wasting (Table 1
).
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The study was placebo-controlled and blind to participants
excluding the main investigator. There were 40 children per treatment
group in the calculated study sample. Power calculations were based on
the variability of the intake of test food estimated during previous
studies and the expected difference in the mean intake of 25% to be
detected with 80% power at 5% significance levels. Using a table of
random numbers, the children were randomly assigned to one of four
treatments: multivitamin-multimineral plus iron,
multivitamin-multimineral plus placebo, placebo plus placebo and
placebo plus iron. The multivitamin-multimineral supplements
(VITALIA tablets) containing 11 vitamins and 10 minerals (Table 2
) were manufactured by Dansk Dröge A/S (Ishøj, Denmark). Iron
tablets were manufactured by Pharmaquick (Cotonou, Republic of Benin).
The daily dose was 66 mg of elemental iron in the form of one tablet of
ferrous fumarate. The placebo tablets, SERESTA FORTE Placebo, were
manufactured by Wyeth-Lederle (Hoofddorp, The Netherlands). The
tablets were given to the children at home, daily for 6 wk by
well-trained field observers. One week before the study and during
the last week of supplementation, all children received a deworming
treatment. Each child was treated with 600 mg of mebendazole (200 mg/d
for three consecutive days). Appetite, body weight, length,
knee-heel length and mid-upper arm circumference were assessed
once a week for the 3 wk before and the 3 wk after the 6-wk
intervention period. Each test day, morbidity data and the mother’s
report on the child’s appetite during the preceding day were recorded.
Blood hemoglobin was assessed at recruitment and in wk 1 and 3 after
the supplementation period. Before as well as after the supplementation
period, dietary intakes were assessed in a subsample of 38 children
randomly selected from each treatment group. Four months after the
intervention, additional anthropometric measurements were performed.
The protocol of the present study was approved by a joint scientific
committee of the Université Nationale du Bénin in Benin and
Wageningen University in The Netherlands.
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Measurements
Dietary intakes.
The habitual food intake of the children was assessed during three
consecutive days in a subsample by means of the observed weighed record
method (9
). The subsample consisted of 38 children
randomly selected from the four treatment groups using a table of
random digits. From the weighed observed records, the daily energy
intakes, the breakfast energy intake and the protein and iron intakes
were calculated for each child using a nutrition software program,
Komeet 2.1 (10
), based on a composite database created
with Vbs Edit 1.0 (11
). The database was made using data
on local foods commonly eaten in the study area and existing food
composition tables for foods commonly eaten in Africa
(12
–14
). Breakfast was defined as the first meal eaten
each day between 0700 and 1000 h.
Appetite test.
The test procedure used was set up in a previous study in the same
environment. A liquid test food (aklui), culturally appropriate and
well-accepted by children in the study area, was used. Aklui is a
porridge prepared using a commercially available dried corn product.
This food was offered to the children in the morning according to a
standardized procedure. The children’s habitual daily and breakfast
intakes were measured for three consecutive days not overlapping with
the days when the test food was provided. Energy intake from the test
food was comparable to breakfast energy intake, which was 0.8–1.0 MJ,
representing 21% of total daily energy intake. Energy intake from the
test food was significantly correlated with daily energy intake
(r = 0.41, n = 38,
P < 0.05) and with energy intake from breakfast
(r = 0.52, P < 0.01). The
within-subject day-to-day variation of the test food intake
(expressed as CV) as calculated from the triplicate measurements was
40%. The same test procedure was applied using a solid test food
(riz-au-gras) and the average within-subject day-to-day variation
of the intake of test food was 40%. This variability was comparable to
that of the energy intake at breakfast (43%). Power calculations
taking into account this variability indicated that if the standardized
test procedures are used, changes in intake of the test food of 25%
can be detected with 80% power at 5% significance level when the
sample size consists of 40 children per treatment group. We
considered the test procedure a proxy measure of appetite of young
children.
Test food.
The test food chosen for the present study was riz-au-gras, which is
rice cooked in tomato sauce. For the choice of the test food,
children’s food habits and preferences were considered. It is a
culturally appropriate food that is well-accepted by most young
children in the study area. It was prepared and supplied in a
standardized way. Its main components were rice, tomatoes and vegetable
oil. The calculated energy value of riz-au-gras was 550 kJ per 100 g. A thermo-container was used for keeping the test food warm,
50°C, during the appetite test.
Test procedure.
