ArticlePDF AvailableLiterature Review

Micronutrient gaps during the complementary feeding period in South Asia: A Comprehensive Nutrient Gap Assessment

Authors:

Abstract and Figures

Micronutrient malnutrition is a key driver of morbidity and mortality for millions of children in South Asia. Understanding the specific micronutrients lacking in the diet during the complementary feeding period is essential for addressing undernutrition caused by inadequate diets. A Comprehensive Nutrient Gap Assessment was used to synthesize diverse evidence and estimate the public health significance of complementary-feeding micronutrient gaps and identify evidence gaps in 8 countries in South Asia. There were important gaps across the region in iron, zinc, vitamin A, folate, vitamin B12, and, to a lesser extent, calcium and vitamin C. The most nutrient-dense, whole-food sources of these micronutrients include liver, small fish, eggs, ruminant meat, and dark leafy greens. Investment is needed in some countries to collect data on micronutrient biomarkers and dietary intakes. A food systems approach is essential for improving child diets and reducing malnutrition, which affects millions of children, their futures, and society at large across South Asia and beyond.
Content may be subject to copyright.
Supplement Article
Micronutrient gaps during the complementary feeding period
in South Asia: A Comprehensive Nutrient Gap Assessment
Ty Beal , Jessica M. White , Joanne E. Arsenault , Harriet Okronipa , Guy-Marino Hinnouho ,
Zivai Murira, Harriet Torlesse, and Aashima Garg
Micronutrient malnutrition is a key driver of morbidity and mortality for millions of
children in South Asia. Understanding the specific micronutrients lacking in the diet
during the complementary feeding period is essential for addressing undernutrition
caused by inadequate diets. A Comprehensive Nutrient Gap Assessment was used
to synthesize diverse evidence and estimate the public health significance of
complementary-feeding micronutrient gaps and identify evidence gaps in 8 coun-
tries in South Asia. There were important gaps across the region in iron, zinc,
vitaminA, folate, vitamin B
12
, and, to a lesser extent, calcium and vitamin C. The
most nutrient-dense, whole-food sources of these micronutrients include liver, small
fish, eggs, ruminant meat, and dark leafy greens. Investment is needed in some
countries to collect data on micronutrient biomarkers and dietary intakes. A food
systems approach is essential for improving child diets and reducing malnutrition,
which affects millions of children, their futures, and society at large across South
Asia and beyond.
INTRODUCTION
A quarter of the global population of children younger
than 5 years live in South Asia (n¼170 million chil-
dren),
1
a third of whom are stunted (n¼56 million)
and 15% of whom are wasted (n¼25 million).
2
Deficiencies of essential vitamins and minerals are
widespread among children in the region.
3
For exam-
ple, in India, in which more than two-thirds of South
Asia’s children younger than 5 years (n¼117 million)
live, the following micronutrient deficiencies among
children aged 12–59 months are widespread: iron
(32%), folate (23%), zinc (19%), vitamin A (18%), vita-
min B
12
(14%), and vitamin D (14%).
4
The consequen-
ces of this high burden of undernutrition among
children are severe, including poor cognitive develop-
ment, failure to reach their full potential, and death.
5,6
One of the main causes of undernutrition in the re-
gion is poor diet.
3,7
Only 20% of children aged 6–
23 months in South Asia consume the minimum
Affiliation: T. Beal is with the Global Alliance for Improved Nutrition, Washington, DC, USA. T. Beal is with the Department of
Environmental Science and Policy, University of California, Davis, Davis, California, USA. J.M. White and A. Garg are with the United Nations
Children’s Fund (UNICEF), New York, New York, USA. J.E. Arsenault, H. Okronipa, and G.-M. Hinnouho are with the Institute for Global
Nutrition, University of California, Davis, Davis, California, USA. J.E. Arsenault is with Intake, Center for Dietary Assessment, FHI Solutions,
Washington, DC, USA. H. Okronipa is with the Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, New
York, USA. G.-M. Hinnouho is with Helen Keller International, New York, New York, USA. Z. Murira and H. Torlesse are with UNICEF, Regional
Office for South Asia, Kathmandu, Nepal.
Correspondence: T. Beal, Global Alliance for Improved Nutrition, 1701 Rhode Island Ave, NW, Washington, DC 20036, USA. E-mail: tbeal@
gainhealth.org.
Key words: CONGA, micronutrient deficiencies, nutrient adequacy, nutrient gap assessment, South Asia.
V
CThe Author(s) 2021. Published by Oxford University Press on behalf of the International Life Sciences Institute.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly
cited.
doi: 10.1093/nutrit/nuaa144
26 Nutrition Reviews
V
R
Vol. 79(S1):26–34
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
recommended number of food groups each day.
8
Consumption of animal-source foods, in particular, is
low.
9
Improving diets of young children is an important
component of efforts to achieve the World Health
Assembly and Sustainable Development Goals nutrition
targets. Identification of micronutrient and dietary gaps
during the complementary feeding period is essential to
inform policies and programs designed to improve
child health and nutrition.
10
Existing evidence that could be used to inform the
understanding of micronutrient gaps in South Asia, in-
cluding prevalence of micronutrient deficiencies or in-
adequate intakes, comes from disparate data sources of
varying quality, representativeness, and recency.
Moreover, this evidence, to our knowledge, has not
been synthesized to produce a comprehensive and clear
picture of the magnitude and significance of micronu-
trient gaps across countries in South Asia. Without this
understanding, it is difficult to identify the public health
significance of micronutrient gaps in diets of young
children and how to best address them.
In another article in this Nutrition Reviews supple-
ment, Beal et al
6
describe a method of compiling avail-
able evidence from a variety of sources to assess the
public health significance of nutrient gaps and identify
evidence gaps. This approach, called Comprehensive
Nutrient Gap Assessment (CONGA), was used to assess
the micronutrient gaps in young children’s diets in the
8 countries of South Asia. After identifying micronutri-
ent gaps, the most nutrient-dense, whole-food sources
(ie, those with minimal processing and typically only 1
or 2 ingredients) of these micronutrients that are avail-
able in the region were identified.
METHODS
To identify nutrient gaps—shortfalls in the diet that
lead to inadequate nutrient intakes—the analysis fol-
lowed the 8-step method for conducting a CONGA, de-
scribed in detail by Beal et al
6
in this journal
supplement. The target population was children 6–
23 months of age in the 8 countries of South Asia:
India, Pakistan, Bangladesh, Afghanistan, Nepal, Sri
Lanka, Bhutan, and the Maldives. Micronutrients
assessed were those identified in the literature as com-
monly lacking in the diets of infants and young children
during the complementary feeding period: iron,
vitamin A, zinc, calcium, iodine, thiamine, niacin, vita-
min B
12
, vitamin B
6
, folate, and vitamin C.
11
Evidence
sources were identified (CONGA step 1) by (1) search-
ing relevant global databases, including Demographic
and Health Surveys (DHS) and DHS STATcompiler
(dhsprogram.com), Multiple Indicator Cluster Surveys
(mics.unicef.org), and United Nations Children’s Fund
(UNICEF) global databases on infant and young child
feeding, malnutrition, and iodine (data.unicef.org); (2)
requesting relevant resources from UNICEF Regional
Office South Asia and UNICEF and Global Alliance for
Improved Nutrition country offices; and (3) conducting
keyword searches in Google and Google Scholar.
Keywords (Table S1 in the Supporting Information on-
line) on specific evidence types (eg, nutrient intake)
were searched in Google and Google Scholar, and key-
words for specific report types or gray literature (eg, na-
tional micronutrient survey) were searched solely in
Google.
Studies were included if they contained informa-
tion on any of the 5 evidence types relevant for assess-
ing nutrient gaps outlined in the CONGA methods
paper:
6
: (1) biological, clinical, and functional markers,
(2) nutrient adequacy of individual diets, (3) nutrient
adequacy of household diets, (4) nutrient adequacy of
national food supplies, and (5) nutrient-informative
food group intake of individuals or households (eg,
iron-rich foods). Priority was given to evidence on chil-
dren aged 6–23 months, but evidence was also included
on populations inclusive of young children (eg, children
younger than 5 years) and relatively similar age and sex
groups (eg, children aged 36–59 months). For micronu-
trient markers that do not vary substantially across age
groups, such as urinary iodine concentration, data on
older age groups were included. Studies on micronutri-
ent supplementation coverage and Cost of the Diet
analyses that could inform micronutrient gap assess-
ment were also included. Studies with sample sizes of
<50 participants , geographic representation of <10%
of the national population, highly vulnerable partici-
pants, and those in which data collection ended before
the year 2000 were excluded. Table S2 available in the
Supporting Information online contains a spreadsheet
with information from all included evidence sources
documented according to the CONGA method
(CONGA step 1).
6
Two experts (T.B. and J.M.W.) conducted CONGA
steps 2–6 to determine ratings for all 11 micronutrients
in each of the 8 countries. In step 2, data points in the
country-specific spreadsheets were reviewed and
assigned an implied nutrient gap burden score per the
CONGA methodology.
