NPS1-8 IMAPP (Intake, Monitoring and Program Planning): Software nutrient intake data
INTAKE, MONITORING AND PLANNING PRO- GRAM (IMAPP) – WHAT ARE ITS CAPABILITIES?
A. Carriquiry1, S. Murphy2, L. Allen3, B. de Benoist4
1Department of Statistics, Iowa State University, USA
2Cancer Research Center, University of Hawaii, USA
3USDA-ARS Western Human Nutrition Research Center, USA
4WHO, Switzerland
IMAPP was developed at Iowa State University in colla- boration with University of Hawaii and USDA-ARS Western Human Nutrition Research Center with funding from WHO.
IMAPP is freely available from http://www.side.stat.iastate.
edu/. IMAPP can be used to assess and to plan nutrient intakes.
For assessment, IMAPP implements the ISU Method (Nusser et al., 1996) to estimate usual nutrient intake distributions and the IOM recommendations (DRIs: Applications in Dietary As- sessment) to compute prevalence of inadequate or of excessive intakes. For planning, IMAPP implements the recommenda- tions by WHO/FAO in Guidelines for Food Fortification with Micronutrients (WHO 2006). IMAPP estimates usual intake distributions of nutrients for groups defined by age, gender and pregnancy/lactation using daily intake information. Ideally, two or more observations are available at least for a sub-sample of individuals. However, IMAPP permits adjustment of data- sets with no replicates by using external intra-person variances supplied by the user or by IMAPP. The EARs and ULs of a long list of nutrients are built into IMAPP and the program “un- derstands” which form of the nutrient (e.g., retinol or vitamin A) should be used to estimate inadequacy or excess. IMAPP also allows for different bioavailability of iron and zinc. Given a target prevalence of inadequacy of a nutrient in a population group and daily intake of potential vehicles, IMAPP will com- pute the amount of the nutrient to be added to each vehicle to meet the target prevalence in the group. It will also estimate the resulting prevalence of inadequacy and of excess in all other population sub-groups. Because of its many built-in functions, IMAPP can be used by practitioners with little statistical or computational background.
Key words: Usual intake, assessment, fortification, inade- quacy, DRI.
USING THE IMAPP SOFTWARE; INFORMATION REQUIRED FOR OPTIMAL APPLICATION
S. Murphy
University of Hawaii, USA
The intake monitoring, assessment, and planning program (IMAPP) provides software to analyze nutrient inadequacies and potential excessive intakes within a population group.
However, the power of the software can only be realized if accurate information is provided by the user. Before using IMAPP, it is necessary to collect daily dietary intake data (e.g., from 24 hour recalls or records) for each individual in a sample of the population. Intakes of the nutrients of interest must be provided for each person.
Thus, the user must have access to food composition data that can correctly convert food intakes into nutrient intakes.
To apply the appropriate nutrient standards, age, gender, and reproductive status should be indicated for each person.
The nutrient standards that are used for the calculations are the average nutrient requirements and the safe upper levels of intake. These standards may be specified by the user or the de- fault “harmonized” values in the program may be used. To ad- just for day-to-day variation in intakes, multiple days of dietary data for at least a representative subsample of the population should be provided, although it is also possible to use default values from other populations for these variance estimates.
Bioavailability factors may be specified for iron and zinc, or may be based on dietary patterns.
If IMAPP is being used to design fortification programs, daily intakes of potential food vehicles for fortification must also be provided. Intake for each vehicle should be calcula- ted after disaggregating mixed dishes into their ingredients.
IMAPP will then calculate new prevalences of nutrient inade- quacies assuming specific levels of fortification of one or more food vehicles. Thus, IMAPP is an important tool for assessing intakes as well as planning intakes, but optimal application de- pends on high quality intake data provided by the user.
Key words: Intake assessment, intake planning, fortifica- tion.
Paralleled Symposia
Ann Nutr Metab 2013;63(suppl 1): 1-1960 Published online: September 13, 2013
HARMONIZING MICRONUTRIENT RECOMMEN- DATIONS WORLD-WIDE
L H. Allen1, S P. Murphy2
1USDA, ARS Western Human Nutrition Research Center, USA
2University of Hawaii Cancer Research Center, Hawaii, USA
Background and Objectives: Harmonization of nutrient intake recommendations is important because advice concer- ning nutrient intakes, formulation of complementary foods, levels for fortification and labeling is usually provided at the global or regional level. Actual requirements vary little across the world yet the process for creating and revising recommen- dations is costly and time-consuming especially for low inco- me countries, and already includes some uncertainty. Current terms for recommended levels are inconsistent and WHO/
FAO has no Estimated Average Requirements or Upper Levels.
