Biodiverse food solutions to enhance complementary feeding

To the Editors,

de Pee, S. (2015) Special nutritious solutions to enhance complementary feeding. Matern Child Nutr, 11: i–viii. doi: 10.1111/mcn.12265 10.1111/mcn.12265.

In her recent editorial, Dr. de Pee (2015) states there are two main ways to provide additional nutrients during complementary feeding: fortification and supplementation. She illustrates some problems associated with these ‘solutions’, including lack of compliance (Kodish et al., 2016). Rather than conclude that lipid‐based nutrient supplements (LNS) and ready‐to‐use therapeutic foods (RUTFs) may thus be ineffective, de Pee advocates research to improve compliance, assuming effectiveness has been demonstrated. We highlight four additional problems: inappropriateness, cost, lack of sustainability and potential adverse effects.

First, RUTFs were designed for therapeutic use under medical prescription. Indeed Briend et al. (2015) state these are not optimized to maximize linear growth, vitamin and mineral status, nor functional outcomes; have problems related to quality and content and are expensive.

Second, De Pee states that linear programming (LP) states a healthy diet is not affordable by many households in low and middle income countries (LMICs). However, at least two examples, Mozambique (Parlesak et al., 2014) and Kenya (Termote et al., 2014), illustrated how a low‐cost diverse diet can be designed using locally available foods. Interestingly, LP's ability to model these appears to depend on which cost‐efficient micronutrient‐dense local foods are selected. These LP diets, modelled for LMICs, were relatively affordable compared with the cost of 150 sachets of LNS weighing 92 g each which cost approximately US$55 in 2013. Moreover, Segrè et al. (2015) found that only 25% of Ethiopian consumers appeared willing to pay for LNS and could afford them.

Third, de Pee states that distribution of LNS is sustainable and lists the practical constraints associated with feeding young children. However, investigators, e.g. in Bangladesh (Bogard et al., 2015), Ecuador, Kenya (Waswa et al., 2015) and Tanzania (Kuyper et al., 2014), have shown how to overcome these constraints using cost‐effective, culturally acceptable and locally available diverse foods. In addition, mothers are empowered by being able to earn income (Jones et al., 2015), which has spin‐off benefits. Both Johns et al. (2013) and Powell et al. (2015) demonstrate the economic importance of how local production improves dietary diversity, can be sustainable, cost‐effective, and culturally acceptable and helps to reduce rates of chronic undernutrition. Indeed the majority of young children in LMICs who do not consume LNS or RUTF are not undernourished.

Fourth, potential adverse effects include the risk that breastmilk can be displaced by LNS (Latham et al., 2010; Greiner, 2014). Yan et al. (2014) indicate that continued breastfeeding is related to a decreasing risk of obesity and whereas LNS cannot help stunted children achieve optimal height it can contribute to increasing prevalence of childhood obesity and double burden of malnutrition (Shrimpton & Rokx, 2012; Parlesak et al., 2014). Moreover, if LNS displace breast milk, this deprives the infant of a unique source of bioavailable micronutrients and immunomodulation. Any move away from optimal breastfeeding and/or consumption of family foods can have an adverse effect on both taste development (Mennella et al., 2016) and adoption of long‐term, healthy eating patterns along with better anthropometric outcomes (Arimond & Ruel 2004) and health (Rao et al. 2001).

In conclusion, all UN agencies have joint responsibility to help Member States achieve their Sustainable Development Goals (SDGs), which create the opportunity to link sustainability and dietary diversity. The Convention on Biological Diversity (WHO 2015) illustrates how dietary diversity can help combat global malnutrition by using practical solutions that can be rolled out as public health strategies. Culturally‐sensitive, cost‐effective, sustainable complementary foods have the potential to increase nutrition security and sovereignty, reduce poverty, hunger and levels of chronic undernutrition while conserving biodiversity and respecting indigenous knowledge (Jones et al., 2015).

Robertson, A. , Parlesak, A. , Greiner, T. , Kent, G. , and Cattaneo, A. (2016) Biodiverse food solutions to enhance complementary feeding. Maternal & Child Nutrition, 12: 639–640. doi: 10.1111/mcn.12316.