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

2. Introduction Complementary feeding – 6 to 24 mo. Low micronutrient content of complementary foods in disadvantaged populations has been associated with -Growth faltering -Increased morbidity -Delayed motor milestone acquisition

3. Possible low-cost solution = home fortification of complimentary foods with multiple micronutrient supplements 3 types of multiple micronutrient supplements: -Sprinkles (SP), powder, 9 vitamins & minerals -Nutritabs (NT), crushable tablet, 16 V&M -Nutributter (NB), peanut-based fortified spread, 19 V&M, with added energy from fat (linoleic and α-linolenic)

4. Rationale Purpose = to compare these 3 supplements and determine whether higher content of micronutrients and/or macronutrients would give more positive growth results in infants from 6-12 months Hypothesis = multiple micronutrient fortification of complementary foods would increase growth and the effect would be greatest with added energy from fat

5. Methods The community-based randomized study was carried out in Koforidua, Ghana between February 2004 and June 2005 313/409 eligible infants were assigned to receive SP, NT, or NB 96/409 eligible infants were recruited for the nonintervention group (NI) at 12 mo.

6. Micronutrient supplements Designed to generally provide the amounts of key nutrients needed from complementary foods SP dose = 1 satchet/d NT dose = 1 tablet/d (came in plastic bags) NB dose = 20 g/d (came in foil packs with screw caps, net wt = 200g)

8. Procedures Parents of selected infants were visited to verify eligibility, explain protocol, and obtain consent Supplements delivered weekly Mothers instructed to administer daily dose in a single meal, 7 days/week, mixed with 1-2 tbsp of food Supplied cups and spoons

9. Data collection Background data collected during recruitment Weekly collection of daily supplement consumption data and morbidity data (diarrhea, symptoms of respiratory infections, fever) Monthly collection of 24-h dietary recall data, used to calculate energy intake from complementary foods At 6, 9, and 12 mo., anthropometric data was obtained

10. Data collection Calculated weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) z-scores using WHO 2006 Child Growth Standards At 12 mo., 4 motor milestones were assessed: -Standing with assistance -Walking with assistance -Standing independently -Walking independently

11. Baseline data

13. Results – Monthly 24-h recall When the energy contribution of NB was included, energy intake was significantly greater in the NB group (~85 kcal/d)

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

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

16. Results- % of children achieving milestones by 12 mo.

17. Results – prevalence of morbidities between 6 and 12 mo.

18. Discussion Multiple micronutrient interventions alone may not improve growth of infants in some populations Supplementation with SP and NT did not increase growth NB group had greater weight and length gains than other two intervention groups

19. Weight and Length gain Difference in weight gain could be explained by increased calorie intake in NB group - Consumption of NB resulted in avg. increase of ~85 kcal daily intake from complementary foods Difference in length gain could be explained by essential fatty acid content of NB (provided 65% of recommended linoleic acid and 145% of α- linolenic acid intake)

20. Motor-skill development SP and NT infants were 2x as likely, and NB infants were 3.4x as likely to be able to walk independently by 12 mo. than the NI group -Can be due to receiving zinc and iron supplements together and with other micronutrients -Can also be due to increased calorie intake in NB group

21. Morbidities The 3 groups did not differ significantly in prevalence of illness, except for cough, which was slightly higher in NT group

22. Limitations Possibility of influence on the amount of attention given to children due to Hawthorne effect Mothers and field workers who delivered supplements were not blind to study design (although anthopometrists were masked to group assignment)

23. Possibilities for further research Address micronutrient interactions Control for micronutrient levels to measure effect of energy/fat intake