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1 Asia Pacific Journal of Clinical Nutrition
       Volume 23, Supplement 1

         (November 2014)


Abstracts

Contents

Abstract Full paper

Foreword

Prospects for better nutrition in India
Rajan Sankar, Tina van den Briel
Asia Pac J Clin Nutr. 2014;23(Suppl 1):S1-S3

doi: 10.6133/apjcn.2014.23.s1.06

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Reviews and Original Articles

Food fortification as a complementary strategy for the
elimination of micronutrient deficiencies: case studies of
large scale food fortification in two Indian States

Sadhana Bhagwat, Deepti Gulati, Ruchika Sachdeva,
Rajan Sankar
Asia Pac J Clin Nutr. 2014;(Suppl 1):S4-S11

doi: 10.6133/apjcn.2014.23.s1.03

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Improving the nutrition quality of the school feeding
program (Mid-Day Meal) in India through fortification:
a case study

Sadhana Bhagwat, Rajan Sankar, Ruchika Sachdeva, Leena Joseph,
Sivaranjani
Asia Pac J Clin Nutr. 2014;(Suppl 1):S12-S19

doi: 10.6133/apjcn.2014.23.s1.01

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Production of fortified food for a public supplementary
nutrition program: performance and viability of a
decentralised production model for the Integrated Child
Development Services Program, India

Clémentine Antier, Salil Kumar, Sadhana Bhagwat, Rajan Sankar
Asia Pac J Clin Nutr. 2014;(Suppl 1):S20-S28

doi: 10.6133/apjcn.2014.23.s1.05

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Capacity of frontline ICDS functionaries to support
caregivers on infant and young child feeding (IYCF)
practices in Gujarat, India

Anuraag Chaturvedi, N Nakkeeran, Minal Doshi, Ruchi Patel,
Sadhana Bhagwat
Asia Pac J Clin Nutr. 2014;(Suppl 1):S29-S37

doi: 10.6133/apjcn.2014.23.s1.04

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The National Coalition for Sustained Optimal Iodine
intake (NSOI): a case study of a successful experience
from India

Kapil Yadav, Arijit Chakrabarty, Jee Hyun Rah, Rakesh Kumar, Victor Aguayo, Mohammad Anas Ansari, Rajan Sankar, Madhu Ganesh Karmarkar, Chandrakant S Pandav
Asia Pac J Clin Nutr. 2014;(Suppl 1):S38-S45

doi: 10.6133/apjcn.2014.23.s1.02

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About GAIN

 

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Prospects for better nutrition in India
RAJAN SANKAR AND TINA VAN DEN BRIEL
Being home to 31% of the world’s children who are stunted and 42% of those who are underweight, and with many children and adults affected by micronutrient deficiencies, India is facing huge challenges in the field of nutrition. Even though the Indian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the Integrated Child Development Services program alone costs 3 billion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons for this reduction are not unambiguous and appear to include state government commitment, focus on the ‘window of opportunity’, improved status and education of women, a lowered fertility rate, and combinations of nutrition-specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked with a range of partners to improve access to nutritious foods for large parts of the population, through public and private delivery channels. This supplement presents a selection of these activities, ranging from a capacityassessment of frontline workers in the ICDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.
Key Words: micronutrient deficiencies, stunting, nutrition programs, India
 

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印度更好營養的展望
全世界發育遲緩兒童中,有31%身在印度,其中42%為體重過輕,還有許多孩
童及成人也受到微量營養素缺乏的影響,讓印度面臨營養領域的巨大挑戰。儘
管為了確保糧食安全、健康與營養,印度政府投入巨額的經費到相關計畫(僅整
合兒童發展服務計畫,ICDS,每年就花費30 億美元),但整體的影響仍相當有
限。即便如此,未來的事還是有一些希望。最近某些州的地區層級的健康調查
(DLHS-4)發現顯著的進展,例如過去6 年中,發展遲緩的比率約降了15%。這
個率下降的原因還不清楚,可能包含了州政府的承諾、聚焦在“關鍵時機”、提
高女性的地位及教育、降低生育率及營養專一及營養敏感的介入組合。除了政
府以外,很多其他單位也扮演推動改善營養的角色。自2006 年起,全球營養
改善聯盟(GAIN)已經與許多夥伴合作,透過公共及私人傳遞管道,改善大部分
族群取得較營養食物的機會。這種營養補助,透過從ICDS 第一線工作者能力
評估、大規模主食類食物營養強化、食鹽加碘、學童中餐強化,到輔助食物去
集中化生產等各類活動而達成。
關鍵字:微量營養素缺乏、發育遲緩、營養計畫、印度

