Elaine Ferguson London School of Hygiene & Tropical Medicine ‘Optifood’ – A tool based on linear programming analysis to inform nutrition programme planning and policy decisions Elaine Ferguson London School of Hygiene & Tropical Medicine Improving health worldwide www.lshtm.ac.uk

Introduction Dietary survey data is important for describing food patterns, intakes of energy and nutrients and estimating the % at risk of inadequate nutrient intakes; however, there are important programme and policy uses of dietary data I will describe how dietary data together with a tool based on linear programming analyses (Optifood), can be used to inform decisions regarding the use of food-based strategies to improve nutrition of high risk target population I will present an illustrative example from SE Asia

Why a food-based intervention? Dietary approaches are more sustainable and will likely provide benefits across a wide range of age groups Avoids unintentional/unexpected adverse effects from providing high or unbalanced levels of nutrients However questions remain – is a food-based approach alone a cost-effective approach for ensuring dietary adequacy? → Culturally acceptable, affordable & nutritionally adequate What nutrient requirements are easy to meet using locally available foods and which are more difficult?

What Optifood can do.... Formulate food-based recommendations (FBR) for a specific target group Test & compare FBRs → cost & nutrient adequacy Identify nutrients whose requirements are difficult to achieve using local foods → “problem nutrients” Identify the lowest cost nutritionally best diet, and the most expensive food sources of nutrients in this diet as well as the most expensive nutrient requirements to achieve

Types of issues it can address FOOD AVAILABILITY/ ACCESSIBILITY: Can locally available food provide all nutrients needed by a target population? → Policy & programme decisions and advocacy. FOOD AFFORDABILITY: How much will the nutritionally best diet cost ? → Cost transfer programme decisions. BEHAVIOUR CHANGE: What food-based recommendations are best to promote for improving the nutritional status of the target population? → Programme decisions and research

Optifood …. Tool based on linear programming analyses (LP) LP is mathematical optimisation which selects the best option from amongst all possible options given specified criteria In Optifood, its diet modeling , so its quickly selects the best diet from hundreds/thousands of modeled diets that are run in each analysis to inform decisions

Data Requirements Dietary Surveys Quantitative (recalls, records) Food frequency data Market surveys Food cost per 100 g edible portion Food composition tables

Select Fe and Zn bioavailability Food Composition Table Energy Protein Water Fat Carbohydrate Vitamin A Vitamin C B1 B2 B3 Ca Fe Zn B6 B12 Folate Select Fe and Zn bioavailability

Optifood Analysis Structure Module Outputs Check parameters Create food-based recommendations; ‘Problem nutrients’ Test & compare alternative FBRs Type of ‘problem nutrient’ Cost analysis: Lowest cost nutritionally best diet Model Constraints Food list Min & max g/wk Food Patterns Min & max serves/wk Main food groups Staples & snacks Food sub-groups Energy content Maximum cost (optional) Food-based recommendations (FBRs) Nutrient content Module#1 Module#2 Module#3 Module#4

>65% or 70% RNI=adequate Module III: models tails of the nutrient intake distribution to test FBRs Test 11 micronutrients Test alternative sets of FBRs >65% or 70% RNI=adequate Define “problem nutrients” Upper tail < 100% RNI/AI Baseline Food-based recommendation Vitamin A intakes

Formulate and Test Food-based Recommendations: What food-based recommendations are best to promote for this target group? Module 2 results are used = “best diet” → potential food-based recommendations Best food and food sub-group sources of nutrients Food group patterns

Food-based Recommendations Test and compare in Module 3 “lower tail of intake distributions” Dairy 14 serves / week Vegetables 21 serves / week Meat, fish or eggs 5 serves / week Legumes 7 serves/week Fruits 7 serves/week Liver 2 serves/week Green leafy vegetables 5 serves/week Vitamin C rich fruits 5 serves/week Potatoes 3 serves/week Tofu/tempeh 7 serves/week Anchovies 3 serves/week

Minimised nutrient content analysis from Module 3 Count number of “lower tails” >65% or 70% RNI and cost

Research in SE Asia

Countries and Target groups Up to 6 target groups representative at national or district level in each country 6-8 month olds 9-11 month olds 12-23 month olds Pregnant women Lactating women or adolescent girls Non-pregnant, non-lactating women In all countries but Laos, dietary data were collected using a 24-hour recall at the national level; in Thailand FFQ in Laos, a 7-day qualitative 24-hour recall at a district level

Define “Problem nutrients” Can a nutritionally adequate diet be promoted given local foods & food patterns?

Numbers of “Problem Nutrients” Cambodia Indonesia Lao PDR Thailand Vietnam Children: 6-8 m 9-11 m 12-23 m 6 4 2 3 1 Women: Pregnant Lactating NPNL 7 5 Not analysed For children: Ca, Fe & Zn; sometimes folate, B1, B2 & B3 For women: Ca & Fe; often folate, B2, B6 & vitamin A

Food-based Recommendations To what extent can food-based recommendations ensure dietary adequacy for these target groups?

