Priority micronutrient density of foods for complementary feeding of young children (6-23 months) in South and Southeast Asia

doi:10.21203/rs.3.rs-947527/v1

Background

Given their high nutrient requirements and limited gastric capacity, young children during the complementary feeding period (6-23 months) should be fed nutrient-dense foods. However, complementary feeding diets in low- and middle-income countries are often inadequate in one or more essential micronutrients. In South and Southeast Asia infants’ and young children’s diets are commonly lacking in iron, zinc, vitamin A, folate, vitamin B₁₂ and calcium, hereafter referred to as priority micronutrients.

Objective

This study aimed to identify the top food sources of priority micronutrients, among minimally processed, locally available foods, for complementary feeding of children (6-23 months) in South and Southeast Asia.

Methods

An aggregated regional food composition database for South and Southeast Asia was built, and recommended nutrient intakes (RNIs) from complementary foods were calculated for children aged 6-23 months. An approach was developed to classify foods into one of four levels of priority micronutrient density based on the calories and grams required to provide one-third (for individual micronutrients) or an average of one-third (for the aggregate score) of RNIs from complementary foods.

Results

We found that the top food sources of multiple priority micronutrients are organs, bivalves, crustaceans, fresh fish, goat, canned fish with bones, and eggs, closely followed by beef, lamb/mutton, dark green leafy vegetables, cow milk, yoghurt, and cheese, and to a lesser extent, canned fish without bones.

Conclusions

This analysis provided insights into which foods to prioritize to fill common micronutrient gaps and reduce undernutrition in children aged 6-23 months in South and Southeast Asia.

Nutrition & Dietetics

nutrient density

complementary feeding

South Asia

Southeast Asia

micronutrient deficiencies

6-23 months

animal-source foods

dark green leafy vegetables

The first two years of a child’s life represent a “critical window” for the achievement of optimal growth and health, for which adequate nutrition is an essential prerequisite. The reversion of stunting becomes difficult after a child reaches two years of age, further demonstrating the crucial importance of intervening during this time. This is also the age when growth impairments, deficiencies in certain micronutrients, and common childhood illnesses are most likely to happen (1). In particular, according to the World Health Organization (WHO) and other available literature, the highest occurrence of stunting in low- and middle‐income countries is registered during the complementary feeding period, which corresponds to 6-23 months of age (2, 3).

Africa and Asia are the regions where the largest proportion of malnourished children under five years of age live. Together, they account for more than nine out of ten of all stunted children and more than nine out of ten of all wasted children globally (4). Within the Asian region, South Asia is home to about a quarter of the world’s children under five years and has the highest percentages and numbers of stunted (30.7%, n = ~54 million) and wasted (14.1%, n = 25 million) children (5), closely followed by Southeast Asia which has the second highest percentages and numbers of stunted (27.4%, n = ~15 million) and wasted (8.2%, n = 4.6 million) children (5). Inadequate diets during the complementary feeding period are among the key determinants of the child-stunting and wasting crisis in South and Southeast Asia (2, 6).

The WHO defines complementary feeding as the transition time when other foods and liquids, along with breast milk, are needed to meet a child’s nutrient requirements and are gradually introduced in their diet (1, 3). Infants and young children 6-23 months of age have very high nutrient requirements per unit body weight, because of their rapid growth and development rates. Continued breastfeeding can significantly contribute to meeting their nutrient needs, but has to be complemented with a variety of nutritionally adequate and safe family foods (1). Children aged 6-23 months have a limited gastric capacity and can only consume small quantities of food, therefore, complementary foods should have high nutrient density (amount of each nutrient per 100 kcal of food) (1, 2). Unfortunately, in practice this is often not the case, and diets of infants and young children are often lacking in one or more essential micronutrients, especially in low- and middle-income countries, but also in high-income countries (e.g. iron and zinc in the US) (1, 2, 7).

