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‘Optifood’ – A tool based on linear programming analysis to inform
nutrition programme planning and policy decisions
Elaine FergusonLondon 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
Food Composition TableEnergyProteinWaterFatCarbohydrateVitamin AVitamin CB1B2B3CaFeZnB6B12Folate
Select Fe and Zn bioavailabilitySelect Fe and Zn bioavailability
Optifood Analysis StructureModel Constraints
Food listMin & max g/wk
Food Patterns Min & max serves/wkMain food groupsStaples & snacksFood sub-groups
Energy content
Maximum cost (optional)
Food-based recommendations (FBRs)
Nutrient content
Module#1
Module#2
Module#3
Module#4
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
Module III: models tails of the nutrient intake distribution to test FBRs
Baseline Food-based recommendation
>65% or 70% RNI=adequate
Vitamin A intakes
• Test 11 micronutrients• Test alternative sets of FBRs
Define “problem nutrients”Upper tail < 100% RNI/AI
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 RecommendationsTest and compare in Module 3
“lower tail of intake distributions”
Dairy 14 serves / weekVegetables 21 serves / weekMeat, fish or eggs 5 serves / weekLegumes 7 serves/weekFruits 7 serves/weekLiver 2 serves/weekGreen leafy vegetables 5 serves/weekVitamin C rich fruits 5 serves/weekPotatoes 3 serves/weekTofu/tempeh 7 serves/weekAnchovies 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”
1. Can a nutritionally adequate diet be promoted given local foods & food patterns?
Numbers of “Problem Nutrients”
Cambodia Indonesia Lao PDR Thailand VietnamChildren:6-8 m9-11 m12-23 m
664
420
330
330
210
Women:PregnantLactatingNPNL
754
Not analysed
321
Not analysed
442
For children: Ca, Fe & Zn; sometimes folate, B1, B2 & B3For women: Ca & Fe; often folate, B2, B6 & vitamin A
Food-based Recommendations
2. 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 monthsAlone With
FBRAlone With
FBRAlone With
FBRCambodia 5* 4* 4* 4* 4* 3Indonesia 5* 3* 5* 3* 4* 4*Lao PDR 5* 4* 5* 4* 5* 3*Vietnam 5* 3 5* 3 4* 3
*Ca adequacy not ensuredFBR – food-based recommendations
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
#Nutrients≥70% RNI
Number per week
Only supplement#Nutrients≥70% RNI
Supplement + FBR
#Nutrients≥70% RNI
1 day2 days3 days4 days5 days6 days7 days
112222
3*
667778
8#
1 day2 days3 days4 days5 days6 days7 days
234699
10**
66789
1010**
*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 ThailandOriginal Tested#1 Tested#2 Tested#3 Tested#4 Optifood
Rice -14MFE – 14Egg – 7
Veg – 14Fruit-14
Oil-7
““““
Fruit -7“
“““““
No oil
““““
Fruit-7Oil-3
““““““
F- rice-14
Not feasible Not feasible 4 low nutrients*
4 low nutrients
2 low nutrients
Problem nutrients
Ca Fe ZnB3
CaFeZnB3
FeB3
Ca Fe Zn
*low nutrients defined as worst-case scenarios <65% RNI
Did intervention foods ensure dietary adequacy?from Cambodia (6-8 months)
FoodsWinfoodWinfood-liteCSB+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 6-8m 6-8m 6-8m 6-8m
B1*B2
B3*B6*B9*
B12*Ca*Fe*Zn*
B1*B2
B9*Fe*
B1*B9Fe*
B1*B9CaFe*
B1*B9Fe*
Skau at al, AJCN 99:130-8, 2014*worst-case scenario <50% RNI
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 TeamLao – 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/wChildren- breastfeed Women
C I* L T V C L V
MFE Pork Liver Eggs
217
7 14
1, 3
14, 21
3
14, 21 2173
21
3
21717
Dairy (12-23 m) 7 14 14 7
Legumes 7 7 7
Fruits 7 7 7 7, 14 7 14 7 7
Vegetables GLV
7 74
72
1414
21 4914
35
Fortified Products
7
*Indonesia – day-based servings not meal-basedMFE – 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 Ca, Fe, Zn
9-11 m Ca, Fe, Zn, folate
Ca, Fe, Zn, B3
Ca, Fe, Zn, B1, B3
Ca, Fe, Zn 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, Fe, folate, B2,
VA
Ca, Fe, B1, B3, B6, folate
Ca, folate, B2
NPNL Ca, Fe, folate, B2,
VA
Ca, Fe, B1, folate
Ca, Fe, B2, B3