Our objective was to use a systematic approach to develop glo- bal recommendations.
Methods: Values were compared from the Institute of Me- dicine (IOM, US/Canada), WHO/FAO and the UK primarily.
IOM was used if values differed <10%, otherwise scientific cri- teria were applied to choose best estimates.
Conclusion: New harmonized values were derived for use in IMAPP and elsewhere. A process for review and revision is needed.
Key words: Recommended nutrient intakes.
APPLICATION OF THE IMAPP FOR PLANNING, MONITORING AND EVALUATION OF FLOUR FOR- TIFICATION PROGRAMS
H. Pachon
Flour Fortification Initiative, Atlanta, USA
Background and objectives: The planning, monitoring and evaluating of cereal-grain fortification programs require dietary intake data (or proxies thereof). These data are nee- ded to determine which food vehicle(s) to fortify and in what amounts (planning); if a change in dietary patterns warrants a change in food vehicles or fortification levels (monitoring);
and whether intended beneficiaries are consuming fortified foods in sufficient quantities and frequency to expect health improvements (evaluation). The objective of this analysis is to explore the use of Intake, Monitoring and Program Planning (IMAPP) software with dietary intake data for countries that are in the planning, monitoring or evaluation stages.
Methods: Dietary data from countries (e.g. Mongolia in the planning stage, South Africa in the monitoring stage, and In-
donesia in the evaluation stage) will be analyzed using IMAPP.
Results and conclusions: Recommendations for countries in the planning, monitoring and evaluation stage will be genera- ted using IMAPP results. The pros and cons of IMAPP for such exercises in the context of fortification will be discussed.
Key words: Fortification, planning, monitoring, evaluation, IMAPP.
ESTABLISHING DESIRABLE FORTIFICANT LEVELS FOR MICRONUTRIENTS IN FOODS FOR INFANT AND YOUNG CHILD FEEDING: EXAMPLES FROM THREE ASIAN COUNTRIES
M M. Gibbs1, A. Carriquiry2, M V. Capanza3, R. Gibson1
1Department Human Nutrition, University of Otago, Dunedin, New Zealand
2DepartmentStatistics, Iowa State University, Ames, Iowa, USA
3Food & Nutrition Research Institute, Bicutan, Mani- la, Philippines
Background and objectives: Concern has been raised whether micronutrient levels in manufactured cereal-based fortified foods for infant and young child feeding available in low income countries meet their high micronutrient needs.
We used WHO recommended procedures to establish desira- ble fortificant levels for three problem micronutrients in Asian children’s diets.
Methods: Dietary data collected earlier from Filipino (n=1374; 6-36 months), Mongolian (n=179; 12-36 months), and Cambodian (n=177; 12-36 months) children were used to assess prevalence of inadequate and excessive intakes of calcium and zinc (cut-point method) and iron (full probabi- lity approach) after adjusting usual intake distributions with PC-SIDE using internal or external within-person variances.
Fortificant levels were determined by repositioning usual in- take distributions so 2.5th percentile for each distribution and target population equalled the EAR (calcium, zinc) or so that full-probability prevalence of inadequate intakes of iron was no larger than 2.5%.
Results: Prevalence of inadequate intakes was 70% for cal- cium and iron, except Filipino infants (30% for calcium) and Cambodian toddlers (41% for iron); but <1% for zinc for todd- lers in Mongolia and 20% in Cambodia. Prevalence of exces- sive intakes was <1% for zinc, calcium, and iron, except for Mongolian toddlers (11% for zinc). Desirable fortificant levels, although apparently negligible for zinc, were 530 to 783 mg for calcium, and 10.8 to 22.8 mg for iron (per 100 gram). Fortifi- cant levels can be estimated from 24-hr recalls, preferably by applying internal within-person variances.
Conclusions: Fortification with calcium and iron was ne- cessary, but seemingly not for zinc, despite a high prevalence of low serum zinc concentrations, suggesting the need for better defined cut-offs for risk of zinc deficiency in young children based on the prevalence of inadequate intakes of dietary zinc and/or serum zinc.
Acknowledgement: Supported by Univ. Otago Research Committee.
