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 ,

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, , 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 and was in powder form and consumed orally 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 and Kampung Tekir) and one food groups in the five weeks (week one: village in the 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, fish and eggs; week five: milk, in these villages was 149 for Kampung dairy products and other beverage e.g. Tekir, 145 for Kampung Jeram Kedah formula milk/ chocolate malted/ malted and 137 for Kampung Bukit Kepong. beverage). Written instructions in simple Data collection was carried out language with visuals for using and from June until August 2017. Households storing the MMS were given to caregivers with children aged 6-36 months were prior to the supplementation. identified and invited to participate in 72 Nur Dayana S, Zalilah MS, Gan WY et al.

Table 1. The composition of multiple- was assessed based on the ease of micronutrient supplement used in this reading instructions for use, ability to study understand instructions for use, ease of Amount mixing MMS with food and willingness No. Nutrient per 1 g sachet to use MMS in the future. Changes in 1 Vitamin A, µg RE 400 food taste, colour or odour, the child’s 2 Vitamin C, mg 30 appetite and acceptance of food mixed 3 Vitamin D, µg 5 with MMS were assessed for child 4 Vitamin E, mg α-TE 5 preference of MMS. Caregivers were also 5 Vitamin B1, mg 0.5 asked to report the types of food mixed 6 Vitamin B2, mg 0.5 with MMS in 3 d/week. Any adverse 7 Vitamin B6, mg 0.5 effect such as cough, diarrhoea, bloody 8 Vitamin B12, µg 0.9 diarrhoea, difficulty in breathing and 9 Folic Acid, µg 90 fever including the admission to hospital 10 Niacin, mg 6 due to these conditions was also assessed 11 Iron, mg 10 during a weekly visit. 12 Zinc, mg 4.1 13 Copper, µg 560 Statistics 14 Iodine, µg 90 Data were analysed using SPSS 15 Selenium, µg 17 version 22.0 (SPSS Inc.) software. Descriptive statistics were expressed Source: WHO, WFP, UNICEF (2007) as mean and standard deviation for continuous variables and as Measurements frequencies for categorical variables. Socio-demographic information such Data on compliance, acceptance, child as household income, age of parents, preference and the adverse effect of their education and employment were MMS were expressed as frequencies and obtained through face-to-face interview percentages. with caregivers using a pre-tested questionnaire and with the assistance RESULTS of a local translator. The date of birth of the child was obtained from The subjects in this study comprised the birth certificate or child’s health 14 (56%) boys and 11 (44%) girls, with records. Data were collected prior to the a mean age of 15.7+7.2 months (Table supplementation. 2). The mean monthly household income Compliance, acceptance, child was RM864. Slightly more than half of preferences and the adverse effects of the mothers (52%) and fathers (56%) MMS were assessed through a weekly had lower secondary education. The face-to-face interview with caregivers. majority of the mothers were housewives The caregivers were visited each week, (80%) while the fathers were mostly self- and given three sachets of MMS for one employed (88%). week of supplementation. After a week, Table 3 shows the compliance, caregivers were required to return the acceptance, child preferences and empty sachets (including unused or half adverse effects of the five-weeks of used) to the investigator. Compliance MMS supplementation. A high level of MMS was measured by dividing the of 85% compliance was seen in this total number of empty sachets with a study. All caregivers reported that the total number of distributed sachets. The instructions for use, were easy to read acceptance of MMS by the caregivers and understand, and 92% reported a Multiple micronutrient supplementation among Orang Asli children 73