In particular, in South and Southeast Asia important micronutrient gaps were identified in infants’ and young children’s diets, with the most commonly lacking micronutrients and those of highest public health significance being iron, zinc, vitamin A, folate, vitamin B₁₂ and calcium, hereafter referred to as priority micronutrients (7–10). Among the main drivers of micronutrient malnutrition in infants and young children living in the two regions are the following: the low micronutrient density and lack of diversity of complementary foods, with most children aged 6–23 months having a primarily cereal-based complementary feeding diet and not consuming the minimum recommended number of food groups each day (6, 7, 10–12), and the inappropriate marketing of nutritionally inadequate, often ultra-processed, complementary foods and beverages that are promoted as suitable for this age group (11).

Given the crucial importance of adequate nutrition in infancy and early childhood and its impact on children’s present and future lives and on societies as a whole, improving the overall quality and diversity of infants’ and young children’s diets is critical to the achievement of the Sustainable Development Goals (SDGs) (6). The purpose of this study is to identify the top food sources of priority micronutrients, among minimally processed, inherently nutrient-dense, locally available foods, to support efforts to reduce micronutrient malnutrition among complementary fed children (6-23 months) in the South and Southeast Asian regions.

Calculating recommended nutrient intakes

Recommended Nutrient Intakes (RNIs) from complementary foods for children aged 6-23 months were calculated from the WHO and the Food and Agriculture Organization (FAO) recommendations (13) for calcium, zinc and iron, and from the Institute of Medicine (IOM) recommendations (14) for folate, vitamin A and vitamin B₁₂, based on a previously adopted approach to identify affordable nutritious complementary foods (7,15). Average Energy Requirements (AERs) from complementary foods for children 6-23 months of age were calculated from the WHO and the United Nations Children’s Fund (UNICEF) recommendations, accounting for average breast milk intake in developing countries (1,3).

Building a regional food composition database for South and Southeast Asia

A regional food composition database, representative of foods locally available in South and Southeast Asia, was built[1], including values for calories, phytate (16), and for the six identified priority micronutrients: vitamin A, folate, vitamin B₁₂, calcium, iron, and zinc, from US Department of Agriculture (USDA) FoodData Central (FDC) (17) and from several South and Southeast Asian countries’ food composition tables (FCTs) (18): Bangladesh, Indonesia, Laos, Vietnam and Thailand. Values from FDC were included in the calculations of composite nutrient values, serving as a reference to ensure plausibility of values from the selected national FCTs and, on a few occasions, they were also used to replace missing values from other FCTs[2]. For foods typically consumed in their cooked form (e.g. meat and poultry), but with values only available as raw in the included FCTs, weight yields and nutrient retention factors for different cooking methods were applied (19).

Foods presenting low nutrient density variance (e.g. pulses, refined grains) or likely to be targeted as a food group rather than individually in policy and programming (e.g. dark green leafy vegetables, cheese) were aggregated for analysis. For foods analyzed individually, nutrient values were obtained by calculating the medians of country-level composite values from the selected FCTs. Composite values were obtained by averaging nutrient values for different cooking methods (and raw foods, if applicable) and for different cuts in the case of meat and poultry. For aggregated food groups, nutrient values were calculated by averaging regional-level composite values from South and Southeast Asia and from FDC. Composite values were obtained by calculating the medians of nutrient values for several individual foods (e.g. spinach, kale, amaranth leaves and others) within a given food group (e.g. dark green leafy vegetables), which were derived from multiple included FCTs located in the South and Southeast Asian regions.

The bioavailability of iron and zinc was accounted for in the analysis. Foods included in the regional food composition database were assigned to one of three levels of iron absorption: 20% for ruminant meat, 15% for all other animal-source foods (ASFs), and 10% for all plant-source foods (PSFs), based on the proportion of heme to non-heme iron contained (20). The following heme-iron percentages were assumed: 68% in ruminant meat, including beef (21–23), goat, and lamb/mutton (23,24); 39% in pork (22,23,25–27);26% in chicken (22,23,25–27), fish and seafood (22,25–28), eggs and dairy (26); and 40% in all other meat, including offal (21,26,27). In addition, foods were categorized into four levels of zinc absorption: 44%, 35%, 30% and 26%, based on the amount of phytate contained in a portion equivalent to one-third of daily mass intake, assuming an energy density of 1.3 kcal/g[3] and considering average energy requirements for a moderately active woman of reproductive age (30) (see Supplemental Material for a more detailed explanation).A similar approach was previously used to build a global food composition database (31).