6
Weights were then assigned to
the metadata to calculate an overall evidence weight
score for each data point in step 3. Assigning an evi-
dence weight score on the basis of metadata helped ac-
count for the fact that not all data points are equally
valuable or robust. Weight scores were systematically
applied to the metadata for each data point (see Beal et
al
6
), ensuring that the most recent, representative, and
relevant data were weighted more heavily when assess-
ing nutrient gaps.
Nutrition Reviews
V
R
Vol. 79(S1):26–34 27
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
In step 4, the implied nutrient gap burden scores
and evidence weight scores were used to calculate a
quantitatively derived nutrient gap burden rating. The
quantitative burden rating was calculated using data
only from the aforementioned 5 core evidence types
(excluding “other” data) that were collected in 2010 or
later and that were for age or sex groups similar to chil-
dren 6–23 months of age. The data points excluded
from this calculation were considered in step 5. A nu-
meric score was calculated for each nutrient in each
country, using the weighted mean of the implied nutri-
ent gap burden score (where the evidence weights are
the weight scores) and assigned a label of high, moder-
ate, low, or negligible, per CONGA methodology.
6
In step 5, the quantitative nutrient gap burden
scores were reviewed alongside the totality of evidence
for each nutrient, including data points that did not
meet criteria for inclusion in the quantitative burden
score calculation and additional available information
for each data point (eg, temporal trends for data points,
where available) to determine whether the final rating
assigned to the nutrient gap should deviate from the
quantitatively derived rating. A final qualitative rating
of high, moderate, low, or negligible was assigned to
each nutrient for each country, and any deviation from
the quantitative burden score was documented and
explained.
The certainty of evidence was rated for each nutri-
ent burden (high, moderate, low, or unknown) in step 6
using established CONGA methodology criteria,
6
by
which the evidence weight scores from step 3 are con-
sidered and level of agreement between data points.
These criteria-based ratings were also subjected to a fi-
nal qualitative review, considering all evidence (includ-
ing data points for which an evidence weight score was
not possible), to determine whether the final certainty
rating should deviate from the criteria-based rating.
Any deviations were discussed and documented.
In step 7, all other coauthors, who are subject mat-
ter and contextual knowledge experts, reviewed the final
qualitative nutrient gap burden and evidence certainty
ratings produced in steps 5 and 6, respectively.
Disagreements with final qualitative ratings were dis-
cussed and critically re-evaluated. Ratings were finalized
only when consensus was achieved and documentation
of additional considerations or deviations from quanti-
tative burden scores was added. Table S2 in the
Supporting Information online contains a spreadsheet
with all data points included in each CONGA, data
sources, and nutrient gap and certainty scores.
For identified micronutrient gaps (ie, those that re-
ceived a nutrient gap burden rating and a certainty-of-
evidence rating of at least moderate) and potential mi-
cronutrient gaps (ie, those that received a nutrient gap
burden rating of at least moderate but a certainty-of-
evidence rating of low), the most nutritious, regionally
available, whole-food sources of these micronutrients
were identified on the basis of food-composition data
from Bangladesh,
12
India,
13
and the US Department of
Agriculture,
14
and consumption patterns from house-
hold consumption and expenditure surveys in
Bangladesh, India, and Pakistan (as specified by
Ryckman et al
15
). With the exception of liver, for which
there were insufficient consumption data, foods were el-
igible for consideration if they were consumed by at
least 10% of households nationally (typically over 1 to 2
weeks) in 1 of the 3 sample countries.
Because many whole foods are good sources of sev-
eral micronutrients, these foods were also assessed for
how well they met the needs of 6 micronutrients critical
for child growth and development and likely to be lack-
ing in South Asian diets: namely, iron, vitamin A, zinc,
folate, vitamin B
12
, and calcium. This metric, called
average share of requirements, was calculated as the av-
erage proportion of daily requirements from comple-
mentary foods for these 6 micronutrients on the basis
of a 100-g quantity (each micronutrient capped at 100%
of daily requirements). The portion size of each food re-
quired to achieve an average of 33.3% of requirements
(again, capped at 100% of requirements for each micro-
nutrient)—the equivalent of 100% of requirements for 2
micronutrients or 33.3% of requirements for all 6
micronutrients—was also calculated to demonstrate the
ideal foods to fill 2 important micronutrient gaps si-
multaneously. Adjustments for differences in bioavail-
ability between plant and animal-source foods were
made for iron and zinc. For more details on how micro-
nutrient density of and average share of requirements
for identified foods were calculated and how local avail-
ability was determined, refer to other articles in this
journal supplement.
15,16
EVIDENCE SUMMARY
A total of 321 qualifying data points from 50 evidence
sources (see Supporting Information online) were iden-
tified in the literature review (CONGA step 1), and 137
of these met criteria for inclusion in the quantitative
burden score (CONGA steps 3 and 4) (Table 1).
Pakistan (n¼63) and India (n¼59) had the highest
number of data points identified in the literature re-
view, followed by Bangladesh (n¼41), Sri Lanka
(n¼40), Nepal (n¼38), Afghanistan (n¼31), the
Maldives (n¼30), and Bhutan (n¼19). In several
countries, fewer than half of these data points met qual-
ifying criteria for inclusion in the quantitative micronu-
trient gap burden score (in Bhutan, only 1 data point
qualified).
28 Nutrition Reviews
V
R
Vol. 79(S1):26–34
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
The variety of evidence sources differed by country.
Pakistan, for example, had a 2018 national nutrition
survey, 2017–2018 DHS, a 2018 Fill the Nutrient Gap
report, a 2017 Cost of the Diet analysis, and 2018
Optifood analysis, among others. In contrast, Bhutan
had a 2015 national nutrition survey with limited rele-
vant data to extract and few other nutrition-specific evi-
dence sources. Recency of data collection for identified
evidence varied across countries; however, all countries
had at least 1 evidence type collected within the previ-
ous 6–7 years. All countries also had relevant nationally
representative data available for several micronutrients
and/or evidence types. Relevance to the age group of in-
terest varied by evidence type and data source; however,
the majority of data reviewed were for children younger
than 5 years or 6–59 months old.
The number of data points varied considerably
across micronutrients and evidence types (Table 2).
Biochemical or functional markers were identified for 7
of the 11 micronutrients of interest. The most common
biochemical or functional markers available were for
iron, zinc, and vitamin A. Prevalence of deficiencies in
iron, vitamin A, and zinc for children younger than 5
years, 6–59 months old, or 12–59 months old were
available in all countries except Bhutan. Estimates of
anemia prevalence were available for all countries, but
these were not used to estimate iron deficiency, because
of limited information on the proportion of anemia due
to iron deficiency in these populations. Prevalence of
folate deficiency was available for children aged 6–
23 months, 6–59 months, or 12–59 months in Pakistan,
India, and Nepal, and for other age groups in
Afghanistan and Bangladesh. Prevalence of vitamin B
12
deficiency was available for children aged 6–59 months
or 12–59 months in Pakistan and India, and for other
age groups in Bangladesh. All countries except Bhutan
had at least 1 biochemical or functional marker of io-
dine deficiency (ie, prevalence of deficiency, median
urinary iodine concentration, or total goiter rate); how-
ever, most estimates were for school-aged children. Sri
Lanka was the only country with an estimate of calcium
deficiency in children (6–59 months old), and Pakistan
assessed calcium deficiency for women of reproductive
age. No qualifying biochemical evidence for any age
group was identified in the literature search for niacin,
thiamine, vitamin C, or vitamin B
6
—similar to a
CONGA in 6 countries in Eastern and Southern
Africa.
17
In contrast to the CONGA in Eastern and
Southern Africa,
17
no qualifying evidence on micronu-
trient adequacy of individual diets was identified in the
literature search for any country in South Asia. Some
evidence was identified that inferred micronutrient ade-
quacy (eg, the proportion of children who consumed
<70% of the recommended daily allowance) but was
not presented in ways that allowed for clear interpreta-
tion. Therefore, this evidence was classified as other and
considered in the qualitative assessment (CONGA step
5). Data on micronutrient adequacy of household diets
were identified in Bangladesh only. Data on micronutri-
ent adequacy of national food supplies were identified
for all micronutrients considered except iodine, and for
all countries except Bhutan. Evidence containing
micronutrient-informative food-group intake of indi-
viduals or households was available for iron and
vitamin A (from consumption of iron- and vitamin A–
rich foods in children aged 6–23 months) and iodine
(from data on coverage of iodized salt). At least 1 data
point classified as other evidence (eg, micronutrient
supplementation, Optifood analyses) was identified for
all micronutrients and all countries.
