Elaine Ferguson London School of Hygiene & Tropical Medicine

1. ‘Optifood’ – A tool based on linear programming analysis to inform nutrition programme planning and policy decisions Elaine Ferguson London School of Hygiene & Tropical Medicine Improving health worldwide www.lshtm.ac.uk

2. 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

3. 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?

4. 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

5. 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

6. 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

7. Data Requirements • Dietary Surveys • Quantitative (recalls, records) • Food frequency data • Market surveys • Food cost per 100 g edible portion • Food composition tables

8. Food Composition Table Energy Protein Water Fat Carbohydrate Vitamin A Vitamin C B1 B2 B3 Ca Fe Zn B6 B12 Folate Select Fe and Zn bioavailability

9. Optifood Analysis Structure Module#1 Model Constraints Food list Min & max g/wk Food Patterns Min & max serves/wk Main food groups Staples & snacks Food sub-groups Energy content Maximum cost (optional) Food-based recommendations (FBRs) Nutrient content 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#2 Module#3 Module#4

10. Module III: models tails of the nutrient intake distribution to test FBRs • Test 11 micronutrients • Test alternative sets of FBRs >65% or 70% RNI=adequate Define “problem nutrients” Upper tail < 100% RNI/AI Baseline Food-based recommendation Vitamin A intakes

11. 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

12. Food-based RecommendationsTest and compare in Module 3 “lower tail of intake distributions” Dairy 14 serves / week Vegetables 21 serves / week Meat, fish or eggs 5 serves / week Legumes 7 serves/week Fruits 7 serves/week Liver 2 serves/week Green leafy vegetables 5 serves/week Vitamin C rich fruits 5 serves/week Potatoes 3 serves/week Tofu/tempeh 7 serves/week Anchovies 3 serves/week

13. Minimised nutrient content analysis from Module 3 Count number of “lower tails” >65% or 70% RNI and cost

14. Research in SE Asia

15. 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

16. Define “Problem nutrients” • Can a nutritionally adequate diet be promoted given local foods & food patterns?

17. Numbers of “Problem Nutrients” For children: Ca, Fe & Zn; sometimes folate, B1, B2 & B3 For women: Ca & Fe; often folate, B2, B6 & vitamin A

18. Food-based Recommendations • To what extent can food-based recommendations ensure dietary adequacy for these target groups?

19. Number of nutrients –lower tails of their intake distributions >70% RNI when FBRs were tested(11 micronutrients)

20. % target groups where nutrient adequacy was not ensured

21. Testing Alternative Interventions -children

22. What is the minimum of sachets/w of multiple micronutrient powders that would ensure dietary adequacy? *Ca adequacy not ensured FBR – food-based recommendations

23. Choose an iron-folate or a multi-micronutrient supplement for pregnant Cambodian women? *Achieved only Fe, folate & niacin #Did not achieve Ca, riboflavin & vitamin A **Did not achieve Ca

24. Will the proposed national sets of Complementary Feeding Recommendations ensure dietary adequacy?

25. CF Recommendations for 6-8 m olds in Thailand *low nutrients defined as worst-case scenarios <65% RNI

26. Did intervention foods ensure dietary adequacy?from Cambodia (6-8 months) Foods Winfood Winfood-lite CSB+ CSB++ Skau et al, AJCN 99:130-8, 2014

27. Dietary Adequacy not ensured: “worst-case scenario” <65% RNI *worst-case scenario <50% RNI Skau at al, AJCN 99:130-8, 2014

28. 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 )

29. The SMILLING Team Lao – 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

30. Thank-you!

31. FBRs – number servings/w *Indonesia – day-based servings not meal-based MFE – meat, fish, eggs

32. Nutrients not adequate (<70% RNI)