Key words: Micronutrient fortificants; PC-SIDE; within- person variation; Estimated Average Requirements.
PS1-8 Food-based approaches to improve multi- ple micro-nutrient deficiencies and protein qua- lity
DIETARY APPROACHES TO DIET QUALITY IMPRO- VEMENT
S. Murphy
University of Hawaii, USA
Although dietary supplements and fortified foods can con- tribute to meeting nutrient intake standards, they do not appear to have many of the health benefits of food sources of nutrients, especially in the prevention of chronic diseases. Furthermore, they are not typically as sustainable as foods that are available locally. In the Child Nutrition Project (CNP) in rural Kenya, school-based snacks were developed to supply six micro-nu- trients of concern: iron, zinc, vitamin B12, vitamin A, calcium, and riboflavin. Two snacks incorporated animal-source foods to provide several of these nutrients: the milk snack supplied calcium, vitamin B12, and riboflavin while the meat snack supplied vitamin B12 and bioavailable iron and zinc. The milk snack provided an average of 48% of the recommendations for these six nutrients, and the meat snack provided 44%. By com- parison, an equi-caloric vegetarian snack provided only 17.5%.
Although it was not tested, a snack that provided both milk and meat would be likely to improve dietary quality even further.
Studies like CNP contribute to the design of food guides which provide practical advice on how to choose a nutritionally ade- quate diet using foods that are readily available to a population.
Food guides that have been derived to ensure nutrient adequa- cy virtually always include meat and dairy groups, as well as fruits, vegetables, and starchy staples. In the United States, My- Plate presents a simple graphic showing the proportions of a plate that should be filled with foods from each food group (see www.choosemyplate.gov). Adapting such food guides to local preferences and food availability may be an important step in improving dietary quality. For countries at any level of develo- pment, these guides can then serve as the basis for educational programs as well as the foundation of national nutrition poli- cies that promote nutritionally adequate diets.
Key words: Diet quality,food guides, micronutrients.
COMPLEMENTARY FEEDING RECOMMENDA- TIONS FROM LOCALLY AVAILABLE FOODS
U. Fahmida
SEAMEO-RECFON, Regional Center For Food and Nutrition, University of Indonesia, Jakarta, Indone- sia
Background and objectives: Adequate nutrition during the first 2y of life is essential to ensure optimal health, growth, and development. In their Global Strategy for Infant and Young Child Feeding, WHO and UNICEF have provided guidance on appropriate complementary feeding, with emphasis on use of suitable locally available foods. Affordable, locally contextual complementary feeding recommendations (CFR) are more likely to result in long-term improvements in complementary feeding practices than general recommendations as it takes into account cultural diversity and differences in food availa- bility. This presentation aims to describe development of CFR using linear/goal programming (LP) approach.
Methods: Four modules in LP were used (1) to formula- te optimal CFR given local food availability, food pattern, and food affordability; (2) to evaluate nutrient adequacy and iden- tify absolute or partial problem nutrients, (3) to identify locally available nutrient-dense foods to fill the nutrient gap, and (4) to choose from amongst alternatives of CFRs based on the com- parative cost and nutritional benefits. Data for the analysis was from the National Basic Health Survey (Riskesdas, 2010) and several studies conducted in rural, peri-urban, and urban area of Indonesia.
Results: The developed CFRs for different age groups revea- led similarities and differences in the problem nutrients across age groups. Comparing results from several studies in Indone- sia, while calcium, iron, and zinc were the typical problem nu- trients, the extent of deficiency and the potential nutrient-den- se foods vary across age groups, area (rural, peri-urban, urban) and socioeconomic level. Animal source foods and fortified foods were identified as nutrient-dense foods which can im- prove micronutrient adequacy from the complementary foods.
Conclusion: CFR from locally available foods can be op- timized by including available nutrient-dense foods. Achieve- ment of nutrient adequacy from the CFR varies by age groups, area and socio-economic condition.
Key words: Complementary feeding recommendation, li- near/goal programming, local foods, problem nutrient.
