A Feasibility Study of Multiple Micronutrient Supplement for Home Fortification of Foods Among Orang Asli Children in Negeri Sembilan, Malaysia
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Mal J Nutr 25(1): 69-77, 2019 A feasibility study of multiple micronutrient supplement for home fortification of foods among Orang Asli children in Negeri Sembilan, Malaysia Nur Dayana Shaari, Zalilah Mohd Shariff*, Gan Wan Ying & Loh Su Peng Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia ABSTRACT Introduction: The prevalence of child undernutrition and micronutrient deficiencies are higher in the Orang Asli (OA) than the general Malaysian population. The World Health Organization recommends the use of multiple micronutrient supplement (MMS) that is a blend of micronutrients in powder form that can be sprinkled onto foods for home fortification to prevent undernutrition among children. This pilot study aimed to assess the feasibility of using MMS among OA children. Methods: A total of 25 OA children (14 boys and 11 girls) aged 6-31 months (mean±SD = 15.7±7.2 months) in Negeri Sembilan were given three sachets of MMS weekly for 5 weeks. Caregivers were instructed to add MMS to three types of food from the same food group per week varying with a different food group weekly. Written instruction for using MMS in simple language was given prior to the supplementation. Caregivers were interviewed for information on socio-demographics, compliance, acceptance, preference and adverse effect of MMS. Results: A high level of compliance was observed (85%). All caregivers reported that the instructions for use were easy to read. No noticeable changes to the foods mixed with MMS were observed and no adverse effects were reported. Conclusion: This study demonstrated feasibility of the use of MMS for future trials among OA children. The easy to read information that comes with the MMS, frequent monitoring of MMS use and support to caregivers were required to ensure compliance. Cultural feeding practices and financial constraints may limit the types of food that can be mixed with MMS. Keywords: Multiple micronutrients supplement, feasibility study, Orang Asli children, micronutrient powder, home food fortification INTRODUCTION generally have high rates of poverty, low education levels, high food insecurity It is estimated that there are more than and less access to health services as 370 million indigenous people residing in compared to the general population 70 countries worldwide, representing 5% (Leite et al., 2013). Their morbidity of the world’s population (IWGIA, 2018). rates are also higher. The prevalence They live predominantly in remote and of tuberculosis among indigenous rural areas, although minority now live population in Bolivia was 5 to 8 times in urban areas. The indigenous people __________________________ *Corresponding author: Zalilah Mohd Shariff Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia Tel: (6)03-8947 2605; Fax: (6)03-8947 2472; Email: [email protected] doi: https://doi.org/10.31246/mjn-2019-0008 70 Nur Dayana S, Zalilah MS, Gan WY et al. higher compared to non-indigenous Aini et al., 2007; Chua et al., 2012; Oui population, while gastrointestinal & Razalee, 2015). diseases were the main cause of death Many strategies such as food for children younger than 5 years of age fortification and supplementation have (Montenegro & Stephens, 2006). The been implemented in population-level same report showed that in 2003, the programmes to prevent undernutrition national infant mortality rates in Brazil, and micronutrient deficiencies in Colombia and Mexico were 31, 19 and developing countries (WHO & FAO, 40 per 1000 infants, whereas it was 106, 2006). Although food fortification can 111 and 81 per 1000 infants, for the improve micronutrient status with a respective indigenous communities. The reasonable cost (WHO & FAO, 2006), prevalence of underweight, stunting and fortified foods require well-absorbed wasting among indigenous children in fortificants that do not change the India were 55%, 54% and 28% compared sensory properties of foods and need to the national level of 43%, 48% and 20%, to be consumed adequately. While food respectively (IIPS & Macro International, supplementation can supply nutrients 2007). In Australia, 14%, 11% and 10% quickly to deficient individuals, poor of indigenous children under 5 years compliance to supplement dosing were underweight, stunted, and had schedules and the side effects have wasting, respectively (Northern Territory been reported as the barriers to success Department of Health and Community (WHO & FAO, 2006). Evaluation of Services, 2007). feasible and acceptable strategies to In Malaysia, the indigenous people deliver multiple micronutrients is, thus, constitute about 