Table 2. Demographic and socio-economic characteristics (N=25) Variables n (%) Mean±SD Gender of child Male 14 (56) Female 11 (44) Age of child (month) 15.7±7.2 Age groups of children 6-8 months 5 (20) 9-11 months 4 (16) 12-14 months 4 (16) 15-17 months 1 (4) 18-20 months 5 (20) 21-24 months 2 (8) 25-31 months 4 (16) Household income (RM) 864±298 Age of mother (years) 26.2±5.4 Age of father (years) 28.4±5.9 Education of mother Primary level 12 (48) Lower secondary level 13 (52) Education of father Primary level 11 (44) Lower secondary level 14 (56) Employment of mother Housewife 20 (80) Employed 5 (20) Employment of father Self-employed 22 (88) Employed 3 (12) willingness to use MMS in the future. the frequency of supplementation, where None of the caregivers reported changes supplementation on alternate days is in taste, colour, or odour of foods mixed simpler to comply compared to other with MMS. About 84% caregivers frequencies. A review by De-Regil et al. reported no change in appetite of the (2011) showed that children receiving children. All caregivers mixed MMS in intermittent iron supplementation had rice porridge or rice from the first week higher compliance compared to those one to the fifth. In week five, only two receiving daily iron supplements. In caregivers (8%) reported they had mixed this study, monitoring and support to MMS in formula milk. No adverse effects caregivers were found to be necessary to were reported in this study. ensure compliance. The caregivers were frequently reminded and encouraged to DISCUSSION give the MMS as instructed during the weekly home visits by the investigator. Compliance among caregivers in this This could explain the high level of study was high. This was also observed in compliance that we obtained (Lundeen other trials using MMS in home-cooked et al., 2010; Halati et al., 2013). food (Ogunlade et al., 2011; Albelbeisi Pangaribuan et al. (2003) found that et al., 2017). This could be attributed to 74 Nur Dayana S, Zalilah MS, Gan WY et al. the understanding of the importance of written and visual instructions for use supplementation of caregivers increased of MMS. Several studies have shown the compliance of vitamin A capsule that locally appropriate written and supplementation among pre-school visual instructions that are tailored to children in Indonesia. suit the local cultural context increases Similar to previous studies (De Pee acceptance of MMS by recipients (De et al., 2007; Loechl et al., 2009; Jefferds Pee et al., 2007; Jefferds et al., 2010; et al., 2010; Albelbeisi et al., 2017), this Kanashiro et al., 2016). Second, the ease study also found that MMS was well of use of MMS did not require caregivers accepted by caregivers. Several factors to change their daily feeding practices which could explain the acceptance of as the MMS was given mixed in foods MMS by caregivers have been identified that were usually given to their children. in this study. First, the printed material It has been shown that MMS added provided to caregivers contained simple into any semi-solid foods or commonly

Table 3. Compliance, acceptance, child preference and the adverse effect of five weeks MMS supplementation (N=25) Variables n (%) Mean±SD †Compliance (%) 85.0±25.5 Acceptance Easy to read instructions for use 25 (100) Understand instructions for use 25 (100) Easy to mix MMS with food 25 (100) Willing to use in the future Yes 23 (92) No 2 (8) Child preference No change in taste of food 25 (100) No change in colour of food 25 (100) No change in odour of food 25 (100) Change in child’s appetite No change 21 (84) Increase appetite 2 (8) Reduce appetite 2 (8) Food mixed with MMS Week 1: Rice, tubers and cereals 25 (100) Week 2: Fruits - Week 3: Vegetables - Week 4: Meat, poultry, fish and eggs - Week 5: Milk, dairy products and other beverages 2 (8) Adverse effect Cough 0 (0) Diarrhoea 0 (0) Bloody diarrhoea 0 (0) Difficulty in breathing 0 (0) Fever 0 (0) Admission to hospital due to these conditions 0 (0) †Compliance rate is calculated by dividing a total number of consumed sachets with the total number of distributed sachets, then multiplying it with 100% Multiple micronutrient supplementation among Orang Asli children 75 taken food by children at home or at of poor people are often monotonous the point of use were well-accepted by and based on cereals, roots and tubers. caregivers (WHO 2011). Third, the home Micronutrient-rich foods such as meat, visits increased the acceptance as they fish, chicken, eggs, milk and dairy provided opportunities for discussion products are usually consumed only in between caregivers and investigator small amounts (WHO & FAO, 2006). (Halati et al., 2013; Kanashiro et al., Only two caregivers reported that 2016). they mixed MMS with formula milk. Child acceptance of MMS in this Other caregivers who did not mix MMS study was good as all caregivers reported with formula milk or other beverages no noticeable changes in the taste, colour reported that their children were still and odour of the foods mixed with MMS. fully breastfeeding, or not taking formula This could be related to encapsulated milk or malted beverages. The children ferrous fumarate with lipid (the source usually consumed tea or coffee, neither of iron in MMS) protects the