USE OF OMENA FISH IN KENYA C. Gewa1, C. Frankenfeld2
1Department of Nutrition and Food Studies, George Mason University, USA
2Department of Global and Community Health, George Mason University, USA
High levels of infections with increased pregnancy-related nutrient demands and inadequate food supplies can place some pregnant women in resource-scarce settings in a vulne- rable health status, often associated with inadequate weight gain, low-birth weight, prematurity, fetal deaths and maternal and child mortality. Animal-source foods provide a rich sour- ce of high quality protein and variety of micronutrients requi- red for adequate growth. However, a majority of these foods are not accessible to a large proportion of populations in poor countries. Locally available small fish like Omena (Rastrino- bola argentea) offers a likely source of nutrient-rich and affor- dable food among communities in Kenya. However, its po- tential to improve nutritional status among pregnant women is still unknown. We utilized a cross-sectional study design to assess the acceptability of fish-enhanced supplemental snacks among a sample of pregnant women in rural Kenya. Isocaloric fish-enhanced, soy-enhanced and wheat snacks were compa- red on taste, odor, texture and color. Wheat snacks were most preferred with more than 95% of mothers indicating that they liked its taste, odor, texture and color. Over 85% of mothers indicated that they liked the taste, odor, texture and color of the fish-enhanced snack and over 81% of mothers indicated that they liked the taste, odor, texture and color of the soy- enhanced snack. No significant differences were noted across mother’s HIV status. Focus group discussions with the mothers further revealed that the fish-enhanced snack was well-liked for its crunch, taste, dark-brown color and spice. Our analysis demonstrates the potential use of locally available and afforda- ble small animal food sources to improve nutritional status of vulnerable population groups in low-income nations.
Key words: Small fish, fish-enhanced snacks, pregnant wo- men, Kenya.
MEATS AS COMPLEMENTARY FOOD FOR OLDER INFANTS
N. Krebs, M. Hambidge
School of Medicine, University of Colorado, Denver, USA
The relatively high iron and zinc requirements of breastfed infants older than about 6 mo of age, and the physiologic com- position of human milk dictate that they must consume either
cellular animal protein foods (meats or organ tissue), or rely on fortified foods or supplements. Common infant feeding practi- ce, however, is to introduce meats only as one of the last foods for older infants. The reasons for this include expense of meats;
assumption that infants can’t or won’t eat meats; perception that meats are too difficult to digest until later. Data obtained by a feeding survey from infants in 4 diverse settings indica- ted that meats were fed to > 60% of toddlers, but to < 25% of infants, suggesting that availability and affordability were not the limiting factors within households. Prior to the Agricul- tural Revolution, mothers most likely pre-masticated meats to enable the infants to eat them. We have undertaken several studies to examine the potential impact of consuming meats vs cereals (fortified and unfortified) by older infants. The forms of meat used for older infants and toddlers included commer- cially available pureed meats; freeze dried meat cubes, which could be eaten either dry or in soups and porridges, and either as a powder or finger foods; cooked and shredded meats; and crumbled and/or mashed liver. Infants’ acceptance of the meats was excellent in all studies, although cultural norms favored cereals over meats as an appropriate infant food. Animal sour- ce proteins contribute micronutrients that are critical to older infants and toddlers, and availability of meats may actually be greater than fortified products in resource poor settings. Edu- cation efforts are warranted to encourage the use of meats as complementary foods for older infants.
Key words: Infants, meat, toddlers, complementary foods, micronutrients.
CONSUMPTION OF ANIMAL SOURCE FOODS AND COGNITIVE PERFORMANCE OF PRIMARY SCHOOL CHILDREN IN HAWASSA TOWN, SOUTHERN ETHIOPIA
M. Girma1, E. Loha3, A. Bogale1,2, Y. Abebe1, M. Hambid- ge4, B. Stoecker1
1School of Nutrition, Food Science & Technology, Hawassa University, Hawassa, Ethiopia
2Department of Nutritional Sciences, Oklahoma State University, Stillwater, Oklahoma, USA
3School of Public & Environmental Health, Hawassa University, Hawassa, Ethiopia
4School of Medicine - Pediatrics, University of Colo- rado, Denver, Colorado, USA
Cognitive development of children is influenced by nutri- tional, socioeconomic and environmental factors. This cross- sectional survey of primary school children (n=116) exami- ned associations among anthropometrics, animal source food (ASF) consumption and cognitive performance. Five schools were randomly selected from fifty-one in Hawassa Town using
probability proportional to size sampling. Twenty-five students were randomly selected from the seven to nine year old chil- dren in these schools. Family socio-economic characteristics and child diets were collected from primary caregivers using individually-administered questionnaires. Dietary diversity was assessed using the eight indicator food groups identified by the Food and Nutrition Technical Assistance Project. Anthro- pometric measurements were transformed to Z-scores using WHO AnthroPlus Software. Cognitive testing utilized Raven’s Colored Progressive Matrices (CPM, board version) and selec- ted tests from the Kaufman Assessment Battery for Children (KABC-II). Data were analyzed using SPSS v.19. Median child age was eight and most had some preschool education. Thirty- six percent of mothers had no formal education while 35% had completed primary education. Thirteen percent of children were stunted and 13% were underweight. Only 3.4% of chil- dren consumed eggs in the 24 hours preceding the dietary sur- vey and only 13.8% consumed meat, poultry or fish. Stunted (height-for-age Z [HAZ] <-2) children had significantly lower scores on the Raven’s CPM, on pattern reasoning and on tests of short-term memory. Children not consuming flesh foods or eggs had lower scores for short-term memory and visual pro- cessing. Multiple regression models including HAZ, ASF, pre- school attendance and maternal education predicted 18 to 26%
of variability in cognitive scores. These results add to the body of data supporting importance of nutritional status for cogni- tive function.