13.8% of the total a priority (WHO, 2011). The Nutrition population of 31 million (IWGIA, 2018). Guidance Expert Advisory Group (WHO, Of this, The Orang Asli (OA) who are 2011) recommends the use of multiple- the indigenous people of Peninsular micronutrient supplements (MMS) as Malaysia, represent 0.7% of the home fortification of foods consumed by approximately 24.5 million population infants and children aged 6-59 months of Peninsular Malaysia. Generally, the of age to prevent child undernutrition. OA are of low socio-economic status MMS is a blend of micronutrients in and have poor health and nutritional powder form that can be sprinkled onto status (Zalilah & Tham, 2002; Chua et home-prepared foods and has been al., 2012). In Malaysia, the prevalence of used in many intervention trials among child undernutrition and micronutrient children aged 6-59 months in developing deficiencies are also much higher in the countries such as Kenya, Indonesia and OA than the general population. The Iran (Samadpour et al., 2011; Inayati et national prevalence of underweight, al., 2012; Jaeggi et al., 2015). stunting, wasting and anaemia among Many factors have been found children under 5 were 12.4%, 17.7%, to be associated with the success of 8.0% and 32.0% respectively (IPH, 2015; MMS programmes such as acceptance, WHO, 2015). Studies published since compliance, preference, and adverse the 1980’s on the nutritional status of effects (De-Regil et al., 2011; OA children have consistently reported Kanashiro et al., 2016). Acceptance high prevalence of underweight (40- and compliance can be enhanced by 60%), stunting (50-60%), wasting (7- providing information on the use and 15%) and anaemia among 2-15 years storage of MMS that are clear, adequate old (41.5%) (Zalilah & Tham, 2002; Nor and culturally appropriate (De Pee Multiple micronutrient supplementation among Orang Asli children 71 et al., 2007; Jefferds et al., 2010). A this study. The children were recruited home visit is also important to ensure based on the selection criteria: (1) age of that correct information on the use 6-36 months; (2) no history of chronic of MMS is delivered to caregivers as diseases e.g. failure to thrive and/or confusion on the preparation, required metabolic or endocrine disorders; (3) no consistency and optimum practices was history of congenital and/or acquired common (Halati et al., 2013; Kanashiro neurological condition; (4) not under et al., 2016). This study was undertaken treatment for communicable diseases to assess the feasibility in terms of such as tuberculosis and human compliance, parental acceptance, child immunodeficiency viruses (HIV). A total preference and adverse effects of the use of 33 young children were screened for of MMS, for a randomised-controlled trial eligibility and from these, 25 children among OA young children in Selangor. were selected based on the responses of their caregivers who consented to MATERIALS AND METHODS participate in the study. Ethical approval Test treatment, dose and mode of The study protocol was approved by administration the Ethics Committee for Research Children were paid weekly visits and involving Human Subjects (JKEUPM) given three sachets of MMS per week, of Universiti Putra Malaysia (Project each containing 1 g sachet, consisting reference number: (FPSK-P077) 2017). of ten vitamins and five minerals (Table Permission to conduct the study in OA 1). The amount of each micronutrient communities was obtained from the provided by MMS was mostly 42% of Department of Orang Asli Development ≥ the Malaysian Recommended Nutrient (JAKOA). Written informed consent to Intake, (RNI). This was adequate to participate in the study was obtained meet the daily nutrient requirement of from caregivers. children in addition to nutrients provided by daily complementary foods (NCCFN, Design and participants 2017). The MMS was manufactured by The study was conducted in the Orang DSM Singapore Industrial Pte. Ltd. It Asli Temuan villages in Seremban and was in powder form and consumed orally Port Dickson districts, in the state of by being sprinkled onto foods that were Negeri Sembilan in Peninsular Malaysia. prepared at home for the child, every A list of 14 villages was obtained from the other day for five weeks. Caregivers Department of Orang Asli Development were instructed to mix the MMS in three (JAKOA, 2016). Two villages in the different types of food from the same Seremban district (Kampung Jeram food group 3 days/week and different Kedah and Kampung Tekir) and one food groups in the five weeks (week one: village in the Port Dickson district rice, tubers and cereals; week two: fruits; (Kampung Bukit Kepong) were randomly week three: vegetables; week four: meat, selected. The total number of households poultry,