Table 1 Number of data points included overall and
that qualified for the quantitative burden scores by
country
No. of data points
included overall
No. of data points that
qualified for quantitative
burden scores
India 59 23
Pakistan 63 20
Bangladesh 41 25
Afghanistan 31 18
Nepal 38 19
Sri Lanka 40 19
Bhutan 19 1
Maldives 30 12
Total 321 137
Table 2 Number of data points included overall and that qualified for the quantitative burden scores by evidence type
and micronutrient
a
Evidence type Iron Zinc Vit A Folate Vit B
12
Ca Vit C Niacin Vit B
1
Iodine Vit B
6
Biological and functional markers 8 (7) 7 (6) 9 (5) 5 (4) 3 (2) 2 (1) 0 (0) 0 (0) 0 (0) 11 (8) 0 (0)
Nutrient adequacy of individual diets 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Nutrient adequacy of household diets 1 (1) 1 (1) 1 (1) 0 (0) 0 (0) 1 (1) 1 (1) 1 (1) 1 (1) 0 (0) 0 (0)
Nutrient adequacy of national food supplies 7 (7) 13 (7) 13 (7) 12 (7) 13 (7) 13 (7) 7 (7) 7 (7) 11 (7) 0 (0) 7 (7)
Nutrient-informative food-group intake of
individuals or households
10 (10) 0 (0) 8 (8) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 13 (9) 0 (0)
a
The parentheses enclose the number of data points that qualified for the quantitative burden scores. Abbreviations: Ca, calcium; Vit,
vitamin.
Nutrition Reviews
V
R
Vol. 79(S1):26–34 29
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
RATINGS ADJUSTMENTS
Adjustments to quantitative burden ratings involved a
critical qualitative assessment of the totality of evidence,
including evidence excluded from the quantitative bur-
den rating, “other” evidence, and temporal trends.
Table S2 in the Supporting Information online includes
all initial and final qualitative micronutrient gap burden
and certainty-of-evidence ratings. Although most initial
ratings remained the same, 15 of 88 micronutrient gap
burden ratings and 6 of 88 certainty ratings were ad-
justed. Among ratings that changed, burden ratings
tended to reduce in severity, whereas certainty ratings
tended to increase in certainty, but there were some
exceptions.
Calcium had the most changes to initial burden rat-
ings (n¼4), all of which reduced in severity (n¼3
changed from high to moderate, n¼1frommoderateto
low), because initial ratings were largely based on high
estimates of inadequacy in the food supply, which did
not fully account for household production of dairy.
18
There were 3 initial folate burden ratings that reduced in
severity from high to moderate after considering evi-
dence that was excluded from the quantitative burden
estimates. For various reasons, 2 vitamin B
12
and 2
vitamin C burden ratings reduced in severity from high
to moderate and 2 niacin burden ratings increased in se-
verity from negligible to low. One iron burden rating
and 1 vitamin B
6
burden rating increased in severity
from negligible to low after evidence was considered that
was excluded from the quantitative burden estimates.
Six certainty-of-evidence ratings changed from
their initial ratings. For various reasons, the vitamin A
and vitamin B
12
certainty ratings for the Maldives in-
creased from low to moderate, the iodine certainty rat-
ing for Bangladesh increased from low to moderate, the
iodine certainty rating for Nepal increased from moder-
ate to high, the iron certainty rating for Sri Lanka de-
creased from high to moderate, and the folate certainty
rating for Afghanistan decreased from moderate to low.
FINAL MICRONUTRIENT GAP RATINGS
Figure 1 shows the final micronutrient gap burden and
certainty-of-evidence ratings for the 11 micronutrients
investigated in the 8 countries of South Asia. Gaps in
iron are the highest priority micronutrient gaps in South
Asia, with estimated high burden gaps in 6 countries, a
moderate burden gap in Bangladesh, and a low burden
gap only in the Maldives. The iron gap burden in
Bangladesh is moderate rather than high, likely because
of high iron in groundwater in many areas in
Bangladesh.
19
Other important micronutrient gaps across
much of South Asia include zinc, vitaminA, folate,
vitamin B
12
, calcium, and, to some extent, vitaminC.
Deficiencies in iron, zinc, vitaminA, folate, and vitamin
B
12
can have severe and/or long-term consequences.
6
Calcium deficiency increases risk of rickets, but the
broader health implications of its deficiency in young
children are poorly understood.
20
Vitamin D gaps were
not assessed, but available evidence suggests vitamin D
may be a high priority gap in India
4
and particularly
Pakistan
21
and Afghanistan.
22
There do not appear to be
important gaps in iodine or vitamin B
6
across the region.
The Maldives is the only country in the region that does
not appear to have important gaps in multiple micronu-
trients. This is likely because the Maldives has a far
higher gross domestic product per capita than any other
country in South Asia and high supplies of meat and es-
pecially fish.
23
In Bhutan, the only micronutrient with
sufficient qualifying evidence to rate was iron.
The micronutrients with the highest certainty of
evidence were iron, zinc, and vitamin A, all of which
had moderate or high certainty of evidence in 6 coun-
tries. There was a moderate or high certainty of evi-
dence for iodine in 5 countries, folate and vitamin B
12
in 3 countries each, and calcium in only 1 country. All
burden ratings for niacin, thiamine, vitamin C, and vita-
min B
6
were based on low certainty evidence.
New data collection and evidence generation
should be prioritized for micronutrients with a moder-
ate or high burden rating and a low certainty rating, as
well as micronutrients with no evidence. These include
folate, vitamin B
12
, calcium, and vitamin C in
Bangladesh; vitamin B
12
, calcium, and vitamin C in
Afghanistan; vitamin B
12
, calcium, and niacin in Nepal;
folate, vitamin C, and thiamine in Sri Lanka; calcium in
India; vitamin C in Pakistan; folate in the Maldives; and
all nutrients, but especially iron, in Bhutan.
NUTRITIOUS FOODS TO FILL IDENTIFIED AND
POTENTIAL MICRONUTRIENT GAPS
There are various ways to fill micronutrient gaps in
young-child diets, including increasing intake of diverse
whole foods, fortified complementary foods, biofortified
foods, fortified staples, point-of-use fortification products,
supplementation, and improving breastfeeding practices.
All these strategies are warranted in South Asia to varying
degrees, depending on the local context. Improving in-
take of minimally processed nutritious whole foods is par-
ticularly important, because food influences more than
nutrient adequacy (ie, food is more than its nutrients).
Minimally processed plant and animal-source foods, in-
cluding breast milk, contain important beneficial bioac-
tive compounds (eg, polyphenols, fiber, conjugated
linoleic acid) that can help regulate the immune system,
build a healthy gut microbiome, and ultimately may help
30 Nutrition Reviews
V
R
Vol. 79(S1):26–34
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
reduce risk of overweight or obesity and diet-related non-
communicable diseases in middle childhood, adolescence,
and adulthood.
2428
Moreover, although overconsump-
tion is not a major concern during the complementary
feeding period, increased consumption of highly proc-
essed, hyperpalatable, and addictive foods could lead to
unhealthy dietary preferences and thus overconsumption
and obesity in older childhood and adulthood.
29,30
For
these reasons, the focus in the following paragraphs is on
identifying nutritious whole-food sources of lacking
micronutrients.
Table 3 provides the micronutrient densities and
average share of requirements across 6 micronutrients
per 100 g of micronutrient-dense foods that can help
address identified and potential micronutrient gaps in
the region. These foods may not be available or accept-
able in all areas of South Asia or may only be available
seasonally. The best whole-food sources of multiple
identified or potential micronutrient gaps (iron, zinc,
vitamin A, vitamin B
12
, folate, and calcium), as mea-
sured by average share of requirements per 100-g por-
tion, are chicken liver, ruminant liver, small fish, eggs,
ruminant meat, and dark leafy greens. Small fish are
also good sources of vitamin D and long-chain omega-3
fats, which are important for child development and
have other health benefits.
34
Figure 2 shows the portion
size of each food needed to meet an average of 33.3% of
requirements across the same 6 micronutrients.
Figure 1 Gap burden and certainty of evidence ratings for 11 micronutrients among children aged 6–23 months in South Asia. Nutrient
gap burden is signified by color: red (high burden), orange (moderate burden), yellow (low burden), or green (negligible burden). The number of
plus (1) signs represents the certainty of evidence: 3 (high certainty), 2 (moderate certainty), or 1 (low certainty). Abbreviations: Ca,calcium;Vit,
vitamin.
Table 3. Micronutrient densities and average share of requirements per 100 g of foods high in priority micronutrients
a
Food
Iron
(mg)
Vit A
(RAE)
Calcium
(mg)
Zinc
(mg)
Folate
(DFE)
Vit B
12
(mg)
Average share of requirements
across all 6 micronutrients (%)
b
Chicken liver 12.3 4139 11 4 569 19 84
Ruminant liver 6.7 11 562 7 5.9 163 69 83
Small fish
c
332382 1.9 10 8.9 70
Eggs 1.2 149 50 1.1 44 1.1 59
Ruminant meat 3.5 0 11 6.1 7 2.7 48
Dark leafy greens 2.7 367 151 0.6 54 0 46
Chicken 1.2 46 14 1.9 5 0.3 42
Milk 0 46 113 0.4 5 0.5 37
Groundnuts 1.3 0 57 2.3 86 0 34
Fresh peas 2.1 54 43 0.3 42 0 33
Mango 0.5 152 13 0.1 33 0 26
Pulses 2.6 1 34 1.3 45 0 24
Carrot/pumpkin 0.5 570 23 0.2 12 0 22
Okra 0.3 14 77 0.4 46 0 21
a
All foods are in the form typically consumed. Values, except small fish, are from Ryckman et al
15
in this issue of Nutrition Reviews. Bold
numbers indicate the highest density of the specified micronutrient or average share of requirements. Abbreviations: DFE, dietary fo-
late equivalent; RAE, retinal activity equivalent.
b
Average share of requirements for iron, zinc, vitamin A, vitamin B
12
, folate, and calcium per 100 g, assuming requirements from com-
plementary foods for children aged 6–23 months (each micronutrient capped at 100% of daily requirements). The proportion of micro-
nutrient requirements from complementary foods were assumed to be 0.98 for iron, 0.87 for zinc, 0.65 for calcium, 0.17 for vitamin A,
0.70 for vitamin B
12
, and 0.60 for folate.