Acknowledgement: Supported by Hawassa University School of Graduate Studies and NIHR01HD053053 [NICHD
& Fogarty International Center].
Key words: Animal foods, children, cognitive performance.
MICROCREDIT WITH ENTREPRENEURIAL AND NUTRITION EDUCATION INTERVENTION IMPRO- VED WOMEN’S INCOMES AND CHILDREN’S ANI- MAL SOURCE FOOD INTAKE AND NUTRITION IN GHANA
G. Marquis1, E. Colecraft2
1McGill University, Montréal, Québec, Canada
2University of Ghana, Accra, Republic of Ghana
The Enhancing Child Nutrition through Animal Source Management (ENAM) project (2004-2009) emanated from participatory formative research that identified six principal constraints to the inclusion of animal source foods (ASF) in Ghanaian children’s diets: low caregiver income, poor produ- cer-consumer linkages, inadequate nutrition knowledge and skills of extension staff and caregivers, cultural beliefs, and in- equitable household food distribution. To address these cons- traints, the ENAM project implemented an integrated micro-
credit, entrepreneurship and nutrition education initiative with 181 caregivers of 2- to 5-y-old children in six rural communi- ties across three agro-ecological zones of Ghana. Six matched communities from the same zones served as comparison sites.
Methods included surveys, anthropometry, and dietary as- sessment to assess the intervention effect on children’s dietary intakes and growth and 12 qualitative case studies to examine household and caregiver outcomes of interest. Women repor- ted that the ENAM experience opened opportunities for obtai- ning microcredit for the first time, which helped increase their business success. Significantly more participant caregivers ex- panded and diversified their small businesses (p<0.01), tended to have higher profits (p<0.01), and had significantly higher savings (p<0.05) than non-participant caregivers. Participant households tended to spend more money (p<0.10) and con- sumed significantly more amounts (in monetary value) of ASF (p<0.01) than non-participant households. About one-third of the caregivers were engaged in an ASF-related business, such as selling smoked fish or eggs, or selling cooked food that contai- ned ASF. After accounting for locale, being involved in an ASF- related business positively predicted children’s ASF diversity (p<0.001). The intervention had a positive effect on children’s nutritional status (p<0.05). Evidence suggests that the micro- credit-education link benefited women’s lives with respect to their small businesses and their personal development as well as the diet and health of their young children.
Acknowledgement: Supported by GL-CRSP/USAID Grant No. PCE-G-00-98-00036-0.
Key words: Child nutrition, animal source foods.
FOOD-BASED APPROACHES TO IMPROVE MULTI- PLE MICRO-NUTRIENT DEFICIENCIES AND PRO- TEIN QUALITY
A. Neumann
University of California, Davis, USA
Recently completed and ongoing research studies using ani- mal source foods to improve a range of nutritional problems will be presented. Researchers form Asia, Africa, and elsewhere will make presentations during this symposium. This is a very important topic now that we have evidence-based research to support the use of food-based approaches to combat mul- tiple micronutrient deficiencies and improve protein quality and nutrition status and function in resource-poor countries.
This important approach holds promise in terms of sustaina- bility and reaching hard to reach rural populations comprised mainly of subsistence farmers. Although short term nutrient supplements are necessary in cases of severe deficiency, we wish to share research outcomes related to the use of food- based approaches by households and communities to combat multiple micronutrient deficiencies and improve function. The