 

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Food fortification as a complementary strategy for the elimination of micronutrient deficiencies: case studies of large scale food fortification in two Indian States
SADHANA BHAGWAT, DEEPTI GULATI, RUCHIKA SACHDEVA AND RAJAN SANKAR
The burden of micronutrient malnutrition is very high in India. Food fortification is one of the most cost-effective and sustainable strategies to deliver micronutrients to large population groups. Global Alliance for Improved Nutrition (GAIN) is supporting large-scale, voluntary, staple food fortification in Rajasthan and Madhya Pradesh because of the high burden of malnutrition, availability of industries capable of and willing to introduce fortified staples, consumption patterns of target foods and a conducive and enabling environment. High extraction wheat flour from roller flour mills, edible soybean oil and milk from dairy cooperatives were chosen as the vehicles for fortification. Micronutrients and levels of fortification were selected based on vehicle characteristics and consumption levels. Industry recruitment was done after a careful assessment of capability and willingness. Production units were equipped with necessary equipment for fortification. Staffs were trained in fortification and quality control. Social marketing and communication activities were carried out as per the strategy developed. A state food fortification alliance was formed in Madhya Pradesh with all relevant stakeholders. Over 260,000 MT of edible oil, 300,000 MT of wheat flour and 500,000 MT of milk are being fortified annually and marketed. Rajasthan is also distributing 840,000 MT of fortified wheat flour annually through its Public Distribution System and 1.1 million fortified Mid-day meals daily through the centralised kitchens. Concurrent monitoring in Rajasthan and Madhya has demonstrated high compliance with all quality standards in fortified foods.
Key Words: micronutrient malnutrition, staple food fortification, India
 

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食品強化作為消除微量營養素缺乏的互補策略:印度兩州大規模食品強化的個案研究
印度微量營養素營養不良的負擔非常高。食品強化是提供大族群微量營養素最
符合成本-效益及永續的策略之一。由於營養不良的高負擔、企業有能力且願
意引進營養強化的主食、標的食物的攝取模式以及有利的環境,全球營養改善
聯盟(GAIN)支持Rajasthan 及Madhya Pradesh 兩州的大規模、自願性、主食類
食物強化。高出粉率輾磨麵粉,食用大豆油及來自合作廠商的牛奶被選作為強
化載體。依據載體的特性及攝取量,選擇微量營養素及其強化量。仔細評估能
力及意願後,完成企業召募。生產單位配備必要的強化設施,工作人員經過強
化及品質管制的訓練。按照制訂的策略,進行社會行銷及傳播活動。在
Madhya Pradesh 州,所有利益關係者成立一個州立食品強化聯盟。每年有超過
260,000 百萬噸食用油、300,000 百萬噸麵粉以及500,000 百萬噸牛奶被強化及
行銷。在Rajasthan 州,經由公共發送系統每年也發送840,000 百萬噸強化麵
粉,及透過中央廚房每日發送1.1 百萬份強化午餐。同步監測Rahasthan 和
Madhya 兩州,顯示達到高度符合強化食物的所有品質標準。
關鍵字:微量營養素營養不良、主食食品強化、印度

 