Aggregate and individual priority micronutrient density ratings

Foods were categorized into four levels of priority micronutrient density based on the portion (calories and grams) needed to achieve one-third (for individual ratings) or an average of one-third (for the aggregate rating) of RNIs from complementary foods for the six selected micronutrients (vitamin A, folate, vitamin B₁₂, calcium, iron and zinc). For the aggregate rating, each micronutrient’s contribution was capped at 100% of RNIs, meaning that each micronutrient can contribute from 0% up to 50% of the overall score. This choice was made to ensure that foods would only be rated high if they were high in at least two out of the six micronutrients included in the analysis; and to prevent foods with very high densities of individual micronutrients from rating higher for providing amounts well above recommended intakes or even above upper limits. A similar approach was previously applied to identify top food sources of priority micronutrients for other population groups (31) and used to determine micronutrient-dense complementary foods (7,15).

Foods were ranked according to the following thresholds on Average Requirements (ARs) for energy from complementary foods for children 6-23 months of age and hypothetical ARs for mass, assuming an energy density of 1.3 kcal/g (obtained by averaging the minimum and maximum composite energy densities of the sample complementary feeding diets for breastfed children developed by the WHO (1,32)):

Very high: ≤ one-sixth of ARs for both energy and mass
High: ≤ one-third of ARs for both energy and mass and < one-sixth of ARs for either energy or mass
Moderate: ≤ one-third and > one-sixth of ARs for both energy and mass
Low: > one-third of ARs for either energy or mass

The above thresholds were chosen by taking into consideration the assumed functional gastric capacity of children aged 6-23 months (30 g/kg body weight/d) and plausible amounts of complementary foods that they could consume at each meal, as well as meal frequency during the complementary feeding period (1,33).

A slightly different approach was taken for milk, to account for the fact that mass is a less limiting factor for liquids than for solid foods in children 6-23 months of age. The same thresholds on energy and mass as for solid foods were applied, but instead of hypothetical ARs for mass, a maximum daily intake of milk of 400 g was assumed, which was considered plausible for children during the complementary feeding period based on a review of Food-Based Dietary Guidelines (FBDGs) from multiple countries (34,35).

[1] Fortified foods not included.

[2] In particular, vitamin B₁₂ from the Bangladesh FCT.

[3] Obtained by averaging the energy densities of a minimally processed plant-based, low-fat diet and a minimally processed, animal-based, ketogenic diet (29).

Recommended nutrient intakes for children 6-23 months of age

The AR for energy from complementary foods for children aged 6-23 months is 450 kcal/d, accounting for average breast milk intake in developing countries (1). In addition to energy requirements, breast milk contributes to the achievement of RNIs for breastfed infants and young children during the complementary feeding period to different extents depending on the nutrient considered (Table 1). For instance, vitamin A requirements are largely covered by breast milk, with only 20% needed from complementary foods. Folate, vitamin B₁₂and calcium requirements are also partially covered by breast milk intake, while for iron, the totality and for zinc, the near totality of RNIs need to be obtained through complementary foods. Moreover, recommended intakes for iron and zinc significantly vary depending on bioavailability: the lower the bioavailability level, the higher the RNIs.