Each test day, a group of 25 children participated in the appetite
test. Before the first appetite test day of a child, the mother was
instructed about the test procedure. From the last meal of the day
before the appetite test until the moment the test was performed, the
child was requested not to eat any food, including breast milk. During
the appetite test, each mother and her child were seated. They were
separated from the other mother-child couples to avoid
interference. Mothers were not allowed to talk to each other during the
test. Before the start of the test, mothers were given a brief reminder
on the offering procedure. At the beginning of the test, 250 g of
test food was served in a standard plate. Then, each mother helped her
child in such a way that the child was eating ad libitum. When a child
asked for more test food, his or her plate was filled again with
another 250 g of food. When a child stopped eating, the amount of
food eaten was recorded as well as the left over amount and the
duration of the eating episode. After a 5-min break, the child was
invited to continue eating. This second eating episode offered the
child the opportunity to continue eating if he or she was not satisfied
after the first episode. Food intake during this second episode was
also measured along with eating duration. The standard offering
procedure included three episodes. During the appetite test, each child
was continuously monitored by an observer whose task was to measure and
present the food. The observer also ensured that the child was not
verbally encouraged to eat or forced by pressure from the mother or
caretaker. The observer recorded the duration of each eating episode,
made notes on mother’s remarks about the child’s attitudes during the
test and performed the interview on morbidity and obtained the
mother’s report on the child’s appetite. Observers were given
instructions for limiting their influences on child’s attitudes during
the test. Based on the intake of the test food and the eating duration,
the individual food intake per minute was calculated for the first
eating episode and for the sum of the three episodes, each test day.
For all calculations, the amount of food left on the plate or not eaten
by a child was also measured and considered.
The within-subject day-to-day variations of energy intake from riz-au-gras, expressed as CV fluctuated from 33% to 39% before supplementation and 26% to 39% after supplementation.
Anthropometry.
Body weight was measured to the nearest 0.1 kg using a beam scale
(Babies and Toddlers scale model 625 T; CMS Weighing Equipment, London,
UK). Length was measured to the nearest 0.1 cm and mid-upper arm
circumference was measured on the left side of the body one-half
way between the tip of the shoulder and the elbow with the subject’s
arm hanging freely along the body using a flexible tape. Readings were
performed to the nearest 0.1 cm. On appetite test days, weight was
measured for each child after he or she had completed the appetite test
and it was corrected later for the amount of test food eaten. This
procedure was used to limit possible fear from the child, which may
affect the appetite test. The knee-heel length was measured by
knemometry (15
, 16
) using a knemometer (type KNB Serial
number 0066; Force Institute, Brondby, Denmark). Each measurement of
the knee-heel length consisted of three sets of five readings and,
then, an average value was calculated. Weight-for-height and
height-for-age Z scores were calculated based on the National Center
for Health Statistics reference data and by means of the ANTHRO
software (Centers for Disease Control and Prevention, Atlanta, GA).
Blood hemoglobin.
Blood hemoglobin concentration (g/L) was measured using a finger prick
blood-sampling technique and a photometry analysis method: the
HemoCue device (HemoCue AB, Ängelholm, Sweden) (17
).
During blood sampling, the child’s hand from which the blood sample
was taken was kept warm. The finger was straight but not tense. Using a
dry absorbent pad, the first two drops of blood were wiped away and the
sample was taken from a spontaneous blood flow. The investigator
ensured that the drop of blood was large enough to fill the cuvette
completely. The cuvette was filled in a continuous process and analyzed
immediately. The HemoCue photometer was checked before each session
using a control cuvette provided with the HemoCue device.
Morbidity status and reported appetite.
Mothers were interviewed on the frequency of specific symptoms of illness on the day before the test day, and on the test day itself. Per child, morbidity status was recorded for 6 d in the presupplementation period and for 6 d in the postsupplementation period. This was done by means of a checklist that includes questions related to presence of diarrhea, coughing and runny nose. Diarrhea was defined as three or more liquid or semiliquid stools per day. Fever was determined by temperature measurement using an ear thermometer (Braun ThermoScan Instant Thermometer model IRT 1020; ThermoScan, San Diego, CA). Fever was defined as temperature > 38°C. Each mother was asked to report on her child’s appetite on the day before the test day. To the question, "How did your child eat throughout the day before the test day? ", the mother’s answers were the following: my child ate well or my child did not eat well. When the child ate well, his or her appetite was labeled as good. When the child did not eat well, his or her appetite was labeled as not good. Per child, before and after supplementation, frequencies of fever, diarrhea, coughing and runny nose were estimated as the number of days with each specific symptom divided by the number of observation days. The frequency of good appetite as reported by mothers was estimated in the same way, before and after supplementation.