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Improving the nutrition quality of the school feeding program (Mid-Day Meal) in India through fortification: a case study
SADHANA BHAGWAT, RAJAN SANKAR, RUCHIKA SACHDEVA, LEENA JOSEPH AND SIVARANJANI
Micronutrient malnutrition is widely prevalent in school children in India. India’s national school feeding program, the Mid-Day Meal (MDM) scheme, is the largest in the world and caters to 120 million children in primary schools. Complementary strategies such as deworming or fortifying meals provided through the MDM scheme could increase the nutritional impact of this program. India’s Supreme Court has directed that only hot, cooked meals be provided in MDM, through a decentralised model. However, in urban areas, big centralised kitchens cook and serve a large number of schools, with some kitchens serving up to 150,000 children daily. The objective of this project was to test the operational feasibility of fortifying the school meal in centralised kitchens, as well as the acceptability of fortified meals by recipients. A pilot was conducted in 19 central kitchens run by the Naandi Foundation in four different States. Several food vehicles were used for fortification: wheat flour, soyadal-analogue and biscuits. More than 750, 000 children were reached with fortified food on all school days for a period of one year. Fortified food was found to be acceptable to all stakeholders. The government is in favour of continuing fortification. The Naandi Foundation has adopted fortification as their norm and continues to fortify all meals provided from their central kitchens. In conclusion: fortification of school meals with micronutrients can be integrated in the normal cooking process and is well accepted by all stakeholders. This pilot could hold lessons for other states in adopting fortification in MDM.
Key Words: school feeding, food fortification, mid-day meal, India
 

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經由強化食物改善學校供餐計畫的營養品質(午餐):個案研究
印度學童存在廣泛的微量營養素營養不良。在印度國家學校供餐計畫中,午餐
(MDM)方案供應一億兩千萬的國小學童飲食,為全世界最大。透過午餐方案,
除蛔蟲或強化餐點等互補策略,可增加這個計畫對營養的影響。印度的最高法
院已指示,MDM透過非集中的模式,只能提供熱的熟食。然而,在鄉村地區,
大型中央廚房烹調並供應大量的學校,有些廚房每日可供應近十五萬名學童餐
點。這個研究的目的為測試中央廚房操作強化餐點的可行性,以及接受者對於
強化餐點的接受性。由Naandi 基金會在4 個省的19 個中央廚房,進行一個前驅
研究。幾種食物載體被用於強化:麵粉、soya-dal-analogue 及餅乾。有超過75
萬名兒童在一年內的所有上學日,都可食用到已強化食物。強化食物被所有利
害關係人所接受,因此,政府傾向繼續實行強化。Naandi 基金會已將食物強化
當作他們的規範,並持續強化所有出自他們中央廚房的餐點。總之,學餐強化
微量營養素可結合於一般烹調過程,並被所有利害關係人接受。這個前驅研究
可提供其他省在MDM 採用強化政策的參考。
關鍵字:學校供餐、食物強化、午餐、印度

 

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Production of fortified food for a public supplementary nutrition program: performance and viability of a decentralised production model for the Integrated Child Development Services Program, India
CLÉMENTINE ANTIER, SALIL KUMAR, SADHANA BHAGWAT AND RAJAN SANKAR
Integrated Child Development Services in India through its supplementary nutrition programme covers over 100 million children, pregnant and lactating women across the country. Providing a hot cooked meal each day to children aged between 3-6 years and a take-home ration to children aged between 6-36 months, pregnant and lactating women, the Integrated Child Development Services faces a monumental task to deliver this component of services of desired quality and regularity at scale. From intermediaries or contractors who acted as agents for procuring and distributing food to procurement directly from large food manufacturers to using women groups as food producers, different State Governments have adopted a variety of strategies to procure and distribute food, especially the take-home ration. India’s Supreme Court, through its directive of 2004, encouraged the Government to engage women’s groups for the production of the supplementary food. This study was conducted to determine the operational performance, economic sustainability and social impact of a decentralised production model for India’s Supplementary Nutrition Program, in which women groups run smallscale industrialised units. Data were collected through observation, interviews and group discussions with key stakeholders. Operational performance was analysed through standard performance indicators that measured consistency in production, compliance with quality standards and distribution regularity. Assessment of the economic viability included cost structure analysis, five-year projections, and financial ratios. Social impact was assessed using a qualitative approach. The pilot unit has demonstrated its operational performance and cost-efficiency. More data is needed to evaluate the scalability and sustainability of this decentralised model.
Key Words: decentralised complementary food production, viability, women empowerment, India, ICDS
 