Regional food composition database for South and Southeast Asia

A regional food composition database for South and Southeast Asia was built, including a total of 36 individual foods and aggregate food groups, with values for energy, the six priority micronutrients, calculated iron and zinc absorption levels, and phytate (Table 2). While most aggregate food groups, such as grains and their products (both whole and refined), “other fruits” and “other vegetables,” present low nutrient density variance across included foods and across different countries’ FCTs (Supplemental Table 2), some, such as dark green leafy vegetables (DGLVs) and fresh fish show greater nutrient density variance across included foods (Supplemental Tables 2 and 4). For instance, spinach, amaranth leaves, and cassava leaves are more nutrient-dense than lettuce and cabbage. In the case of fresh fish, herring, carp and mackerel (fatty fish) have higher nutrient values than sea bass and tilapia (lean fish). In addition, for a few foods and food groups, differences in the amounts of some nutrients were identified across the included FCTs. For example, values for folate in pulses and for vitamin A in beef liver are higher in USDA FDC than in South and Southeast Asian countries’ FCTs, which may be due to different varieties, soil conditions, types of animal feed, culinary traditions, cooking methods and length, and/or the quality of sampling and analysis, including methods of mass spectrometry, conducted to develop the FCTs.

Aggregate priority micronutrient density scores of foods for children 6-23 months of age

Portion sizes, expressed as calories and grams, required to achieve an average of one-third of RNIs from complementary foods of vitamin A, folate, vitamin B₁₂, calcium, iron, and zinc for children aged 6-23 months range from less than 5 g and kcal for liver (from different sources – beef, goat/lamb, chicken, and pork) to more than 600 g and kcal for refined grain products (Figure 1). Foods presenting very high aggregate priority micronutrient density (referred to as “top sources” hereafter) are the following: organs, including liver, spleen, kidney and heart from beef, goat/lamb, chicken and pork; bivalves (clams, mussels and oysters); crustaceans; fresh fish, including different species of marine and freshwater fish; goat; canned fish with bones; and eggs. Foods with a high aggregate micronutrient density include beef, lamb/mutton, DGLVs, cow milk, yoghurt, and cheese, followed by canned fish without bones which was rated as moderate. All other foods analyzed presented low aggregate priority micronutrient density, including some animal-source foods (goat milk, pork and chicken) and several plant-source foods.

Individual priority micronutrient density scores of foods for children 6-23 months of age

All analyzed foods scored low in at least one of the six priority micronutrients (Figure 2), exemplifying the importance of varied diets during the complementary feeding period, with a particular focus on the most nutrient-dense foods, to satisfy all nutrient requirements of infants and young children. For instance, liver and kidney were rated as very high in all included micronutrients except for calcium, for which they scored low. Most animal-source foods (besides chicken and canned fish without bones) and DGLVs scored very high or high in two or more micronutrients. Some plant-source foods presenting a low aggregate score were rated as very high or high in certain micronutrients. For example, vitamin A-rich fruits and vegetables scored very high in vitamin A; pulses and whole grain products scored very high in folate; and seeds scored high in zinc and folate. Others, such as starchy roots, tubers and plantains, refined grains and their products, “other vegetables,” and “other fruits” were not rated as very high or high in any of the priority micronutrients.

Top sources of iron included organs, fresh fish, bivalves, and goat, closely followed by beef and, to a lower extent, canned fish with bones, lamb/mutton, and pulses (Figures 2 and 3). Organs, bivalves, fresh fish, and goat are also top zinc sources, together with crustaceans, beef, lamb/mutton, and eggs, followed by cheese, pork, and seeds. In addition to liver, kidney, bivalves, eggs, goat milk, and cheese, top vitamin A sources included two plant-source foods groups: DGLVs and vitamin A-rich fruits and vegetables, followed closely by cow milk, yoghurt and canned fish with bones. Cheese was identified as the only top source of calcium, closely followed by DGLVs, canned fish with bones, cow milk, goat milk, and yogurt. Top folate sources included liver, kidney, pulses, and whole grain products, followed by eggs, DGLVs, and seeds. Finally, all animal-source foods scored very high in vitamin B₁₂, except for chicken and goat milk.