31
Iron and zinc requirements were adjusted for bioavailability. For iron, we assumed 15% die-
tary iron bioavailability for animal-source foods and 10% for plant foods; for zinc we assumed 50% dietary zinc bioavailability for ani-
mal-source foods and 30% for legumes, nuts, and seeds.
32
c
Nutrient values from canned sardines in the US Department of Agriculture food composition data.
33
Nutrition Reviews
V
R
Vol. 79(S1):26–34 31
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
Strikingly, only 1 g of ruminant liver, 3 g of chicken
liver, 27 g of ruminant meat, 32 g of small fish, or 35 g
of eggs are required to reach this threshold for a child
aged 6–23 months, demonstrating the importance of
these nutrient-dense animal-source foods in young
children’s diets. Larger quantities are required, however,
for animal-source foods like chicken and milk to
achieve this threshold. Although a moderate-sized por-
tion (57 g) of dark leafy greens can meet the threshold,
a much larger portion of pulses (138 g) would be re-
quired to achieve the same outcome.
According to Food and Agriculture Organization
Food Balance Sheets, South Asia has the lowest per cap-
ita availability of meat (19 g/day) of any region globally,
and India the lowest of any country (10 g/day).
23
However, given young children’s low overall food in-
take, social and behavioral change communication cam-
paigns and counselling on child diets could encourage
the increased allocation of existing supplies of chicken
liver, ruminant liver, and ruminant meat for children
aged 6–23 months and provide meaningful intake of
bioavailable nutrients. Small fish are only widely avail-
able in the Maldives, Sri Lanka, and Bangladesh; in
other South Asian countries, they may only be available
in specific geographic areas (eg, fresh small fish in areas
near water or tinned small fish in select cities).
23
Fewer
than 10 g of eggs are available per capita in South
Asia,
23
which indicates a need for preferential allocation
of existing supplies to young children and/or increased
production. The availability of dark leafy greens is less
clear, but they are likely available at least in moderate
quantities in most areas in South Asia.
15
For differences
in household consumption of common whole-food
sources among India, Bangladesh, and Pakistan, refer to
Ryckman et al.
15
CONCLUSION
Unsurprisingly, there was heterogeneity in micronutri-
ent gap burdens and certainty ratings across countries
and micronutrients in South Asia. Although micronu-
trient gaps varied across countries, most countries had
identified or potential gaps in multiple micronutrients.
Diets were apparently inadequate in micronutrients, es-
pecially iron, zinc, vitamin A, folate, vitamin B
12
, cal-
cium, and vitamin C. Previous literature on regional
patterns of micronutrient gaps in South Asia is limited.
In accordance with our findings in the present study, a
review of iron, iodine, vitamin A, and zinc deficiencies
in South Asia found that there was a low burden of io-
dine deficiency (largely a result of widespread salt iod-
ization in the region) but a high burden of iron,
vitamin A, and zinc deficiencies.
3
Animal-source foods,
particularly liver, small fish, eggs, and ruminant meat,
are the best sources of the highest priority micronu-
trients but likely have major obstacles to increased con-
sumption, including availability,
18
affordability,
15
access, knowledge, and cultural preferences.
35
Dark
leafy greens are also a good source of multiple high-
priority micronutrients. Special attention should be
given to including these diverse sources of micronu-
trients in young children’s diets.
Evidence on micronutrient gaps was most robust
in India, Pakistan, and Nepal, because of their recent
national micronutrient surveys. In accordance with a
CONGA on Eastern and Southern Africa,
17
across
South Asia there was limited biochemical evidence on
folate, vitamin B
12
, and especially calcium deficiencies,
and no evidence for vitamin C, niacin, thiamine, or vita-
min B
6
deficiencies. Among these, investment is war-
ranted in collecting biomarkers on folate, vitamin B
12
,
calcium, and vitamin C status where recent evidence
does not exist, given that low-certainty evidence sug-
gests there are potential gaps in these micronutrients in
several South Asian countries. Although vitamin D gaps
were not assessed, deficiency is common in at least parts
of South Asia,
4,21,22
which suggests vitamin D
Pulses
Groundnuts
Milk
Chicken
Dark leafy greens
Eggs
Small fish
Ruminant meat
Chicken liver
Ruminant liver
138
99
95
83
57
35
32
28
3
1
0 50 100 150
g
Figure 2 Portion size needed to achieve an average of 33.3%
of requirements for iron, vitaminA, zinc, folate, vitamin B
12
,
and calcium from complementary foods in South Asia (each
micronutrient capped at 100% of daily requirements). The pro-
portion of micronutrient requirements from complementary foods
was assumed to be 0.98 for iron, 0.87 for zinc, 0.65 for calcium,
0.17 for vitamin A, 0.70 for vitamin B
12
, and 0.60 for folate.
31
Iron
and zinc requirements was adjusted for bioavailability. For iron, it
was assumed there was 15%dietary iron bioavailability from ani-
mal-source foods and 10%from plant foods; for zinc, it was as-
sumed there was 50%dietary zinc bioavailability from animal-
source foods and 30%from legumes, nuts, and seeds
32
32 Nutrition Reviews
V
R
Vol. 79(S1):26–34
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
biomarkers are important to collect across the region.
Biochemical data should be collected at the national
level at least every 10 years, and ideally more frequently,
to monitor programs, track progress, and inform poli-
cies and programs. Importantly, there was very little ev-
idence from studies assessing micronutrient adequacy
of individual or household diets, a clear gap in collec-
tion and/or use of dietary intake and household con-
sumption data in the region. Other than for iron, there
was not enough evidence in Bhutan to assess micronu-
trient gaps, highlighting the urgent need to collect and
analyze biomarker, dietary, and household consump-
tion data in the country. Overall, however, there was
much more robust evidence on micronutrient gaps in
South Asia than was identified by a related CONGA on
Eastern and Southern Africa.
17
Assessing micronutrient gaps in young-child diets
across South Asia using the CONGA method allowed
for a critical assessment of the relevant evidence from
different types of data sources that are not usually syn-
thesized (ie, biochemical, nutrient intake and availabil-
ity, and nutrient-informative food-group intake). This
comprehensive assessment addresses this knowledge
gap and provides a more complete understanding of
micronutrient gaps in each country than would have
been possible if relying on only 1 type of data or a sub-
set of the evidence base. Moreover, evidence sources,
even robust sources, often have conflicting findings.
Therefore, the use of multiple sources reduced the like-
lihood of erroneous conclusions. Furthermore, assess-
ing the certainty of the micronutrient gap ratings
provided transparency about the evidence behind them,
which will help limit inappropriate use of evidence or
overconfidence in findings that are not robust, repre-
sentative, validated, or recent. Finally, because CONGA
is a standardized process,
6
it enabled valid comparisons
across countries.
This assessment has important limitations. A sys-
tematic search was not conducted to identify evidence
sources for inclusion in the CONGA. Although it is un-
likely that robust, large-scale evidence sources were not
identified, it is likely that some qualifying evidence was
not. Thus, it is unclear how many additional resources
would have been included in a systematic review and the
extent to which their inclusion would have influenced
ratings. Also, although the CONGA method was
designed to be standardized and minimize bias, it has
built-in flexibility to allow reviewers to override auto-
mated ratings on the basis of their qualitative assessment
of the total evidence base, including data points excluded
from the automated rating process. As a result, the final
ratings, to some extent, are a reflection of the subjective
perspective of experts who reviewed the evidence. The
impact of this bias was minimized by having 2 experts
make the initial ratings and revisions jointly and multi-
ple subject-matter and local experts review and validate
the final ratings. Notably, although the CONGA method
can be applied subnationally, we did not assess in this
analysis subnational differences in nutrient gaps (which
can vary considerably within countries) or foods to fill
these gaps. In addition, there may be other nutrient gaps
that we did not identify in this analysis because there
was limited robust evidence for several micronutrients.
Finally, differences in ratings across countries may be
due, in part, to differences in the date of data collection
across countries. Additional limitations of the CONGA
method are specified elsewhere.
6
The findings from this CONGA are essential for
addressing micronutrient malnutrition and inadequate
diets among young children in South Asia. They pro-
vide a clear understanding of the specific issues and
limitations in data on micronutrient gaps and evidence
across the region. The numerous causes of these impor-
tant micronutrient gaps should be further studied and
addressed through a food-systems approach that identi-
fies and removes the largest barriers to adequate
intakes, including availability, accessibility, affordability,
cultural acceptability, desirability, convenience, knowl-
edge, and feeding practices.
36
For example, only 57% of
the population in South Asia can afford a healthy diet
37
;
in many areas, animal-source foods are not widely
available
23
; and cultural preferences make it challenging
to ensure young-child diets are adequately nutrient
dense.