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生產營養強化食品為公眾補充計畫:印度整合兒童發展服務的去集中化生產

模式的成果及可行性
印度整合兒童發展服務的營養補充計畫,涵蓋全國超過1 億名的兒童、孕婦及
哺乳婦。每天供應3-6 歲的兒童一餐熱食,6-36 個月的幼兒、懷孕婦女及哺乳
婦則提供可帶回家的口糧。整合兒童服務面臨提供一個包含品質、規律性及相
當規模服務的艱鉅任務。不同的州政府採用多種採購及分發食物策略,特別是
帶回家的口糧。代理採購或分發食物的中間商或承包商,從由女性團體為食品
製造者的大型食品製造廠直接採購。印度最高法院,透過2004 年的指示,鼓
勵政府聘僱女性團體生產補充食物。印度營養補充計畫是女性團體經營的小規
模工廠的去集中化生產模式,本研究旨在評估其營運績效、經濟的永續性以及
對社會影響。透過觀察、訪談、及與利害關係者的小組討論收集資料。營運績
效是透過分析包括產品的一致性、符合品質標準的程度及分送規律等標準績效
指標。經濟生存力的評估包含成本結構分析、五年預測及財務比率。以質性方
法評估社會影響。前驅研究已證實它的營運績效及成本效益。需要更多的資料
來評估這個去集中化模式的擴展性及永續性。
關鍵字:去集中補充食品生產、可行性、女權、印度、整合兒童服務

 

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Capacity of frontline ICDS functionaries to support caregivers on infant and young child feeding (IYCF)
practices in Gujarat, India

ANURAAG CHATURVEDI, N NAKKEERAN, MINAL DOSHI, RUCHI PATEL AND SADHANA BHAGWAT
Improved infant and young child feeding practices have the potential to improve child growth and development outcomes in India. Anganwadi Workers, the frontline government functionaries of the national nutrition supplementation programme in India, play a vital role in promoting infant and young child feeding practices in the community. The present study assessed the Anganwadi Workers’ knowledge of infant and young child feeding practices, and their ability to counsel and influence caregivers regarding these practices. Eighty Anganwadi Workers from four districts of Gujarat participated in assessment centres designed to evaluate a range of competencies considered necessary for the successful promotion of infant and young child feeding practices. The results of the evaluation showed the Anganwadi Workers possessing more knowledge about infant and young child feeding practices like initiation of breastfeeding, pre-lacteal feeding and colostrum, age of introduction of complementary foods, portion size and feeding frequency than about domains which appear to have a direct bearing on practices. A huge contrast existed between the Anganwadi Workers’ knowledge and their ability to apply this in formal counselling sessions with caregivers. Inability to empathetically engage with caregivers, disregard for taking the feeding history of children, poor active listening skills and inability to provide need-based advice were pervasive during counselling. In conclusion, to ensure enhanced interaction between the Anganwadi Workers and caregivers on infant and young child feeding practices, a paradigm shift in training is required, making communication processes and counselling skills central to the training.
Key Words: infant and young child feeding practices, knowledge, skills, ICDS, Anganwadi Workers, India
 

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印度Gujarat第一線整合兒童發展服務(ICDS)公務員支持嬰幼兒照護者從事餵食的能力
改善嬰幼兒餵食方式,具有改善印度兒童的成長及發育成果的潛力。印度
Anganwadi 工作人員為國家營養補充計畫的第一線公務人員,在社區中扮演推
動嬰幼兒餵食方式的重要角色。本研究評估Anganwadi 工作人員對於從事嬰幼
兒餵食的知識,以及針對嬰幼兒餵食與照護者的諮商及影響的能力。80 名來自
Gujarat 四個區的Anganwadi 工作人員參與評估,評估他們在一系列與嬰幼兒餵
食施行成功必要的競爭力。評估結果顯示,比起那些直接與餵食直接相關的壓
力,Anganwadi 工作人員具備較多與嬰幼兒餵食的知識,例如開始母乳哺育、
哺乳前餵食及初乳、副食品的介入年齡、份數及餵食頻率。不過,Anganwadi
工作人員的知識,與他們將知識應用於正式諮詢時傳授給照護者的能力,有極
大的差異。在諮商時,普遍存在缺乏吸引照護者情感的能力、忽視孩童的哺餵
歷史、主動聆聽技巧不足,以及沒有足夠能力提供照護者需求的建議。總而言
之,需確保加強Anganwadi 工作人員及照護者在嬰幼兒餵食方式的互動,改變
訓練模式是必要的。應該以溝通過程及諮商為訓練的核心。
關鍵字:嬰幼兒餵食施行、知識、技巧、整合兒童發展服務、Anganwadi 工作
人員、印度