Statistical analyses.
Before and after supplementation, the energy intake from the test food,
eating duration, intake per minute, habitual daily energy intake and
breakfast energy intakes were evaluated by ANOVA. For each variable,
day and subject were the main sources of variance studied. Because
there was no systematic day effect on each variable, means were
calculated for each subject, before and after supplementation. Changes
in the energy intake from the test food, intake per minute, eating
duration, habitual daily energy intake and energy intake from the
habitual breakfast, height-for-age and weight-for-height Z scores, arm
circumference, knee-heel length and blood hemoglobin were compared
among treatment groups using one-way ANOVA (18
).
Within each treatment group, differences in intake of test food and
anthropometric variables before and after the supplementation period
were examined using paired t test. Associations between
the energy intake from the test food and energy intakes from habitual
daily and breakfast were studied by the Pearson’s correlation
procedure (18
). Before and after supplementation,
frequencies of fever, diarrhea, runny nose, coughing and good appetite
as reported by mothers were compared within each study group by means
of the Mann-Whitney U test and among groups by means
of Wilcoxon signed-ranks tests (19
). Data analyses
were performed using SPSS Statistical Package for Windows (SPSS,
Chicago, IL). All statistical tests were two-tailed and statistical
significance was set at 5%.
RESULTS
Appetite test.
The total energy intake from the test food increased significantly in
all treatment groups after supplementation (P < 0.05).
However, there were no significant differences among groups
(Table 3
).
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The habitual energy, protein and iron intakes were mainly provided by foods of plant origin. Within each group, the habitual daily and breakfast energy intakes did not change significantly after supplementation. Means for the overall sample were 3.6 ± 1.0 MJ for the daily energy intake, 23 ± 11 g for protein intake and 6.2 ± 2.5 mg for iron intake. Breakfast energy intake was significantly associated with energy intake from the test food before supplementation (r = 0.49, n = 38, P = 0.002) as well as after supplementation (r = 0.42, n = 38, P = 0.008). Correlations between the energy intake from the test food and the habitual daily energy intake were positive but less pronounced before supplementation (r = 0.22, n = 38, P = 0.18) as well as after supplementation (r = 0.26, n = 38, P = 0.12).
Anthropometry.
Height-for-age and weight-for-height Z scores, arm circumference and knee-heel length increased similarly in all groups (P < 0.05). Weight-for-height Z scores improved in children who received a combination of multivitamin-multimineral and iron supplements and in children who received only placebos (P < 0.05). Knee-heel length increased similarly in all groups after supplementation (P < 0.001). Additional anthropometric measurements performed 4 mo after the intervention revealed no significant differences in changes among study groups.
Blood hemoglobin.
In the first week after supplementation, blood hemoglobin increased by
3 g/L (P = 0.071) in children who received both
multivitamin-multimineral and iron tablets and by 5 g/L
(P < 0.007) in those who received only iron
supplements (Table 4
). Blood hemoglobin decreased by 4 g/L (P = 0.166) in the
group of children who received only placebos and by 1 g/L (P
= 0.745) for those who received multivitamin-multimineral and
placebo. Changes in blood hemoglobin in the 1st wk after
supplementation were significantly higher in the two groups who
received iron supplements than in the other two groups (P
= 0.027). In wk 3 after supplementation, blood hemoglobin did not
differ among groups, as was the case before supplementation. Blood
hemoglobin measured 4 mo after the intervention did not differ among
groups, with a mean concentration of 100 ± 14 g/L.
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Frequencies of fever, diarrhea, runny nose and coughing were comparable
in all groups before and after supplementation (Table 5
). Children who were reported by their mothers to have good appetites
had higher energy intake from the test food compared with their
counterparts who did not have good appetites (P < 0.05), before and after supplementation.
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DISCUSSION
The objective of this study was to investigate whether a
combination of multivitamin-multimineral and iron supplements
improved the appetite and growth of young stunted and anemic Beninese
children. We were interested in detecting among-group differences
in intake of the test food of 25%. Such an improvement seems to be
feasible if we consider the decrease in food intake that is commonly
observed in children living in comparable environments. Indeed,
according to data from community-based studies in several
developing countries, the decrease in food intake due to various
infections in young children may fluctuate between 15% and 33% and
even more in cases of severe infections (20
–22
).
As expected, blood hemoglobin measured in wk 1 after supplementation was significantly increased in the children who received iron supplements. This means that anemia in the children was in part due to iron deficiency. However, anemia remained prevalent in all groups, suggesting that other factors also contributed to the anemia and/or the 6-wk iron supplementation was insufficient for a proper reduction of anemia in these children.