35
Poor dietary diversity and quality are modifi-
able risk factors underlying child malnutrition in South
Asia. Addressing all context-specific barriers contribut-
ing to micronutrient gaps will go a long way in acceler-
ating reductions in child malnutrition, which affects
millions of children, their futures, and society at large
across South Asia and beyond.
Policy and programmatic interventions to address
micronutrient gaps should be guided by a systematic
analysis of context-specific determinants and by drivers
influencing access to and consumption of nutritious
and safe whole-food sources, identified in this study,
that can fill critical micronutrient gaps during the com-
plementary feeding period. Finally, a multisystem re-
sponse involving the health, food, water and sanitation,
and social protection systems is warranted in countries
in the region to collectively create the necessary condi-
tions for micronutrient-adequate diets and adequate
feeding practices.
Acknowledgements
Author contributions. T.B. and J.M.W. designed the
study and wrote the manuscript. All authors critically
Nutrition Reviews
V
R
Vol. 79(S1):26–34 33
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
reviewed the ratings, revised the content, and approved
the manuscript for publication.
Funding. This work was funded by contributions from
the Ministry of the Foreign Affairs of the Netherlands
(grant MINBUZA-2019.334151 to the Global Alliance
for Improved Nutrition) and the Bill & Melinda Gates
Foundation through the Regional Initiatives for
Sustained Improvements in Nutrition and Growth
(grant OPP1179059 to UNICEF). The findings and con-
clusions contained within are those of the authors and
do not necessarily reflect positions or policies of the Bill
& Melinda Gates Foundation.
The funder had no role in data collection and analy-
sis, manuscript preparation and revision, or the deci-
sion to publish. This study used data from public
sources, and all authors had access to the data analyzed
as part of this study.
Declaration of interest. All authors declare no conflicts
of interest.
Supporting Information
Table S1 Search terms used in the literature review
Supplementary Material:References that qualified for
inclusion in the CONGA in South Asia
Table S2 Spreadsheet of nutrient gap burden and cer-
tainty-of-evidence ratings in the 8 countries included
in this study
REFERENCES
1. United Nations Department of Economic and Social Affairs. World Population
Prospects 2019. https://population.un.org/wpp/Download/Standard/Population/.
Accessed July 10, 2020.
2. United Nations Children’s Fund. Malnutrition. 2020. https://data.unicef.org/topic/
nutrition/malnutrition/. Accessed April 21, 2020.
3. Harding KL, AguayoVM, Webb P. Hidden hunger in South Asia:a review of recent
trends and persistent challenges. Public Health Nutr. 2018;21:785–795.
4. Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF,
Population Council. Comprehensive National Nutrition Survey (CNNS) 2016–2018
National Report. New Delhi, India. 2019.
5. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and over-
weight in low-income andmiddle-income countries. Lancet. 2013;382: 427–451.
6. Beal T, White JM, Arsenault JE, et al. Comprehensive Nutrient Gap Assessment
(CONGA): A method for identifying the public health significance of nutrient gaps.
Nutr Rev. 2021;79(Suppl 1):4 –15.
7. Kim R, Mej
ıa-GuevaraI, Corsi DJ, et al. Relative importance of 13 correlates of child
stunting in South Asia: insights from nationally representative data from
Afghanistan, Bangladesh, India, Nepal, and Pakistan. Soc Sci Med.
2017;187:144–154.
8. United NationsChildren’s Fund. Global UNICEF Databases: Infant and Young Child
Feeding. 2020. https://data.unicef.org/topic/nutrition/infant-and-young-child-
feeding/.
9. United Nations Children’s Fund. The State of the World’s Children 2019: Children,
Food and Nutrition: Growing Well in a Changing World. UNICEF; 2019. https://
www.unicef.org/publications/index_103751.html. Accessed March 27, 2020.
10. United Nations Children’s Fund. Improving Young Children’s Diets During the
Complementary Feeding Period. UNICEF Programming Guidance. New York:
UNICEF, 2020.
11. Dewey KG. The challenge of meeting nutrient needs of infants and young chil-
dren during the period of complementary feeding: an evolutionary perspective. J
Nutr. 2013;143:20 50–2054.
12. Shaheen N, Bari L, Mannan MA. Food composition table for Bangladesh. University
of Dhaka; 2013. http://www.fao.org/fileadmin/templates/food_composition/docu-
ments/FCT_10_2_14_final_version.pdf. October 26, 2020.
13. Amalraj A, Pius A. Bioavailability of calcium and its absorption inhibitors in raw
and cooked green leafy vegetables commonly consumed in India – an in vitro
study. Food Chem. 2015;170: 430–436.
14. US Department of Agriculture, Agricultural Research Service, Nutrient Data
Laboratory. USDA National Nutrient Database for Standard Reference, Release 27
(slightly revised). Version Current: May 2015. Methods and Application of Food
Composition Laboratory home page, http://www.ars.usda.gov/nea/bhnrc/mafcl.
Accessed June 1, 2015.
15. Ryckman T, BealT, Nordhagen S, et al. Affordability of nutritious foods for comple-
mentary feeding in South Asia. Nutr Rev. 2021;79(Suppl 1):53– 69.
16. Ryckman T, BealT, Nordhagen S, et al. Affordability of nutritious foods for comple-
mentary feeding in Eastern and Southern Africa. Nutr Rev.2021;79(Suppl
1):35–52.
17. White JM, Beal T, Chimanya K, et al. Micronutrient gaps during the complemen-
tary feeding period in Eastern and Southern Africa: A Comprehensive Nutrient
Gap Assessment. Nutr Rev. 2021;79(Suppl 1):16–25.
18. Beal T, Massiot E, Arsenault JE, et al. Global trends in dietary micronutrient sup-
plies and estimated prevalence of inadequate intakes. Plos One.
2017;12:E0175554.
19. Rahman S, Ireen S. Groundwater iron has the ground: low prevalence of anemia
and iron deficiency anemia in Bangladesh. Am J Clin Nutr. 2019;110:519–520.
20. Pettifor JM. Calcium and vitamin D metabolism in children in developing coun-
tries. Ann Nutr Metab. 2014;64:15–22.
21. Government of Pakistan, United Nations Children’s Fund. Pakistan National
NutritionSurvey 2018 Key Findings Report; Islamabad: UNICEF, 2019.
22. Ministry of Public Health, United Nations Children’s Fund. National Nutrition
Survey Afghanistan (2013). Kabul, Afghanistan: UNICEF, 2013.
23. Food and Agriculture Organization of the United Nations. New food balances.
http://www.fao.org/faostat/en/#data/FBS.AccessedJuly9,2020.
24. Teodoro AJ. Bioactive Compounds of Food: Their Role in the Prevention and
Treatment of Diseases. Oxidative Medicine and Cellular Longevity. 2019:4. doi:
Https://doi.org/10.1155/2019/3765986
25. Shi M, Loftus H, McAinch AJ, et al. Blueberry as a source of bioactive compounds
for the treatment of obesity, type 2 diabetes and chronic inflammation. JFunct
Foods. 2017;30:16–29.
26. Liu RH. Health-promoting components of fruits and vegetables in the diet. Adv
Nutr. 2013;4:384S–392S.
27. Kim JH, Kim Y, Kim YJ, et al. Conjugated linoleic acid: potential health benefits as
a functionalfood ingredient. Annu Rev FoodSci Technol. 2016;7:221–244.
28. Bhat ZF, Kumar S, Bhat HF. Bioactive peptides of animal origin: a review. JFood
Sci Technol.2015;52:5377–5392.
29. Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie in-
take and weight gain: an inpatient randomized controlled trial of ad libitum food
intake. Cell Metab. 2019;30:67– 77. e3.
30. Rauber F, Campagnolo PDB, Hoffman DJ, et al. Consumption of ultra-processed
food products and its effects on children’s lipid profiles: a longitudinal study. Nutr
Metab Cardiovasc Dis. 2015;25:116–1 22.
31. Dewey KG. Nutrition, growth, and complementary feeding of the brestfed infant.
Pediatr ClinN Am. 2001;48:8 7–104.
32. World Health Organization, Food and Agriculture Organization of the United
Nations. Vitamin and Mineral Requirements in Human Nutrition. 2nd edn. World
Health Organization; FAO; 2004. https://apps.who.int/iris/bitstream/handle/
10665/42716/9241546123.pdf
33. US Department of Agriculture, Agricultural Research Service. FoodData Central.
2019. https://fdc.nal.usda.gov./ Accessed January 26, 2020.
34. Parks CA, Brett NR, Agellon S, et al. DHA and EPAin red blood cell membranes are
associated with dietary intakes of omega-3-rich fish in healthy children.
Prostaglandins Leukot Essent Fatty Acids. 2017;124:11–16.
35. Aguayo VM. Complementary feeding practices for infants and young children in
South Asia. A review of evidence for action post-2015. Matern Child Nutr.
2017;13:E12439.
