With programmes currently underway in Kenya, Indonesia and India, Otago nutritionists are working with local collaborators to develop food-based strategies to improve the health and development of young children.
Optimal nutrition has a profound effect on health, especially in early childhood. So, in addition to focusing on exclusive breastfeeding for infants under the age of six months in developing countries, University of Otago nutritionists have turned their attention to improving complementary feeding practices for older infants and children.
Dr Lisa Houghton (Department of Human Nutrition) says children under five years are most at risk because they are going through a period of rapid growth and because nutrition is intricately linked with cognitive, immune and social development.
“Any kind of deficiency in the early years of development is more detrimental than you would see in an older child – even more so for children under two years of age.”
Although complementary foods are introduced after six months, mothers are urged to also continue breastfeeding to two years or beyond because of the disease protection and long-term benefits breastfeeding provides.
Houghton says introducing iron-rich complementary foods is also recommended, but often developing countries lack ready access to safe and nutritious foods.
“There's a number of programmes now using micronutrient powders, where a single-dose packet of vitamin and mineral supplements can be sprinkled onto complementary foods, but compliance can be very low.”
There are also issues around a one-size-fits-all approach which could see children getting more iron than they need, affecting the absorption of other micronutrients and, possibly, increasing infections.
The Otago work is looking at food-based strategies to combat nutritional deficiencies using locally-available food and examining whether education programmes can be implemented to maximise their use.
Houghton says complementary foods using vegetables and grains, although an important part of a healthy diet, may cause problems because they can be high in phytate, a known anti-nutrient which inhibits zinc absorption.
“We also look at cost barriers because animal-source foods are often unaffordable yet they are an important source of iron and zinc – both very important nutrients for growth and optimal development.
“Zinc is under appreciated. It is important in immune system function and cell proliferation. In fact, growth is very sensitive to zinc deficiency so once an infant is zinc deficient we start to see stunting and its associated health consequences.
Enabling households and communities to produce their own food is an important component of malnutrition prevention.
In Kenya, Otago researchers are working with ChildFund New Zealand, supported in part by the Ministry of Foreign Affairs and Trade (MFAT), to run a five-year programme for building resilience in a diverse rural community.
Work is being undertaken with two very different tribes on each side of the Mombasa Highway: one tribe – the Maasai – mainly raise goats and cows; while the other – the Kamba – grow crops and vegetables.
ChildFund supports pre-schools for each tribal population and is working with the communities to develop ways for women to generate income they can use to buy food for their children.
Otago has also been asked to look at food-based strategies at the pre-schools. Currently, pre-schools are provided with “Unimix” – a fortified porridge containing vitamins and minerals – but the aim is to replace this with a locally-produced product.
Houghton says the only food many children get is the morning tea and lunch at the pre-school.
“We are looking at cultivation and use of edible indigenous plants grown in school gardens to increase their micronutrient intake, and we have also introduced chickens and rabbits at the school to provide an animal-based food source such as eggs, chicken meat or rabbit meat.”
They are working closely with Professor Judith Kimiywe (Kenyatta University) whose team implemented the recommended interventions and is monitoring them.
While the Kenya work focuses on three to five year olds, research in Indonesia involves even younger children, says Houghton.
“It is good to be able to intervene earlier than three years of age because, once a child is stunted, it becomes much harder to reverse ¬– and some windows are closed in terms of critical development. So, in Indonesia, we're looking at breastfed babies and what they're eating from the time they stop exclusive breastfeeding.”
Baseline data show the children are at risk of iron and zinc deficiencies so the plan is to trial the use of desiccated beef liver to create an affordable food-based powder, high in vitamins and minerals, to be incorporated into common meals and snacks.
The powder is being developed in partnership with Meat and Livestock Australia which is keen to see beef liver and other nutrient-rich off-cuts being used instead of thrown away.
Its acceptability to mothers and children is currently being tested and these results will inform a randomised control trial to test its effectiveness.
Otago's key Indonesia collaborator is Dr Aly Diana at the Universitas Padjadjara, West Java.
A study of one-to-two year olds in the slums of Delhi is designed to provide a strategy to tackle widespread vitamin D deficiency in South Asia.
Working with both Emeritus Professor Rosalind Gibson (University of Otago) and Associate Professor Geeta Trilok-Kumar (Institute of Home Economics, Delhi), the Otago team is looking at the high prevalence of rickets, particularly in the slums where it is often not safe for children to play outside.
Poor vitamin-D status coupled with inadequate calcium intakes is impacting on bone mineralisation, says Houghton.
“There are very little dietary data available in these areas because it is difficult to collect. In order to build the optimal diet we need to know what they're eating and what's in their local environment that we could add.”
Indian collaborators have collected detailed dietary, biochemical, morbidity and growth data in a cross-sectional survey of 120 12-to 24-month-old children and analysis has begun.
Houghton says having local collaborators on the ground is vital in this intervention and all of their international projects. It links them with the people who are trusted by the community and it also builds local research capacity.
A DEDICATED CAREER
Emeritus Professor Rosalind Gibson has dedicated much of her long career to working in international nutrition and has played a significant role in developing Otago's involvement in this area, including the establishment of a WHO Collaborating Centre for Nutrition in the Western Pacific Region at the University of Otago.
Her interest stretches back to the 1960s when she spent three years in Ethiopia as a nutritionist with the Ethio-Swedish Children's Nutrition Unit in Addis Ababa.
Later, at the University of Guelph in Canada, Gibson coped with the demands of family life while researching the importance of zinc, which is significant in reducing morbidity and mortality among young children. This was to become an important focus throughout her career. A sabbatical in Dunedin in 1987 and three months in Papua New Guinea with the PNG Medical Research Institute rekindled her interest in international nutrition.
“From that time on I really restricted most of my work to low-income countries.” This list includes Guatemala, Malawi, Ghana, Mongolia, Brazil, Cambodia, Indonesia, Kenya and India. Through those contacts she has also supervised many masters' and PhD students.
Since returning to Dunedin in 1996, Gibson has continued her links with Ethiopia and has been there to teach three-week short courses in nutritional assessment. She also teaches nutritional assessment in the Regional Centre for Community Nutrition, University of Indonesia, in Jakarta, as part of the Department of Human Nutrition's role as a WHO Collaborating Centre in Nutrition.
She has served on a number of WHO committees, one developing breastfeeding guidelines and another creating guidelines for complementary feeding.
“We have done work on complementary feeding in Mongolia, Cambodia and Ethiopia. Our contributions have been recognised by WHO and that is one of the reasons why I was invited to serve on that committee.”
Gibson is also a member of the International Zinc Nutrition Collaborative Group (IZiNCG), an eight-member committee whose mandate is to increase the knowledge and use of zinc in low-income countries.
- India New Zealand Education Council
- ChildFund New Zealand
- New Zealand Ministry of Foreign Affairs and Trade (MFAT)
- Meat and Livestock Australia
- University of Otago