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Supplement: Nutrient Composition for Fortified Complementary Foods

Proposed Vitamin A Fortification Levels¹

International Science and Technology Institute, Inc., Arlington, VA 22209

²To whom correspondence should be addressed. E-mail: Jmora{at}istiinc.com.

	ABSTRACT

TOP ABSTRACT Methods Results Discussion LITERATURE CITED

 
Fortified complementary foods could be effective in preventing and controlling vitamin A and other common nutritional deficiencies in young children. Milk from well-nourished women is an excellent source of vitamin A. However, in Latin America many children are weaned prematurely and must receive the entire requirement of vitamin A from food. This paper proposes vitamin A fortification levels for foods targeted for children aged 6–23 mo to meet the existing intake gap among both breast-fed and weaned infants and young children. Estimates assume a nonsignificant contribution of common complementary foods and average levels of human milk intake by breast-fed infants and children. The estimated vitamin A gap for breast-fed infants aged 6–11 mo amounts to 63–92 µg RE [16–23% of recommended daily intake (RDI)] and for breast-fed children reaches 125 µg RE (31% of RDI). Weaned infants and children would have to fully meet the RDI (400 µg RE) from complementary foods. A fortified complementary food with 500 mg RE/100 g of dry product provided daily in a single ration of 40 g would meet 50% of the gap for weaned infants aged 6–11 mo and would raise the total intake above RDI for breast-fed infants aged 6–8 mo (125%) and 9–11 mo (127%). The same fortified food given in a daily ration of 60 mg would meet most of the gap (75%) for weaned children aged 12–23 mo and would increase total intake of breast-fed children aged 12–23 mo well above the RDI (144%), with no risk of exceeding established upper tolerable intake levels.

KEY WORDS: • vitamin A • fortified complementary foods • infants and children

Vitamin A and other micronutrient deficiencies in children have been found to be important public health problems in a number of countries in Latin America and the Caribbean (LAC)²,with obvious implications for children’s health and survival (1). Vitamin A deficiency to a great extent results from deficient dietary intake and use of vitamin A. Despite recent positive trends, vitamin A deficiency remains a significant problem in several countries. Recommended interventions include periodic pharmaceutical supplementation, food fortification and dietary diversification to increase consumption of food sources of the vitamin through nutrition education and social-marketing programs.

Fortification of selected food staples with vitamin A is a sound option for increasing consumption and diminishing the intake gap. Currently, mandatory fortification of sugar is implemented in El Salvador, Guatemala, Honduras and Nicaragua. Voluntary fortification of other foods is also encouraged in the region. Fortification of specially designed noncommercially marketed complementary foods is targeted for infants and young children in the critical weaning period from 6–24 mo of age, when the risk of vitamin A deficiency tends to be the highest; fortification has been used as a part of public health and nutrition programs to prevent and control nutritional deficiencies (2). If properly designed, manufactured and distributed to children at risk, fortified complementary foods may significantly contribute to control nutritional deficiencies in the target population. Their nutritional impact might be even greater and more sustainable if such foods could be made commercially available at affordable prices to populations at risk. Specially fortified foods are also used in school feeding programs in Central America and Peru.

In the LAC region, governments and international agencies allocate considerable resources to programs that provide fortified complementary foods to low income and malnourished infants and young children. The role of such foods in Latin America was recently reviewed in a Pan-American Health Organization technical consultation regarding their nutrient composition and relevant nutritional impact (3). A salient finding was the wide variation in nutrient composition of existing fortified complementary foods. Although the rationale for this variation is not clear, it may have important implications in nutrient absorption, acceptability and effect on nutritional status. Eight processed complementary foods that are regularly consumed in the LAC region were identified. All of these are water-soluble cereal-based powdered products with large differences in vitamin A content (600–1500 µg RE/100 g of dry food), protein and other nutrients. Food preparations have a liquid or semisolid consistency (e.g., low density beverage, pap or porridge of higher viscosity or soup, puree, sauce and cake). The foods were usually targeted for infants aged >6 mo and had a ration size of 20–90 g of dry product to be dissolved in water in amounts ranging from 25 mL for a pap or porridge to 150–250 mL for a beverage.