36. United Nations Children’s Fund, Global Alliance for Improved Nutrition. Food
Systems for Children and Adolescents. Working Together to Secure Nutritious
Diets. United Nations Children’s Fund; 2019. https://doi.org/10.36072/cp.3
37. Food and Agriculture Organization of the United Nations (FAO), the International
Fund for Agricultural Development (IFAD), the United Nations Children’s Fund
(UNICEF), the World Food Programme (WFP), the World Health Organization
(WHO). The State of Food Security and Nutrition in the World 2020: Transforming
Food Systems for Affordable Healthy Diets. FAO, IFAD, UNICEF, WFP and WHO;
Rome, Italy.2020. doi:10.4060/ca9692en
34 Nutrition Reviews
V
R
Vol. 79(S1):26–34
Downloaded from https://academic.oup.com/nutritionreviews/article/79/Supplement_1/26/6164904 by guest on 10 March 2021
... An important aspect of food, among others, is the vitamins and minerals it provides. Yet in many lowand middle-income countries (LMICs) diets are known to be lacking in micronutrients, especially for population groups with increased needs, leading to deficiencies, particularly in iron, zinc, folate, vitamin A, calcium, and vitamin B 12 (hereafter referred to as "priority micronutrients"), that can have severe and lasting effects (1)(2)(3)(4)(5)(6). For example, more than four in five Indian adolescents have a deficiency in one or more micronutrients (7). ...
... A similar approach was previously used to identify micronutrient-dense complementary foods for young children (4,32). Ratings were calculated for different population groups according to the following thresholds for Average Requirements (ARs) of energy for a moderately active individual (18) and hypothetical ARs for mass, assuming an energy density of 1.3 kcal/g [the mean energy density of a minimally processed plant-based, low-fat diet and animal-based, ketogenic diet (33)]: ...
... As indicated in the formula for the aggregate score, each micronutrient's contribution was capped at 100% of recommended intakes, which means that each micronutrient can contribute nothing or up to one-half of the total score (4,32). To illustrate this, a food containing only two of the six nutrients would provide 100% of recommended intakes of both nutrients, while a food with a perfectly even proportion of recommended intakes across all six nutrients would provide 33.3% of recommended intakes of all six nutrients-each micronutrient thus contributing an equal one-sixth of the total score. ...
Article
Full-text available
Background Despite concerted efforts to improve diet quality and reduce malnutrition, micronutrient deficiencies remain widespread globally, especially in low- and middle-income countries and among population groups with increased needs, where diets are often inadequate in iron, zinc, folate, vitamin A, calcium, and vitamin B12. There is a need to understand the density of these micronutrients and their bioavailability across diverse foods and the suitability of these foods to help meet requirements for populations with high burdens of micronutrient malnutrition.Objective We aimed to identify the top food sources of these commonly lacking micronutrients, which are essential for optimal health, to support efforts to reduce micronutrient malnutrition among various populations globally.Methods We built an aggregated global food composition database and calculated recommended nutrient intakes for five population groups with varying requirements. An approach was developed to rate foods according to their density in each and all priority micronutrients for various population groups with different nutrient requirements.ResultsWe find that the top sources of priority micronutrients are organs, small fish, dark green leafy vegetables, bivalves, crustaceans, goat, beef, eggs, milk, canned fish with bones, mutton, and lamb. Cheese, goat milk, and pork are also good sources, and to a lesser extent, yogurt, fresh fish, pulses, teff, and canned fish without bones.Conclusion The results provide insight into which foods to prioritize to fill common micronutrient gaps and reduce undernutrition.
... Children aged 6-23 months have a limited gastric capacity and can only consume small quantities of food, therefore, complementary foods should have high nutrient density (amount of each nutrient per 100 kcal of food) (1,2). Unfortunately, in practice this is often not the case, and diets of infants and young children are often not sufficiently diverse and nutrient dense and are lacking in one or more essential micronutrients, especially in low-and middle-income countries, but also in high-income countries [e.g., iron and zinc in the US; (1,2,7)]. ...
... In particular, in South and Southeast Asia important micronutrient gaps were identified in infants' and young children's diets (7)(8)(9)(10). The micronutrients most commonly known to be lacking and those of highest public health significance in the two regions are iron, zinc, vitamin A, folate, vitamin B 12 , and calcium, hereafter referred to as priority micronutrients (7)(8)(9)(10). ...
... In particular, in South and Southeast Asia important micronutrient gaps were identified in infants' and young children's diets (7)(8)(9)(10). The micronutrients most commonly known to be lacking and those of highest public health significance in the two regions are iron, zinc, vitamin A, folate, vitamin B 12 , and calcium, hereafter referred to as priority micronutrients (7)(8)(9)(10). Among the main drivers of micronutrient malnutrition in infants and young children living in South and Southeast Asia are the following: (1) the low micronutrient density and lack of diversity of complementary foods, with most children aged 6-23 months having a primarily cereal-based complementary feeding diet and not consuming the minimum recommended number of food groups each day (6,7,(10)(11)(12); and (2) the inappropriate marketing of nutritionally inadequate, often ultra-processed, complementary foods, and beverages that are promoted as suitable for this age group (11). ...
Article
Full-text available
Background: Given their high nutrient requirements and limited gastric capacity, young children during the complementary feeding period (6–23 months) should be fed nutrient-dense foods. However, complementary feeding diets in low- and middle-income countries are often inadequate in one or more essential micronutrients. In South and Southeast Asia infants' and young children's diets are commonly lacking in iron, zinc, vitamin A, folate, vitamin B 12 , and calcium, hereafter referred to as priority micronutrients. Objective: This study aimed to identify the top food sources of priority micronutrients among minimally processed foods for complementary feeding of children (6–23 months) in South and Southeast Asia. Methods: An aggregated regional food composition database for South and Southeast Asia was built, and recommended nutrient intakes (RNIs) from complementary foods were calculated for children aged 6–23 months. An approach was developed to classify foods into one of four levels of priority micronutrient density based on the calories and grams required to provide one-third (for individual micronutrients) or an average of one-third (for the aggregate score) of RNIs from complementary foods. Results: We found that the top food sources of multiple priority micronutrients are organs, bivalves, crustaceans, fresh fish, goat, canned fish with bones, and eggs, closely followed by beef, lamb/mutton, dark green leafy vegetables, cow milk, yogurt, and cheese, and to a lesser extent, canned fish without bones. Conclusions: This analysis provided insights into which foods to prioritize to fill common micronutrient gaps and reduce undernutrition in children aged 6–23 months in South and Southeast Asia.
... An 24 important aspect of food, among others, is the vitamins and minerals it provides. Yet in many 25 low-and middle-income countries (LMICs) diets are known to be lacking in micronutrients, 26 especially for population groups with increased needs, leading to deficiencies, particularly in 27 iron, zinc, folate, vitamin A, calcium, and vitamin B12 (hereafter referred to as "priority 28 micronutrients"), that can have severe and lasting effects (1)(2)(3)(4)(5)(6). Even in high-income countries 29 (HICs) like the United States, micronutrient deficiencies such as iron deficiency may be 30 common, especially among women (7). ...
... We calculated recommended intakes for adults ≥ 25 10% for all plant-source foods), based on the proportion of heme to non-heme iron contained (1): 83 68% heme-iron in ruminant meat, including beef (22)(23)(24), goat, and lamb/mutton (24,25); 39% 84 heme-iron in pork (23,24,(26)(27)(28); 26% heme-iron in chicken (23,24,(26)(27)(28), fish and seafood 85 (23,(26)(27)(28)(29), and eggs and dairy (27); and 40% heme-iron in all other meat, including offal 86 (22,27,28). Regarding zinc, foods were classified into one of four levels of zinc absorption (44%, 87 35%, 30%, and 26%), based on the amount of phytate contained in each food in a portion 88 equivalent to one-third of daily mass intake, assuming an energy density of 1. for young children (4,30). Ratings were calculated for different population groups according to 100 the following thresholds for Average Requirements (ARs) of energy for a moderately active 101 individual and hypothetical ARs for mass, assuming an energy density of 1.3 kcal/g (the mean 102 energy density of a minimally processed plant-based, low-fat diet and animal-based, ketogenic 103 diet (31)): 104 ...
... nothing or up to one-half of the total score (4,30). To illustrate this, a food containing only two 117 of the six nutrients would provide 100% of recommended intakes of both nutrients, while a food 118 with a perfectly even proportion of recommended intakes across all six nutrients would provide 119 33.3% of recommended intakes of all six nutrients-each micronutrient thus contributing an 120 equal one-sixth of the total score. ...
Preprint
Full-text available
Background: Despite concerted efforts to improve diet quality and reduce malnutrition, micronutrient deficiencies remain widespread globally, especially in low- and middle-income countries and among population groups with increased needs, where diets are often inadequate in iron, zinc, folate, vitamin A, calcium, and vitamin B12. There is a need to understand the density of these micronutrients and their bioavailability across diverse foods and the suitability of these foods to help meet requirements for populations with high burdens of micronutrient malnutrition. Objective: We aimed to identify the top food sources of these commonly lacking micronutrients, which are essential for optimal health, to support efforts to reduce micronutrient malnutrition among various populations globally. Methods: We built an aggregated global food composition database and calculated recommended nutrient intakes for five population groups with varying requirements. An approach was developed to rate foods according to their density in each and all priority micronutrients for various population groups with different nutrient requirements. Results: We find that the top sources of priority micronutrients are organs, small fish, dark green leafy vegetables, bivalves, crustaceans, goat, beef, eggs, milk, canned fish with bones, lamb, and mutton. Cheese, goat milk, and pork are also good sources, and to a lesser extent, yogurt, fresh fish, pulses, teff, and canned fish without bones. Conclusions: The results provide insight into which foods to prioritize to fill common micronutrient gaps and reduce undernutrition.