Number of nutrients –lower tails of their intake distributions >70% RNI when FBRs were tested (11 micronutrients)

% target groups where nutrient adequacy was not ensured

Testing Alternative Interventions -children

What is the minimum of sachets/w of multiple micronutrient powders that would ensure dietary adequacy? 6-8 months 9-11 months 12-23 months Alone With FBR Cambodia 5* 4* 3 Indonesia 3* Lao PDR Vietnam *Ca adequacy not ensured FBR – food-based recommendations

Daily Fe – folate Supplement Choose an iron-folate or a multi-micronutrient supplement for pregnant Cambodian women? Daily Fe – folate Supplement Daily Multiple Micronutrient Supplement Number per week Only supplement #Nutrients ≥70% RNI Supplement + FBR 1 day 2 days 3 days 4 days 5 days 6 days 7 days 1 2 3* 6 7 8 8# 3 4 9 10** 10 *Achieved only Fe, folate & niacin #Did not achieve Ca, riboflavin & vitamin A **Did not achieve Ca

Will the proposed national sets of Complementary Feeding Recommendations ensure dietary adequacy?

CF Recommendations for 6-8 m olds in Thailand Original Tested#1 Tested#2 Tested#3 Tested#4 Optifood Rice -14 MFE – 14 Egg – 7 Veg – 14 Fruit-14 Oil-7 “ Fruit -7 No oil Fruit-7 Oil-3 F- rice-14 Not feasible 4 low nutrients* 4 low nutrients 2 low nutrients Problem nutrients Ca Fe Zn B3 Fe increased from 18 or 19% RNI to 57% RNI; B3 – 61 & 62% RNI; but with fortified rice = 39% RNI *low nutrients defined as worst-case scenarios <65% RNI

Did intervention foods ensure dietary adequacy Did intervention foods ensure dietary adequacy? from Cambodia (6-8 months) Foods Winfood Winfood-lite CSB+ CSB++ Skau et al, AJCN 99:130-8, 2014

Dietary Adequacy not ensured: “worst-case scenario” <65% RNI Baseline Winfood Winfood-lite CSB+ CSB++ 6-8m B1* B2 B3* B6* B9* B12* Ca* Fe* Zn* B9 Ca 8 PN *worst-case scenario <50% RNI Skau at al, AJCN 99:130-8, 2014

Conclusions Food-based approaches can improve the micronutrient content of diets in SE Asian countries but they may not ensure dietary adequacy for all nutrients especially Ca, Fe, and Zn for children; and perhaps also folate, thiamin, riboflavin & niacin Ca, Fe and folate for women; and perhaps also thiamin, riboflavin, niacin, B6, VA Alternative strategies are needed to ensure dietary adequacy in these SE Asian populations (advocacy) Food-based recommendations plus an alternative strategy, such as multiple micronutrient powders/supplements or tailored fortified foods, can ensure dietary adequacy for most micronutrients if successfully adopted (programmes/policy – need evaluations )

The SMILLING Team Lao – National Institute of Public Health Dr Sengchanh Kownnavong Dr Manithong Vonglokham Dr Daovieng Douangvichith Thailand – Mahidol University Dr Uraiporn Chittchang Dr Nipa Rojroongwasiukul Dr Pattanee Winnichagoon Indonesia – SEAMEO TROPMED RCCN Dr Umi Fahmida Mr Otte Santika Cambodia – Ministry of Health; Ministry of Agriculture, Forestry & Fisheries Dr Mary Chea Mr Seyha Sok Ms Daream Sok Mr Kuong Khov Dr Jutta Skau Vietnam – National Institute of Nutrition Prof Le Bach Mai Dr Tran Thaan Do Dr Tran Lua-NIN

Thank-you!

FBRs – number servings/w Children- breastfeed Women C I* L T V MFE Pork Liver Eggs 21 7 14 1, 3 14, 21 3 1 Dairy (12-23 m) Legumes Fruits 7, 14 Vegetables GLV 4 2 49 35 Fortified Products *Indonesia – day-based servings not meal-based MFE – meat, fish, eggs

Nutrients not adequate (<70% RNI) Cambodia Indonesia Lao PDR Thailand Vietnam 6-8 m Ca, Fe, Zn, folate Fe, Zn, B3 Ca, Fe, Zn, B1, B3 Ca, Fe, Zn 9-11 m Ca, Fe, Zn, B3 Fe 12-23 m Fe, folate Ca, B2, B3 Fe, Zn, B1, B3, folate Fe, B3, folate Ca, Fe, B1 Pregnant Ca, Fe, folate, B2, VA Ca, Fe, B1, B3, B6, folate Ca, Fe, folate, B2, B3, B6 Lactating Ca, folate, B2 NPNL Ca, Fe, B1, folate Ca, Fe, B2, B3