As countries expand the use of specially designed fortified complementary foods in their nutrition and supplementary feeding programs for infants and young children, the need for guidelines on nutrient composition of such foods becomes more pressing. The purpose of this paper is to develop recommendations on vitamin A fortification levels for processed complementary foods targeted for children aged 6–23 mo in the LAC region. In view of the scant information available on the vitamin A intake gap of infants and young children in LAC countries, these recommendations should be taken as tentative and should be adjusted to the particular local context whenever relevant information is available.

	Methods

TOP ABSTRACT Methods Results Discussion LITERATURE CITED

 
A simple method was used to estimate the overall nutrients required from complementary foods in a WHO review of current scientific knowledge on complementary feeding of young children in developing countries (4). In this paper, a similar method has been used to estimate the needs for vitamin A from fortified complementary foods for infants and young children in the LAC region. In the WHO review, total nutrient requirements for complementary foods were estimated by subtracting the amounts commonly provided by human milk from the 1988 FAO/WHO recommended daily intakes (RDI) (5). Because there are wide variations in the amount of human milk consumed by children in developing countries, the WHO report estimates nutrient needs from complementary foods for low, average and high levels of the usual human milk intake. The volume of human milk for each consumption level was multiplied by an average content of 500 µg RE/L and the resulting vitamin A intake was subtracted from the RDI. The difference is proposed as the total amount of vitamin A that must be provided by complementary foods to meet the intake gap of infants and children with different levels of human milk consumption at ages 6–8, 9–11 and 12–23 mo.

We have adjusted these estimates in reference to the RDI for vitamin A established by FAO/WHO in 2002 (6) as the safe levels of intake for infants aged 6–11 mo (400 µg RE/d) and for children aged 12–23 mo (400 µg RE/d). To be consistent with the process followed for estimating dietary gaps in other papers of this supplement, the vitamin A gap to be met by fortified complementary foods was estimated for breast-fed infants and children assuming medium levels of breastmilk intake from Table 7 of the WHO publication (4). To estimate the intake gap that needs to be supplied by fortified complementary foods, intake from foods other than human milk (common complementary foods) were not taken into account because many infants and young children may not receive any other source of vitamin A in their diet apart from breastmilk, particularly in other regions. The goal would be to meet most, if not all, of the estimated gap by means of a fortified complementary food.

	Results

TOP ABSTRACT Methods Results Discussion LITERATURE CITED

 
Estimates of the vitamin A gap of children aged 6–23 mo are provided in Table 1. There is a significant contribution of human milk to meet the vitamin A needs of breast-fed infants and children. RDI would be fully met when breastmilk intake levels are high, particularly in infants, whereas a mild-to-moderate gap would remain at medium levels of intake. Some evidence exists for a significant increase in human milk retinol levels up to >600 ug RE/L associated with universal sugar fortification in Central America (7). Weaned infants and children will have to meet practically all of their vitamin A needs from complementary foods. At average levels of intake, human milk would meet 77–84% of RDI for infants aged 6–11 mo and 69% of RDI for children aged 12–23 mo. The estimated intake gap would be 63–92 ug RE (16–23% of RDI) for breast-fed infants aged 6–11 mo and 125 ug RE (31% of RDI) for breast-fed children aged 12–23 mo. The actual size of the gap may vary by country and even among areas in each country as a result of the vitamin A content in human milk, different breast-feeding patterns and variable quantity and quality of complementary foods commonly consumed.

Based on our estimated intake gaps, a 40-g daily ration of a food containing 500 µg RE/100 g of dry product would provide 200 µg RE (50% of RDI), which would largely meet the intake gap of breast-fed infants aged 6–11 mo at 125–127% of RDI, and 50% of the gap of fully weaned infants of the same age. The same fortified food given as a daily ration of 60 g (300 µg RE or 75% of RDI) would meet the intake gap of breast-fed children 12–23 mo and most (75%) of the requirement for weaned children of the same age, with no risk of exceeding the 600 ug RE/d Tolerable Upper Intake Levels (UL) established by the Institute of Medicine of the US Academy of Sciences (9). These estimates should be adjusted for countries where universal vitamin A fortification of a food staple widely consumed by the target population, such as sugar, is implemented.