... In turn, a wider social and economic assessment should evaluate the impacts of different livelihood options, examining, for example, how different systems provide both affordable and high-quality animal products. Such analyses would then encompass the trade-offs between cheap products versus high-quality nutrition, and the meeting of particular dietary needs, especially of those who are nutritionally vulnerable, including younger people and pregnant or nursing women (e.g., Adesogan et al., 2020;Beal et al., 2021;Iannotti et al., 2021;Moughan, 2021). ...
Article
Full-text available
The relationship between livestock production and climate change is the subject of hot debate, with arguments for major shifts in diets and a reduction in livestock production. This Perspective examines how global assessments of livestock‐derived methane emissions are framed, identifying assumptions and data gaps that influence standard life‐cycle analysis approaches. These include inadequate data due to a focus on industrial not extensive systems; errors arising due to inappropriate emission factors being applied; questions of how global warming potentials are derived for different greenhouse gases and debates about what baselines are appropriate. The article argues for a holistic systems approach that takes account of diverse livestock systems—both intensive and extensive—including both positive and negative impacts. In particular, the potential benefits of extensive livestock systems are highlighted, including supporting livelihoods, providing high‐quality nutrition, enhancing biodiversity, protecting landscapes, and sequestering carbon. By failing to differentiate between livestock systems, global assessments may mislead. Inappropriate measurement, verification and reporting processes linked to global climate change policy may in turn result in interventions that can undermine the livelihoods of extensive livestock‐keepers in marginal areas, including mobile pastoralists. In the politics of global assessments, certain interests promote framings of the livestock‐climate challenge in favour of contained, intensive systems, and the conversion of extensive rangelands into conservation investments. Emerging from a narrow, aggregated scientific framing, global assessments therefore can have political consequences. A more disaggregated, nuanced approach is required if the future of food and climate change is to be effectively addressed. This article is categorized under: Integrated Assessment of Climate Change > Assessing Climate Change in the Context of Other Issues Climate and Development > Social Justice and the Politics of Development
... Acknowledging the need for targeted interventions in the LMIC's, where affordability is a key factor influencing the food choices, the CONGA approach considers the population specific data along with the demographic data and identify gaps for prioritized nutrients and rate them from negligible to high in terms of severity. Based on this method, nutrient gaps in Indian children aged 6-23 months have been identified as high for iron, zinc and folate, and moderate for vitamin A, vitamin B12 and calcium, and key foods, such as organ meats, other animal products and green leafy vegetables are proposed to fill many of these gaps (30). ...
Article
Full-text available
Sustainably addressing the crisis of undernutrition for children and adolescents in underserved and resource-limited communities will require, among other investments, interventions aimed at optimizing the diets of these vulnerable populations. However, to date, there are substantial global gaps in the collection of dietary data in children and adolescents. This review article summarizes the challenges and opportunities in assessing diet among children and adolescents in India. National surveys in India identify the scale of the triple burden of malnutrition (undernutrition, micronutrient deficiencies and overnutrition) in children and adolescents and assess key nutrition and food security indicators for making informed policy decisions. However, national surveys do not collect data on diet, instead relying on anthropometry, biomarkers of micronutrient deficiencies, and summary measures of diet, such as the WHO infant and young child feeding summary indicators. Sub-national surveys and the scientific literature thus fill important gaps in describing the nutrient intakes of children and adolescents in India; however large gaps remain. Future research can be improved by investments in infrastructure to streamline the assessment of diet in India. The current challenges confronting the collection and analysis of high-quality dietary data occur in both the data collection and data analysis phases. Common methods for assessing diets in low-resource settings—such as 24 h recalls and food frequency questionnaires are particularly challenging to implement well in young children and adolescents due to motivation and memory issues in young respondents. Additionally, there are challenges with parental recall including children having multiple caretakers and meals outside the home. Furthermore, analysis of dietary data is hindered by the lack of affordable, accessible software for dietary data analysis relevant to the diversity in Indian diets. New technologies can address some of the challenges in dietary data collection and analysis, but to date, there are no platforms designed for population-level dietary assessment in India. Public and private sector investment in dietary assessment, as well as collaboration of researchers and the creation of open-source platforms for the sharing of data inputs (local food lists, recipe databases, etc.) will be essential to build infrastructure to better understand the diets of children and adolescents in India and improve dietary interventions in these target groups.
... Simple processing of foods rich in iron, zinc, and calcium, and folate-rich foods, such as dried/powder forms of liver, fish, anchovy, mungbean, and moringa leaf, can be a potential intervention because it significantly increases the nutrient density in the diet of infants and under-five children. The Comprehensive Nutrient Gap Assessment also identified liver, small fish (anchovy), and eggs as the best food sources with regards to micronutrient density to fill the potential micronutrient gaps (iron, zinc, vitamin A, vitamin B-12, folate, and calcium) in countries in South Asia (15). ...
Article
Background Stunting and anemia among pregnant women and children remain a challenge in developing countries, including Indonesia. One of the significant contributors of these problems is inadequate nutrient intake. Objectives The aim of the study was to identify, using linear programming (LP) approach, problem nutrients and optimized food-based recommendations amongst under-five children and pregnant mothers in 10 stunting prioritized districts in Indonesia. Methods LP analysis was done using Optifood on dietary data collected using single 24-hour dietary recall in Pemantauan Konsumsi Gizi conducted by the Ministry of Health from 10 stunting prioritized districts in Indonesia. Problem nutrients and nutrient-dense foods were identified, and all alternative food-based recommendations or complementary feeding recommendations were compared to identify which recommendation will best contribute to fulfill dietary adequacy. Results Amongst under-five children, the number of problem nutrients in each district ranged from 0–7 nutrients for under-five children and 1–6 nutrients for pregnant mothers. The top three problem nutrients were iron, zinc, folate (6–11mo); zinc, folate, calcium (12–23mo and 24–35 35mo); and folate, zinc and vitamin C/riboflavin (36–59mo); and iron, folate, and calcium (pregnant mothers). The findings showed that problem nutrients identified using LP were in line with nutritional problems in under-five children (stunting and anemia) and pregnant mothers (anemia). FBRs/CFRs were developed which best meet dietary adequacy of the nutrients. Conclusions Despite the similarity in stunting prevalence across the districts, there was variation in number and types of problem nutrients. The developed food-based recommendations which promoted nutrient-dense foods suited to the problem nutrients in each area need to be promoted to improve nutrient intakes of under-five children and pregnant mothers in these areas with high stunting prevalence.
... The NDRs are country-specific dietary guidelines that address public health and nutrition priorities and accessibility of foods. Nutritional reasons to include ASF in NDRs encompass that ASF provide proteins with a high bioavailability and an amino acid profile meeting human requirements (Elmadfa & Meyer, 2017) and that they are important sources of micronutrients such as zinc, selenium, iron, vitamins A, B12 and folic acid (Beal et al., 2021;Biesalski, 2005), specifically for the world's poor (Adesogan et al., 2020). Aquatic ASFs are also a good source of highly unsaturated fatty acids. ...
Article
Full-text available
In the discourse about the development of farmed animal production (terrestrial livestock production and aquaculture) in the tropics, two important food system outcomes emerge: (1) to supply animal-sourced food (ASF) at a level that suffices healthy future diets, including for poor people, and (2) to contribute to climate change mitigation and minimize pollution with nitrogen and phosphorus. Livestock production and aquaculture contribute to food security directly by increasing producers’ food diversity and availability, but also that of urban consumers, and indirectly through income generation and increased farm resilience. Recently, circularity has come to the fore as an integrated approach to food system development. Circularity has four cornerstones: (1) food crops have highest priority (which implies no food-feed competition), (2) avoid losses, (3) recycle waste and (4) use animals to unlock biomass that humans cannot eat. In this review, the role of farmed animals in circular food systems in the tropics is presented in four case studies and the impacts of circularity on food security and environmental impact mitigation are discussed. The cases are ruminants in grazing systems in West Africa and in Colombia, fish in pond aquaculture in general, and land-limited dairy production in Indonesia. Additionally, options for novel protein sources for use in livestock and fish feeding are presented. It is concluded that farmed animals are important in circular food systems because of their use of land unsuited for crop production, their upgrading of crop residues, and their supply of manure to crop production. Nevertheless, the increasing demand for ASF puts pressure on important characteristics of circularity, such as minimizing food-feed competition, maximization of use of waste streams in feed, and the value of manure for fertilization. Hence, in line with conclusions for Western countries, maximum circularity and sustainability of food systems can only be achieved by optimizing the population size of animals. Thus, a sustainable contribution of ASF production to global food security is complex and in not only a technical matter or outcome of an economic process balancing supply and demand. It requires governance for which public, private, and social actors need to partner.