 

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The National Coalition for Sustained Optimal Iodine intake (NSOI): a case study of a successful experience from India
KAPIL YADAV, ARIJIT CHAKRABARTY, JEE HYUN RAH, VICTOR AGUAYO, MOHAMMAD ANSARI, RAJAN SANKAR, MADHU GANESH KARMARKAR AND CHANDRAKANT S PANDAV
Iodine deficiency disorders (IDD) constitute the single most important preventable cause of mental handicap at global level. Recognizing the importance of coordination and synergy of the activities of wide range of universal salt iodisation (USI) stakeholders, WHO/ Unicef/ ICCIDD has prescribed a national multi-sectoral coalition as one of the ten indicators essential for attaining sustainable elimination of IDD at national level. Challenge for coordination among different stakeholders of IDD/USI is even greater in democratic and diverse country like India. In the present article we present successful experience from India regarding formation of a national coalition and contributions made by the coalition towards promoting USI in India. The activities of the national coalition in India are classified into three phases; 1) Phase 1- year 2006 to 2009- the inception; 2) Phase 2- year 2009 to 2012- consolidation; 3) Phase 3- year 2013 and ongoing- expansion. The National coalition for Sustained Optimal Iodine Intake (NSOI) has been instrumental in ensuring greater coordination and synergy amongst IDD and USI stakeholders in India and partially responsible for the current 71 percentage household level coverage of adequately iodised salt. The most significant contribution of the national coalition has been to act as a high level advocacy channel and provide a platform for regular dialogue for all partners of the coalition. With “mission” approach and allocation of optimal resource, India can achieve and should achieve USI by 2015, an apt culmination of a decade of existence of the national coalition.
Key Words: universal salt iodisation, iodine deficiency disorders, multi-sectoral, national coalition
 

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永續最適碘攝取量全國聯盟(NSOI):一個印度成功經驗的個案研究
碘缺乏失調(IDD)是全球構成智力障礙最重要的單一可預防因素。全面食鹽加
碘(USI) 各個利害關係人,世界衛生組織/聯合國兒童基金會/ICCIDD,認知到
行動協調以及共同合作的重要性。他們已經規劃一個國家級多部門聯盟,當作
國家永續消弭IDD 十項必要的指標之一。在民主及多元的國家如印度,協調
各個碘缺乏失調/全面食鹽加碘利害關係者的挑戰更大。本文,我們呈現印度
全國聯盟組成,及共同推動全面食鹽加碘貢獻的成功經驗。全國聯盟在印度的
行動分成三個階段;1)第一階段 - 2006 至2009 年 - 創始;2)第二階段 -2009 年
至2012 年 - 鞏固;3)第三階段- 2013 年之後 - 擴展。永續最適碘攝取(NSOI)全
國聯盟已確保印度IDD 和全面食鹽加碘的利害關係者有更多的協調及合作,
對目前71%的家戶加碘鹽涵蓋率負部分的責任。全國聯盟最重要的貢獻為扮演
高層級的宣傳管道,並提供給所有聯盟夥伴作例行對話的平台。隨著任務的推
動及最適當的資源配置,印度應可以在全國聯盟成立十年之2015 年前,達到
全面食鹽加碘的目標。
關鍵字:全面性食鹽加碘、碘缺乏失調、多部門、全國聯盟

 

 

Last Updated: November 2014