	Discussion

TOP ABSTRACT Methods Results Discussion LITERATURE CITED

 
Recommendations for vitamin A levels in fortified complementary foods are expected to be relevant for countries where deficient vitamin A intake and the resulting vitamin A deficiency in infants and young children is a significant public health problem. In the past decade, subclinical vitamin A deficiency has been documented as an important public health problem in 16 countries of the LAC region from which information was available: a severe problem in 5 countries, a moderate problem in 6 and a mild problem in 5 (1). More recently, significant progress has been reported from countries where mandatory sugar fortification has been properly implemented (El Salvador, Guatemala and Honduras) or high coverage levels of supplementation have been achieved (Nicaragua). There is no recent information from other countries, but in the absence of either specific programs or significant social and economic improvements, vitamin A deficiency is likely to persist.

Based on the FAO food balance sheets, the daily per capita availability of vitamin A has been estimated to reach 599 µg RE for South America and 920 µg RE for North and Central America. West (10) recently revised such estimates because of strong evidence that the actual bioavailability (conversion to retinol) of provitamin carotenoids is significantly lower (e.g., 1:12–24 ratio) than the 1:6 ratio previously estimated. The revised per capita figures are 372 µg RE for South America and 581 µg RE for North and Central America, which are 38% lower than the original estimates. On the basis of the revised supply estimates, deficient intake of vitamin A is likely to be widespread in the LAC region, and infants and young children are known to be at highest risk.

It has been recommended that full-term infants with appropriate weight for gestational age should be exclusively breast-fed until 6 mo of age, with complementary foods required thereafter. With optimum retinol levels in human milk (>500 µg RE/L), the daily amounts of human milk consumed in developing countries would provide nearly 100% of the RDI during the 1st 6 mo of life but a significantly lower proportion after 6 mo (6). This is in part because both human milk production and its vitamin A content drop over time. It has been suggested that the vitamin A needs of children whose mothers have normal milk vitamin A concentrations would be met by the appropriate selection of complementary foods (4). However, the bioavailability of vitamin A from plant sources appears to be significantly lower than previously estimated, thus the actual contribution of common complementary foods to meet vitamin RDI may have been overestimated (10).

Human milk alone, if consumed regularly at the high levels of intake and vitamin A content observed in exclusively breast-fed children, would theoretically be sufficient to fully meet the vitamin A needs of practically all children aged 6–23 mo. However, the duration of exclusive breast-feeding is very short in the LAC region (1–4 mo) and throughout the 6–23-mo period a growing proportion of children are fully weaned. According to recent Demographic and Health Surveys in eight LAC countries, the proportion of fully weaned children is 30% by age 12 mo and 52% by age 18 mo. For fully weaned infants and children and for breast-fed children consuming average-to-low amounts of human milk, fortified complementary foods would be needed to meet the remaining vitamin A intake gap. The actual size of this gap is hard to estimate without reliable food consumption data for each age group.

Some countries are currently implementing large-scale supplementation programs (11). However, coverage rates are not consistent over time, supplementation is independent from the food supply and there are concerns about its long-term sustainability. There, the contribution from supplementation to meet the vitamin A needs is not constant enough to have an important bearing on estimating the intake gap to be met by fortified foods. Furthermore, supplementation is usually conceived as a temporary intervention that would be phased out as food-based vitamin A intake improves. However, in countries with sustained high coverage of supplementation in children aged 6–23 mo, fortified complementary foods for this age group may not be needed to meet their vitamin A requirements.

In four countries of Central America (El Salvador, Guatemala, Honduras and Nicaragua), sugar fortified with 5 µg RE/g is almost universally consumed. Based on an average sugar consumption of 20 g/d, fortified sugar has been estimated to provide 100 µg RE/d (25% of RDI) for children aged 12–23 mo (12), but sugar intake of infants would be too low to make a significant contribution to meet their intake gap, although they may benefit from the increased retinol content of human milk. Estimates in these countries may be adjusted to reflect the actual vitamin A content of sugar at the household level. In Guatemala the vitamin A level of Incaparina, a fortified complementary food, has been reduced to account for the contribution of fortified sugar. It has been estimated that at the usual consumption levels of Guatemala, fortified sugar may meet the intake gap of individuals older than 2 y but only partially meet that of young children, particularly those who are not breast-fed (13). No other commercially processed staple food is universally fortified with vitamin A in the LAC region.

A fortified complementary food should meet most if not all of the vitamin A intake gap after considering the contribution of human milk and eventually of universally fortified staple foods (e.g., sugar in Central America). Breast-fed infants and children with high breastmilk intake levels would be expected to fully meet their vitamin A needs from human milk thus would not need to be provided a fortified complementary food. Breast-fed infants and children 6–23 mo with medium levels of breastmilk intake would still have a significant gap to meet (16–31%). For fully weaned infants and children, a fortified complementary food should meet most of the intake gap resulting from the absence of human milk.