The purpose of this study was to identify top inherent food sources of multiple and individual micronutrients commonly lacking in complementary feeding diets of children aged 6-23 months in South and Southeast Asia. All analyzed animal-source foods, except for canned fish without bones, goat milk, pork and chicken, presented very high (organs, bivalves, crustaceans, goat, eggs, fresh fish and canned fish with bones) or high (beef, lamb/mutton, cow milk, yoghurt and cheese) aggregate priority micronutrient density; while, DGLVs were the only plant-source food to score high for the aggregate micronutrient density rating. Our findings are in alignment with UNICEF’s and WHO’s (1, 3, 33, 36) recommendations for complementary feeding, according to which infants and young children should be fed animal-source foods daily or as often as possible, given that primarily plant-based or vegan diets, even when carefully planned, “cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used”(1). Consumption of ASFs remains very low among children aged 6-23 months in South and Southeast Asia (6, 10, 37) and has been found to be strongly associated with infant and young child growth and development (11, 38). Results from the quantitative analysis conducted by UNICEF in its latest Child Nutrition Report (10) show that only 24% of children 6-23 months of age in South Asia consume eggs, fish and/or meat. In alignment with UNICEF’s findings, other recent evidence on South and Southeast Asia highlights that the vast majority of children aged 6-23 months are traditionally fed cereal- and pulse-based complementary foods for the most part (e.g. rice flour and rice porridge), while very few receive meat-, fish-, and/or egg-based complementary foods (2, 6, 9). Unavailability and unaffordability were identified as two of the main factors limiting consumption of animal-source foods in infants and young children in the two regions (2, 10, 39). Indeed, while some foods of animal origin, such as liver, eggs and dairy, may be more available and affordable than others (particularly in terms of cost per nutrients provided), efforts to increase access to ASFs in South and Southeast Asia are still needed (40).

Despite DGLVs being the only plant-source food with high aggregate priority micronutrient density, other PSFs scored very high or high in individual micronutrients. These PSFs could make an important contribution to the reduction of specific micronutrient gaps in complementary feeding diets, especially when appropriate low-cost, easy-to-implement processing techniques are adopted at the household level to increase absorption of non-heme iron and zinc, by reducing the negative effects of phytate on absorption (e.g., consumption of vitamin C, consumption of animal protein, heating, germination, soaking, fermentation) (13). For instance, vitamin A deficiency in early childhood is widespread in South and Southeast Asia, and can have severe health consequences, which has led to countries’ governments carrying out vitamin A supplementation campaigns targeted at infants and young children (6, 8). Consumption of micronutrient-dense fruits and vegetables, particularly DGLVs and vitamin A-rich fruits and vegetables (both scoring very high in vitamin A in our analysis) is very limited during the complementary feeding period in the two regions (2, 6). For instance, in South Asia only one in three (~33%) children aged 6-23 months receive these foods (2). Therefore, in addition to supplementation and fortification - both key strategies in the fight against micronutrient malnutrition - improving consumption of available, affordable vitamin A food sources in infants and young children would significantly contribute to the reduction of vitamin A deficiency in South and Southeast Asia (6, 40). Other examples of widely available, affordable plant-source foods with very high or high individual micronutrient density include: pulses and whole grain products for folate, and seeds for zinc and folate (in addition to DGLVs) (6, 36, 40).

Among the foods which scored low in all six included micronutrients, some, such as nuts, “other fruits” and “other vegetables” (non-vitamin A-rich and non-DGLVs), are often promoted as nutrient-dense in nutrition policies and programs to improve infants’ and young children’s diets in South and Southeast Asia and globally (6, 36). However, given the limited gastric capacity of infants and young children (1, 2), these foods could displace more nutrient-dense foods and prevent complementary fed children from obtaining adequate micronutrients necessary for proper growth and development. Though not particularly dense in priority micronutrients, moderate quantities of these foods, which provide energy and other essential nutrients, as well as non-essential beneficial compounds, can contribute to the overall quality and diversity of complementary feeding diets in South and Southeast Asia (2, 7, 37, 38).