Article
Full-text available
In Sub-Saharan Africa, inadequate complementary feeding practices and being nutritionally inadequate are primary factors in infant and young child malnutrition, growth failure, and high morbidity and mortality. Therefore, novel complementary foods need to be developed to alleviate malnutrition problems in IYC. Therefore, this experimental study aimed to assess the effects of newly developed grain-bee larvae blended complementary foods on the growth performance, haematological, and biochemical parameters of BALB/c mice. A complete randomized design was used and a total of 75 BALB/c mice were assigned to each of the five treatments. The treatments were: T1 = Casein diet; T2 = 57 % Maize, 29 % Teff, 14 % Soybean; T3 = 58 % Maize, 29 % Teff, 13 % Bee larvae; T4 = Commercial wean mix; and T5 = Basal diet alone. The in vivo experiment trial was done for 28 days along with seven days of adaptation. Dietary intake was not significantly different (P = 0.96) between treatments, but it was noted that T3 had gained the highest final body weight (38.52 g). The examined biochemical parameters showed T4 had the lowest serum protein (6.27 mg/dl) and globulin (3.61 mg/dl). Compared to others, T3 significantly (P < 0.001) increased WBC (4 × 10⁶ mm³), RBC (11.37 × 10³ mm³), Haemoglobin (16.42 g/dl), and Hematocrit (63.04 %). The highest serum levels of zinc (0.55 mg/dl) and iron (2.08 mg/dl) were reported on T2, while the highest serum calcium content (10.64 mg/dl) was reported on T1. The results indicated that T3 can aid body growth, health, and prevent malnutrition in infants and young children.
Article
Full-text available
Reductionist approaches to food focus on isolated nutritional criteria, ignoring the broader physiological and societal benefits and trade-offs involved. They can lead to the inadvertent or, potentially, intentional labelling of foods as good or bad. Both can be considered worrisome. Among our present-day array of issues is the disproportionate stigmatisation of animal-source foods as harmful for human and planetary health. The case for a protein transition reinforces this trend, overemphasising one particular nutritional constituent (even if an important one). In its strongest formulation, animal-source foods (reduced to the notion of 'animal protein') are represented as an intrinsically harmful food category that needs to be minimised, thereby falsely assuming that 'proteins' are nutritionally interchangeable. We caution against using the word 'protein' in food policy-making to describe a heterogenous set of foods. Rather, we suggest referring to said foods as 'protein-rich foods', while acknowledging the expanded pool of non-protein nutrients that they provide and their unique capabilities to support a much broader range of bodily functions. Several essential or otherwise beneficial nutrients are generally more bioavailable in animal-source foods than in plant-source foods. A similar complementarity exists in reverse. Nutritional and environmental metrics should be carefully interpreted, as considerable contextuality is involved. This needs to be undertaken, for instance, with respect to the biochemistry of food and in light of individual and genetically inherited human physiology. Also, the assessments of the environmental impact need a fine-grained approach, especially when examining a product at the system scale. Harms and benefits are multiple, multi-dimensional, and difficult to measure on the basis of the narrow sets of descriptive metrics that are often used (e.g. CO 2-eq/kg). A more appropriate way forward would consist of combining and integrating the best of animal and plant solutions to reconnect with wholesome and nourishing diets that are rooted in undervalued benefits such as conviviality and shared traditions, thus steering away from a nutrient-centric dogma. Humans do not consume isolated nutrients, they consume foods, and they do so as part of culturally complex dietary patterns that, despite their complexity, need to be carefully considered in food policy making.
Article
Full-text available
Animal source foods are evolutionarily appropriate foods for humans. It is therefore remarkable that they are now presented by some as unhealthy, unsustainable, and unethical, particularly in the urban West. The benefits of consuming them are nonetheless substantial, as they offer a wide spectrum of nutrients that are needed for cell and tissue development, function, and survival. They play a role in proper physical and cognitive development of infants, children, and adolescents, and help promote maintenance of physical function with ageing. While high-red meat consumption in the West is associated with several forms of chronic disease, these associations remain uncertain in other cultural contexts or when consumption is part of wholesome diets. Besides health concerns, there is also widespread anxiety about the environmental impacts of animal source foods. Although several production methods are detrimental (intensive cropping for feed, overgrazing, deforestation, water pollution, etc.) and require substantial mitigation, damaging impacts are not intrinsic to animal husbandry. When well-managed, livestock farming contributes to ecosystem management and soil health, while delivering high-quality foodstuffs through the upcycling of resources that are otherwise non-suitable for food production, making use of marginal land and inedible materials (forage, by-products, etc.), integrating livestock and crop farming where possible has the potential to benefit plant food production through enhanced nutrient recycling, while minimising external input needs such as fertilisers and pesticides. Moreover, the impacts on land use, water wastage, and greenhouse gas emissions are highly contextual, and their estimation is often erroneous due to a reductionist use of metrics. Similarly, whether animal husbandry is ethical or not depends on practical specificities, not on the fact that animals are involved. Such discussions also need to factor in that animal husbandry plays an important role in culture, societal well-being, food security, and the provision of livelihoods. We seize this opportunity to argue for less preconceived assumptions about alleged effects of animal source foods on the health of the planet and the humans and animals involved, for less top-down planning based on isolated metrics or (Western) technocratic perspectives, and for more holistic and circumstantial approaches to the food system.
Article
Full-text available
The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6–23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children’s diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.
Article
Full-text available
Insufficient quantity and inadequate quality of foods in early life are key causes of all forms of malnutrition. Identification of nutrient and dietary gaps in the diets of infants and young children is essential to inform policies and programs designed to improve child diets. A Comprehensive Nutrient Gap Assessment was used to assess the public health significance of nutrient gaps during the complementary feeding period and to identify evidence gaps in 6 countries in Eastern and Southern Africa. Important gaps were identified in iron, vitamin A, zinc, and calcium and, to a lesser extent, vitamin B12 and folate. The best whole-food sources of these micronutrients available in part or all of the countries studied include beef liver, chicken liver, small dried fish, beef, and eggs. Investment is needed in many countries to collect data on micronutrient biomarkers and dietary intake. Strategic actions to improve child diets will require engagement and intervention across relevant systems to accelerate progress on improving the diets of infants and young children.
Article
Full-text available
Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.
Article
Full-text available
Identifying dietary nutrient gaps and interpreting their public health significance are essential for improving poor diets and reducing malnutrition. Evidence indicative of the burden of nutrient deficiencies and inadequate nutrient intake or availability exists in many countries yet is often misinterpreted or underused in decision-making. Clear guidance is lacking on how to synthesize and interpret the relevant evidence, which comes in many forms. To fill this methodological gap, an approach called Comprehensive Nutrient Gap Assessment was created to enable use of existing evidence to assess the public health significance of nutrient gaps and identify evidence gaps. Comprehensive Nutrient Gap Assessment requires ≥ 2 experts in nutritional assessment but does not require primary data collection or secondary quantitative data analysis. It can be implemented relatively quickly with low costs, for specific countries and subnational regions, and updated on the basis of new data with minimal effort. The findings from a Comprehensive Nutrient Gap Assessment are easily interpretable by nontechnical decision makers yet include clear justification for technical audiences.
Article
Full-text available
We investigated whether ultra-processed foods affect energy intake in 20 weight-stable adults, aged (mean ± SE) 31.2 ± 1.6 years and BMI = 27 ± 1.5 kg/m2. Subjects were admitted to the NIH Clinical Center and randomized to receive either ultra-processed or unprocessed diets for 2 weeks immediately followed by the alternate diet for 2 weeks. Meals were designed to be matched for presented calories, energy density, macronutrients, sugar, sodium, and fiber. Subjects were instructed to consume as much or as little as desired. Energy intake was greater during the ultra-processed diet (508 ± 106 kcal/day; p = 0.0001), with increased consumption of carbohydrate (280 ± 54 kcal/day; p < 0.0001) and fat (230 ± 53 kcal/day; p = 0.0004), but not protein (-2 ± 12 kcal/day; p = 0.85). Weight changes were highly correlated with energy intake (r = 0.8, p < 0.0001), with participants gaining 0.9 ± 0.3 kg (p = 0.009) during the ultra-processed diet and losing 0.9 ± 0.3 kg (p = 0.007) during the unprocessed diet. Limiting consumption of ultra-processed foods may be an effective strategy for obesity prevention and treatment.
Article
Full-text available
‘Hidden hunger’ is a term used to describe human deficiencies of key vitamins and minerals, also known as micronutrients. While global in scale, the prevalence of micronutrient deficiencies is particularly high in South Asia despite recent successes in economic growth, agricultural output and health care. The present paper reviews the most recent evidence on patterns and trends of hidden hunger across the region, with a focus on the most significant deficiencies – iodine, Fe, vitamin A and Zn – and interprets these in terms of health and economic consequences. The challenge for South Asian policy makers is to invest in actions that can cost-effectively resolve chronic nutrient gaps facing millions of households. Appropriate solutions are available today, so governments should build on evidence-based successes that combine targeted health system delivery of quality services with carefully designed multisector actions that help promote healthier diets, reduce poverty and ensure social protection simultaneously.
Article
https://academic.oup.com/ajcn/advance-article-abstract/doi/10.1093/ajcn/nqz052/5490303