A 40-g daily ration of a cereal-based fortified complementary food containing 500 µg RE/100 g of dry product, that is 200 µg RE, would meet 50% of the estimated dietary gap of weaned infants aged 6–11 mo and would increase total intake for breast-fed infants to 125% and 127% of RDI for ages 6–8 and 9–11 mo, respectively. A 60-g ration of the same food would provide 300 µg RE (75% of RDI) to meet a large proportion of the gap for weaned children aged 12–23 mo and would increase total intake of breast-fed children well above the RDI (144%), with no risk of exceeding the 600 ug RE/d UL recommended by the Institute of Medicine of the U.S. National Academy of Sciences (9). The food can be added to a clean source of water and consumed in the form of a pap.

	FOOTNOTES

 
¹ Presented as part of the technical consultation "Nutrient Composition for Fortified Complementary Foods" held at the Pan American Health Organization, Washington, D.C., October 4–5, 2001. This conference was sponsored by the Pan American Health Organization and the World Health Organization. Guest editors for the supplement publication were Chessa K. Lutter, Pan American Health Organization, Washington, D.C.; Kathryn G. Dewey, University of California, Davis; and Jorge L. Rosado, School of Natural Sciences, University of Queretaro, Mexico.

³ Abbreviations used: LAC, Latin America and the Caribbean; RDI, recommended daily intake; RE, retinol equivalents.

	LITERATURE CITED

TOP ABSTRACT Methods Results Discussion LITERATURE CITED

 

1. Mora, J. O., Gueri, M. & Mora, O. L. (1998) Vitamin A deficiency in Latin America and the Caribbean: an overview. Pan. Am. J. Public Health 4:178-186.

2. Brown, K. H. & Lutter, C. K. (2000) Potential role of processed complementary foods in the improvement of early childhood nutrition in Latin America. Food Nutr. Bull. 21:5-11.

3. Pan American Health Organization (2000) Special issue on processed complementary foods in Latin America. Food Nutr. Bull. 21:3-101.

4. World Health Organization (1998) Complementary Feeding of Young Children in Developing Countries: a review of current scientific knowledge (WHO/NUT/98.1) 1998 WHO Geneva, Switzerland.

5. FAO/WHO Joint Expert Consultation (1988) Requirements of Vitamin A, Iron, Folate and Vitamin B12. FAO Food and Nutrition Series No. 23 1988 FAO Rome, Italy.

6. FAO/WHO (2002) Human Vitamin and Mineral Requirements. Report of a joint FAO/WHO expert consultation, Bangkok, Thailand 2002 FAO Rome, Italy.

7. Arroyave, G., Aguilar, J. R., Flores, M. & Guzman, M. A. (1979) Evaluation of Sugar Fortification with Vitamin A at the National Level. Institute of Nutrition of Central America and Panama-Pan American Health Organization (PAHO). Scientific Publication No. 384 1979 PAHO Washington, D. C.

8. Codex Alimentarius (1999) Codex Standard for Processed Cereal-Based Foods 1999 FAO Rome, Italy.

9. Institute of Medicine (2001) Dietary Reference Intakes for Vitamin C, Vitamin K, Arsenic, Boron, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc 2001 National Academy Press Washington, D.C.

10. West, C. E. (2000) Meeting requirements for vitamin A. Nutr. Rev. 58:341-345.[Medline]

11. PAHO/WHO (2001) Integrated Vision for Vitamin A Supplementation in the Americas. May 2–4, 2001–Managua, Nicaragua. Pan American Health Organization (PAHO/WHO) 2001 PAHO Washington, D.C.

12. Dary, O. (1998) Sugar fortification with vitamin A: A Central American contribution to the developing world. Food Fortification to End Micronutrient Malnutrition. State of the Art. Symposium Report August 2, 1997. 1998:95-98 The Micronutrient Initiative Ottawa, Canada.

13. Krause, V., Delisle, H. & Solomons, N. W. (1998) Fortified foods contribute one half of recommended vitamin A intake in poor urban Guatemalan toddlers. J. Nutr. 128:860-864.[Abstract/Free Full Text]

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