interaction of which is recommended for mixing of iron with food and masks the metallic with MMS. The low intakes of milk and taste of the food upon adding MMS dairy products among the children could (Zlotkin et al., 2005; De Pee et al., 2007). be because of the higher price of formula There was no change in the appetite of milk as compared to tea or coffee. Giving the majority of the children. This could tea or coffee to the children was easier have been due to the short duration of for parents as these beverages were the supplementation, as previous studies routinely prepared for other family have shown that the appetite of the members. Chua et al. (2012) also found children increased in supplementation that OA children did not commonly take of longer duration such as two or six milk or malted beverages and about months (Loechl et al., 2009; Kanashiro 69% of them took tea or coffee in their et al., 2016). daily diets. The present study reported In this study, caregivers were no adverse effect of MMS use and this instructed to mix the MMS in five finding was in line with previous studies different food groups in each week. (Samadpour et al., 2011; Inayati et al., However, all caregivers only mixed MMS 2012; Albelbeisi et al., 2017). in rice or rice porridge from week one to This study was not without week five as foods from other food groups limitations. Low variety of foods in were not affordable for them. Caregivers the diets of the children may have frequently feed their children with plain contributed to the limitation of assessing rice or porridge with a bit of salt and acceptance and preference of MMS when occasionally with a small quantity of combined to foods. In addition, the short fish. Several studies on dietary intake duration of MMS supplementation could of OA children also reported that rice is be a limiting factor in this study. the most frequently consumed food with limited intakes of fruits, milk and dairy CONCLUSION products (Zalilah & Tham, 2002; Chua This study found that simple and easy et al., 2012). Low dietary diversity in to read information on MMS, frequent OA children could be due to the limited visits and communication to monitor household income as well as cultural MMS use and support to caregivers feeding practices. Such low food variety were essential to ensure compliance and was also observed in the diets of OA acceptance of MMS. Cultural feeding adults (Haemamalar, Zalilah & Neng practices, education level and knowledge Azhanie, 2010). In generally, the diets 76 Nur Dayana S, Zalilah MS, Gan WY et al. of nutrition among the OA community, Haemamalar K, Zalilah MS & Neng Azhanie A as well as financial constraints should (2010). Nutritional status of Orang Asli (Che Wong Tribe) adults in Krau Wildlife Reserve, be considered when designing an . Mal J Nutr 16(1):55-68. intervention. This study demonstrates Halati S, Van Hees J, Uprety S, Schapendonk E the feasibility of using MMS for future & De Pee S (2013). Micronutrient powder trials among OA young children (6-24 supplementation program for Bhutanese months) to prevent undernutrition and refugee children in Jhapa and Morang anaemia. districts, Nepal; Home fortification in refugee camps. Home fortification with micronutrient powders joint publication by the World Food Acknowledgements Programme, Sight and Life, CDC and Home This study was supported by a grant from Universiti Fortification Technical Advisory Group (HF- Putra Malaysia (GP-IPS/2016/9514200). The MMS TAG). Sight and Life, Switzerland. was sponsored by the DSM Nutritional Products Asia Pacific. The authors would like to thank the Inayati DA, Scherbaum V, Purwestri RC, Wirawan Department of Orang Asli Development (JAKOA) NN, Suryantan J, Hartono S, Bloem MA, and study participants for their contributions to Pangaribuan RV, Biesalski HK, Hoffmann this study. V & Bellows AC (2012). Combined intensive nutrition education and micronutrient powder Authors’ contributions supplementation improved nutritional status of mildly wasted children on Nias Island, NDS, designed the study, collected and analysed Indonesia. Asia Pac J ClinNutr 21(3):361-373. the data and prepared the manuscript; ZMS, conceptualized and designed the study, International Institute for Population Sciences supervised the project, reviewed and finalized the (IIPS) and Macro International (2007) National manuscript; GWY, supervised the project and Family Health Survey (NFHS-3), 2005–06: India: reviewed the manuscript; Loh SP, supervised the Volume I. Mumbai: IIPS. project and reviewed the manuscript. IPH (2015). 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