Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor developmentAuthors: Seth Adu-Afarwah, Anna Lartey, Kenneth H Brown, Stanley Zlotking, André Briend, and Kathryn G Dewey

Presented by Brittany Washington

Introduction

•Complementary feeding – 6 to 24 mo.

•Low micronutrient content of complementary foods in disadvantaged populations has been associated with- Growth faltering- Increased morbidity- Delayed motor milestone acquisition

•Possible low-cost solution = home fortification of complimentary foods with multiple micronutrient supplements

•3 types of multiple micronutrient supplements:- Sprinkles (SP), powder, 9 vitamins &

minerals- Nutritabs (NT), crushable tablet, 16 V&M- Nutributter (NB), peanut-based fortified

spread, 19 V&M, with added energy from fat (linoleic and α-linolenic)

Rationale•Purpose = to compare these 3 supplements

and determine whether higher content of micronutrients and/or macronutrients would give more positive growth results in infants from 6-12 months

•Hypothesis = multiple micronutrient fortification of complementary foods would increase growth and the effect would be greatest with added energy from fat

Methods•The community-based randomized study

was carried out in Koforidua, Ghana between February 2004 and June 2005

•313/409 eligible infants were assigned to receive SP, NT, or NB

•96/409 eligible infants were recruited for the nonintervention group (NI) at 12 mo.

Micronutrient supplements•Designed to generally provide the

amounts of key nutrients needed from complementary foods

•SP dose = 1 satchet/d•NT dose = 1 tablet/d (came in plastic

bags)•NB dose = 20 g/d (came in foil packs with

screw caps, net wt = 200g)

Procedures•Parents of selected infants were visited to

verify eligibility, explain protocol, and obtain consent

•Supplements delivered weekly•Mothers instructed to administer daily

dose in a single meal, 7 days/week, mixed with 1-2 tbsp of food

•Supplied cups and spoons

Data collection•Background data collected during

recruitment•Weekly collection of daily supplement

consumption data and morbidity data (diarrhea, symptoms of respiratory infections, fever)

•Monthly collection of 24-h dietary recall data, used to calculate energy intake from complementary foods

•At 6, 9, and 12 mo., anthropometric data was obtained

Data collection•Calculated weight-for-age (WAZ), length-

for-age (LAZ), and weight-for-length (WLZ) z-scores using WHO 2006 Child Growth Standards

•At 12 mo., 4 motor milestones were assessed:- Standing with assistance- Walking with assistance- Standing independently- Walking independently

Baseline data

Baseline data

Results – Monthly 24-h recall•When the

energy contribution of NB was included, energy intake was significantly greater in the NB group (~85 kcal/d)

Results – Mean (+/- SE) absolute weight gain from 6-9 and 9-12 mo.

Results - Mean (+/- SE) absolute length gain from 6-9 and 9-12 mo.

Results- % of children achieving milestones by 12 mo.

Results – prevalence of morbidities between 6 and 12 mo.

Discussion •Multiple micronutrient interventions

alone may not improve growth of infants in some populations

•Supplementation with SP and NT did not increase growth

•NB group had greater weight and length gains than other two intervention groups

Weight and Length gain•Difference in weight gain could be explained

by increased calorie intake in NB group- Consumption of NB resulted in avg. increase

of ~85 kcal daily intake from complementary foods

•Difference in length gain could be explained by essential fatty acid content of NB (provided 65% of recommended linoleic acid and 145% of α-linolenic acid intake)

Motor-skill development•SP and NT infants were 2x as likely, and

NB infants were 3.4x as likely to be able to walk independently by 12 mo. than the NI group- Can be due to receiving zinc and iron

supplements together and with other micronutrients

- Can also be due to increased calorie intake in NB group

Morbidities•The 3 groups did not differ significantly in

prevalence of illness, except for cough, which was slightly higher in NT group

Limitations •Possibility of influence on the amount of

attention given to children due to Hawthorne effect

•Mothers and field workers who delivered supplements were not blind to study design (although anthopometrists were masked to group assignment)

Possibilities for further research•Address micronutrient interactions•Control for micronutrient levels to

measure effect of energy/fat intake