1. Elaine Ferguson London School of Hygiene & Tropical Medicine
‘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

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. Select Fe and Zn bioavailability
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 Outputs
Check parameters
Create food-based recommendations; ‘Problem nutrients’
Test & compare alternative FBRs
Type of ‘problem nutrient’
Cost analysis:
Lowest cost nutritionally best diet
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#1
Module#2
Module#3
Module#4

10. >65% or 70% RNI=adequate
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 Recommendations Test 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”
Cambodia
Indonesia
Lao PDR
Thailand
Vietnam
Children:
6-8 m
9-11 m
12-23 m 6 4 2 3 1
Women:
Pregnant
Lactating
NPNL 7 5
Not analysed
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?
6-8 months
9-11 months
12-23 months
Alone
With FBR
Cambodia 5* 4* 3
Indonesia 3*
Lao PDR
Vietnam
*Ca adequacy not ensured
FBR – food-based recommendations

23. Daily Fe – folate Supplement
Choose an iron-folate or a multi-micronutrient supplement for pregnant Cambodian women?
Daily Fe – folate Supplement
Daily Multiple Micronutrient Supplement
Number per week
Only supplement
#Nutrients
≥70% RNI
Supplement + FBR
1 day
2 days
3 days
4 days
5 days
6 days
7 days 1 2 3* 6 7 8 8# 3 4 9
10** 10
*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
Original
Tested#1
Tested#2
Tested#3
Tested#4
Optifood
Rice -14
MFE – 14
Egg – 7
Veg – 14
Fruit-14
Oil-7 “
Fruit -7
No oil
Fruit-7
Oil-3
F- rice-14
Not feasible
4 low nutrients*
4 low nutrients
2 low nutrients
Problem nutrients Ca Fe Zn B3
Fe increased from 18 or 19% RNI to 57% RNI; B3 – 61 & 62% RNI; but with fortified rice = 39% RNI
*low nutrients defined as worst-case scenarios <65% RNI

26. Did intervention foods ensure dietary adequacy
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
Baseline
Winfood
Winfood-lite
CSB+
CSB++
6-8m
B1* B2
B3*
B6*
B9*
B12*
Ca*
Fe*
Zn* B9 Ca
8 PN
*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
Children- breastfeed
Women C I* L T V
MFE
Pork
Liver
Eggs 21 7 14
1, 3
14, 21 3 1
Dairy (12-23 m)
Legumes
Fruits
7, 14
Vegetables
GLV 4 2 49 35
Fortified Products
*Indonesia – day-based servings not meal-based
MFE – meat, fish, eggs

32. Nutrients not adequate (<70% RNI)
Cambodia
Indonesia
Lao PDR
Thailand
Vietnam
6-8 m
Ca, Fe, Zn, folate
Fe, Zn, B3
Ca, Fe, Zn, B1, B3
Ca, Fe, Zn
9-11 m
Ca, Fe, Zn, B3 Fe
12-23 m
Fe, folate
Ca, B2, B3
Fe, Zn, B1, B3, folate
Fe, B3, folate
Ca, Fe, B1
Pregnant
Ca, Fe, folate, B2, VA
Ca, Fe, B1, B3, B6, folate
Ca, Fe, folate, B2, B3, B6
Lactating
Ca, folate, B2
NPNL
Ca, Fe, B1, folate
Ca, Fe, B2, B3