This study has several strengths. First, while the importance of nutrient-dense foods, particularly ASFs, for infants and young children has already been extensively acknowledged in previous studies and guidelines (1, 3, 33, 36, 10, 41), this analysis brings added value to the literature by transparently ranking a diverse set of inherent food sources of two or more micronutrients commonly lacking during the complementary feeding period in South and Southeast Asia, and whose deprivation is the cause of significant public health burdens in these regions (6–9). It does so by developing a resource-inexpensive, reproducible approach, which is widely applicable in the two regions considered and could be easily adapted for use in other geographic areas of the world, unlike other existing approaches and tools requiring extensive resources and availability of dietary intake data for the population of interest, such as dietary optimization through linear programming (41, 42). Second, the approach used for rating foods takes into consideration infants’ and young children’s limited gastric capacity and plausible amounts of food they could consume at each meal and daily, as well as the adequate meal frequency during the complementary feeding period (1, 33). Third, the micronutrient density analysis was conducted based on an aggregate regional food composition database, which compiles data from multiple countries’ FCTs and is reflective of foods locally available in Southern and Southeastern Asia, unlike other nutrient scoring systems which typically analyze data from a single national FCT, usually USDA FDC (43, 44). Fourth, iron and zinc values were adjusted for bioavailability in different foods. Finally, the methodology adopted is fully transparent, and the analysis is based on publicly available data, as has been recommended for nutrient profiling systems (43, 44). In addition, the results are presented both in written text and figures in a form that is easily interpretable by non-technical audiences, including policy makers and program managers.

The specific focus of this study on priority micronutrients is both a strength and a limitation. Indeed, in addition to the six micronutrients included in the analysis, foods provide energy, protein, essential amino acids and fatty acids, as well as other essential vitamins and minerals, which are crucial to optimal growth and development in the first two years of a child’s life and which can also be lacking to some extent in complementary feeding diets (1, 4, 9, 11, 20, 36, 45, 46). Moreover, minimally processed foods of both plant and animal origin contain countless non-essential compounds, including fiber, phytonutrients, and bioactive compounds, with potential beneficial effects on human health (47–50). However, this study focuses on micronutrients that are known to be commonly lacking in the two regions of interest and globally among infants and young children and are hindering optimal growth and development (7–9).

Other limitations should be acknowledged. First, the choice of countries’ FCTs used and foods included in the regional food composition database was constrained by limitations in data quality and availability. Indeed, only one country FCT from South Asia (Bangladesh) was considered appropriate for inclusion, while all other selected FCTs are from Southeast Asia. Moreover, countries’ FCTs only provide values for a limited selection of commonly consumed foods, and rarely include wild or indigenous fruits, vegetables, nuts, seeds, grains and pulses, many of which are more nutrient-dense than commercial varieties (51) or, when they are included, data is often missing or unreliable. Second, the adopted approach accounts for bioavailability of iron and zinc based on the heme-iron and phytate contents of foods, respectively, which are only two out of numerous factors influencing absorption, particularly the differing micronutrient status, overall diet and genetics of individuals. Third, there can be significant variations in nutrient values of a given food across countries’ FCTs, which may be due to different varieties, soil characteristics, climate conditions, quantity and type of fertilizers used, animal feed, production and processing methods, including local culinary traditions, as well as the quality of sampling, analysis and reporting processes. However, this study attempts to mitigate such differences and uncertainties by building a regional food composition database with aggregate nutrient values from multiple national FCTs, including the robust USDA FDC. Fourth, as mentioned in the Results section, some of the analyzed food groups show high nutrient density variance across included foods, meaning that the overall score of an aggregate food group might not reflect the micronutrient density of all individual foods included. In this regard, certain foods (e.g. fruits and vegetables) may be more likely to be targeted in policies and programming as food groups rather than individually, and consequently they were aggregated despite presenting significant intra-group nutrient density variance.

In conclusion, results from this study clearly show that the introduction of small quantities of priority micronutrient-dense animal- (e.g. organs, fish and shellfish, eggs) and plant- (DGLVs) source foods would significantly contribute to achieving adequacy of micronutrients commonly lacking in complementary feeding diets in South and Southeast Asia. Noticeably, top sources of priority micronutrients should be consumed together with a variety of other nutrient-dense foods, as part of a diverse and balanced diet, able to meet all nutrient requirements of children aged 6-23 months. Further analyses are needed to explore ways to integrate these findings into food, agriculture, and nutrition policies and programs aiming to reduce micronutrient malnutrition in the first two years of life through the promotion of inherently nutrient-dense foods.