None of the among-group differences in changes in the energy
intakes from the test food, after the intervention, were significant.
If the 6-wk micronutrient supplementation had resulted in an
improvement in energy intake from the test food by at least 300 kJ,
representing 25% of their mean intake, we would have detected a
significant difference among groups with a power of at least 80% at a
significance level of 5%. Therefore, we can safely assume that the
intervention did not result in a 25% improvement in intake of test
food over the 6-wk intervention. Likewise, the growth performance of
the children was not affected by the intervention.
It is unlikely that the lack of improvement of our appetite measure and
linear growth would be related to the targets of the intervention.
Indeed, the young children had height-for-age Z scores < -2 and
blood hemoglobin < 110 g/L. Most of the children showed a
pronounced trend to wasting. They were all likely to have multiple
micronutrient deficiencies and reduced appetites. Therefore, a positive
appetite and growth response to the intervention could be expected. It
is also unlikely that the morbidity status of the children would be a
confounding factor. In fact, helminth infection was under control.
Frequencies of fever and diarrhea stayed low during the study and
frequencies of runny nose and coughing were not different among groups
throughout the study. It is also unlikely that the dose of each
micronutrient present in the multivitamin-multimineral supplements
would be insufficient. Indeed, for all vitamins and minerals present,
the recommended daily allowances for proper growth were fulfilled. The
additional iron was also supplied in sufficient amount (66 mg of
elemental iron/d), in agreement with the current recommended doses for
the treatment of iron deficiency anemia (23
, 24
). The lack
of improvement of our appetite measure could not be related to the
method used for appetite measurement. In fact, we have studied the test
procedure in previous studies in young children in the study area and
found that the mean energy intake from the test food measured in
triplicate can be considered a good estimate of the children’s
appetite. In the present study, the correlation between the energy
intake from the test food and the energy intake from the habitual
breakfast was positive, before supplementation (r = 0.49, n = 38, P = 0.002) and after
supplementation (r = 0.42, n = 38,
P = 0.008). The observed within-subject variability
in the test food intake was high (40%), despite the careful choice of
test food and the standardization of the test procedure but this value
is consistent with variations commonly reported in dietary studies
(25
–28
).
The results of the dietary assessment suggested that the children’s
habitual energy intake was insufficient, meeting only 75% of the
recommended energy intakes for children of the same ages
(29
). The quality of their usual diet may also have been
inadequate, as suggested by its monotony and the marginal amounts of
animal foods it provides. This means that the overall dietary intakes
of the children were likely to be inadequate; therefore, most of them
might have not only multiple micronutrient deficiencies, but also
chronic energy-protein deficiencies. This finding is consistent
with the results of our previous dietary studies in young children in
the south of Benin (8
). It also supports the general
agreement that the level of the dietary intakes of young children in
developing countries is less than the current recommendations
(30
, 31
). If the children had a chronic energy-protein
deficiency in addition to multiple micronutrient deficiencies,
micronutrient supplementation alone may not have been sufficient to
generate a significant improvement of their nutritional status.
Consequently, their appetite and linear growth might not improve
meaningfully until these deficiencies are eliminated. Therefore,
supplementation of energy and high quality protein may be needed as
well.
A second factor that may explain the lack of improvement in intake of the test food and growth is the duration of the supplementation. Because the suspected multiple micronutrient deficiencies in the children may have been present for a long period, the size of the body stores and the tissue concentrations of several micronutrients could have been marginal. Consequently, the metabolic pathways that depend upon these micronutrients might be severely compromised and therefore, a longer supplementation period would be required to replete micronutrient stores and permit optimum body functioning.
We conclude that a 6-wk multivitamin-multimineral and iron supplementation improved iron status but was not sufficient to improve the intake of the test food and growth of young stunted and anemic Beninese children. These children have probably been continuously exposed to a poor quality diet and possibly also have chronic energy and protein deficiencies. Therefore, we suggest that to achieve a substantial improvement of our appetite measure and growth in these children, supplementation of energy, protein and micronutrients for a period long enough to permit a sufficient correction of the energy-protein-micronutrient deficiencies might be necessary.
FOOTNOTES
1 Financial support was provided by the Foundation
for Nutrition and Health Research (SOVG) and by the Nestlé
Foundation. 
Manuscript received 14 March 2001. Initial review completed 2 May 2001. Revision accepted 22 August 2001.
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