This study focuses specifically on infants and young children living in South and Southeast Asia, however the same approach could be used to analyze the priority micronutrient density of foods for complementary feeding in other regions of the world presenting similar micronutrient gaps in complementary feeding diets, such as Eastern and Southern Africa (52). Future research could build on this analysis, for instance, by expanding the regional food composition database through the inclusion of nutrient-dense wild or indigenous fruits, vegetables, nuts, seeds, grains, pulses (51), and insects (53), the safety and nutritional adequacy of which is currently being studied for potential application in complementary foods (54). In addition, findings from this study could be compared and complemented with affordability and environmental impact metrics, to assess these variables based on priority micronutrient density by expanding on existing approaches (15, 40, 55).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author contributions

FO and TB designed the study and conducted the analyses.

Acknowledgements

The authors wish to thank Zivai Murira for reviewing and providing feedback on a draft version of this manuscript.

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Table 1: Recommended Nutrient Intakes (RNIs) for children 6-23 months of age

Nutrient	Total recommended nutrient intakes c	Proportion required from complementary foods d	Recommended nutrient intakes from complementary foods e
Vit A (µg RAE)	367	0.2	73
Folate (µg DFE)	127	0.6	76
Vit B₁₂ (µg)	0.8	0.7	0.5
Calcium (mg)	467	0.7	327
Iron ^a (mg) 20%	3.5	1.0	3.5
Iron ^a (mg) 15%	4.7	1.0	4.7
Iron ^a (mg) 10%	7.0	1.0	7.0
Zinc ^b (mg) R	2.8	0.9	2.5
Zinc ^b (mg) SR	3.5	0.9	3.1
Zinc ^b (mg) SU	4.1	0.9	3.7
Zinc ^b (mg) U	4.7	0.9	4.2
Recommended intakes for calcium, iron and zinc from the World Health Organization and the Food and Agriculture Organization (13). Recommended intakes for vitamin A, folate and vitamin B₁₂ from the Institute of Medicine (14). ^aPercentages (20%, 15%, 10%) indicate the three levels of iron absorption considered in the analysis. ^bAssuming 300 mg phytate/day and 44% absorption for refined (R) diets, 600 mg phytate/day and 35% absorption for semi-refined (SR) diets, 900 mg phytate/day and 30% absorption for semi-unrefined (SU) diets, and 1200 mg phytate/day and 26% absorption for unrefined (U) diets. ^c Total recommended intakes to be achieved through the combination of breast milk (or formula) and complementary foods. ^d Assuming that the remaining proportion of recommended intakes would be provided by breast milk (or formula), based on Dewey KG (56). ^e Recommended intakes to be achieved through complementary foods only, accounting for breast milk intake. RAE: retinol activity equivalent; DFE: dietary folate equivalent; R: refined; SR: semi-refined; SU: semi-unrefined; U: unrefined; Vit: vitamin.

Table 2: Regional food composition database for South and Southeast Asia

Food (100 g)	kcal	Vit A (mcg RAE)	Folate (mcg DFE)	Vit B₁₂(mcg)	Calcium (mg)	Iron (mg)	Zinc (mg)	Iron Abs	Zinc Abs	Phytate (mg)
Pulses	140	1	97	0	27	2.7	1.3	0.10	0.26	441
Whole grains ^a	158	0	15	0	13	1.7	1.1	0.10	0.26	443
Refined grains ^a	131	0	5	0	9	0.4	0.6	0.10	0.44	42
Whole grain products ^a	194	0	84	0	28	1.2	1.2	0.10	0.35	77
Refined grain products ^a	155	0	6	0	9	0.7	0.5	0.10	0.44	49
Millet	132	0	23	0	10	2.0	1.1	0.10	0.26	200
Nuts	581	1	80	0	76	4.3	3.1	0.10	0.26	646
Seeds	561	1	97	0	134	6.9	5.6	0.10	0.26	402
Starchy roots, tubers and plantains	101	16	11	0	22	0.7	0.3	0.10	0.44	12
DGLVs	27	286	37	0	102	2.0	0.3	0.10	0.44	16
Vit A-rich fruits and veg, excl DGLVs	38	126	21	0	20	0.4	0.2	0.10	0.44	24
Other fruits, excl vit A‑rich fruits	62	4	17	0	11	0.3	0.1	0.10	0.44	10
Other vegetables, excl DGLVs and vit A-rich veg	24	15	15	0	19	0.5	0.3	0.10	0.44	11
Hen egg	157	164	45	1.1	43	1.5	1.8	0.15	0.44	0
Beef	273	3	3	1.7	10	2.5	6.3	0.20	0.44	0
Goat	112	0	4	1.2	12	2.8	3.9	0.20	0.44	0
Lamb/mutton	210	2	10	2.5	13	1.7	4.1	0.20	0.44	0
Pork	234	1	3	0.6	21	1.5	2.1	0.15	0.44	0
Chicken	197	17	4	0.2	10	0.8	1.3	0.15	0.44	0
Fresh cow milk	67	52	5	0.4	120	0.1	0.4	0.15	0.44	0
Cooked cow milk	61	32	5	0.5	113	0.1	0.4	0.15	0.44	0
Fresh goat milk	69	45	1	0.1	143	0.1	0.3	0.15	0.44	0
Yoghurt	61	27	7	0.4	121	0.1	0.6	0.15	0.44	0
Cheese	358	224	19	0.9	691	0.4	3.3	0.15	0.44	0
Beef liver	151	6166	226	60.4	10	7.7	4.3	0.15	0.44	0
Goat/lamb liver	229	7637	237	81.1	9	9.2	6.8	0.15	0.44	0
Chicken liver	147	3492	509	16.1	12	9.4	3.4	0.15	0.44	0
Pork liver	139	4924	149	16.9	10	15.9	5.7	0.15	0.44	0
Heart ^b	128	5	15	6.1	9	5.3	3.3	0.15	0.44	0
Spleen ^b	149	0	4	5.0	13	38.7	3.5	0.15	0.44	0
Kidney ^b	104	86	53	14.7	12	5.6	2.7	0.15	0.44	0
Fresh fish^c	120	9	15	4.0	30	3.1	2.1	0.15	0.44	0
Crustaceans	92	3	15	1.2	87	1.2	3.2	0.15	0.44	0
Bivalves	106	68	7	17.6	68	4.0	1.9	0.15	0.44	0
Canned fish, without bones	136	20	4	2.6	17	1.4	0.7	0.15	0.44	0
Canned fish, with bones	182	43	10	3.9	240	2.5	1.2	0.15	0.44	0
^aThe terms “whole grains” and “refined grains” refer to cereals, such as wheat, rice, and barley, while the terms “whole grain products” and “refined grain products” refer to products obtained from cereal flours, such as breads, pasta, noodles and vermicelli. ^b From different animals, including beef, lamb, pork and chicken. ^c Includes different species of marine and freshwater fish. Vit: vitamin; RAE: retinol activity equivalent; DFE: dietary folate equivalent; Excl: excluding; Veg: vegetables; Abs: absorption.

Supplementarymaterial.docx
Supplementary material

Priority micronutrient density of foods for complementary feeding of young children (6-23 months) in South and Southeast Asia

Status:

Journal Publication

Version 1

Abstract

Background

Objective

Methods

Results

Conclusions

Figures

Introduction

Methods

Calculating recommended nutrient intakes

Building a regional food composition database for South and Southeast Asia

Aggregate and individual priority micronutrient density ratings

Results

Recommended nutrient intakes for children 6-23 months of age

Regional food composition database for South and Southeast Asia

Aggregate priority micronutrient density scores of foods for children 6-23 months of age

Individual priority micronutrient density scores of foods for children 6-23 months of age

Discussion

Declarations

Conflict of Interest

Author contributions

Acknowledgements

References

Tables

Supplementary Files

Status:

Journal Publication

Version 1