Scholarly article on topic 'Authors' Reply: Sprinkles as a Home Fortification Strategy to Improve the Quality of Complementary Foods'

Authors' Reply: Sprinkles as a Home Fortification Strategy to Improve the Quality of Complementary Foods Academic research paper on "Psychology"

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Academic research paper on topic "Authors' Reply: Sprinkles as a Home Fortification Strategy to Improve the Quality of Complementary Foods"

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Sustainable Super-Sprinkle: Powdered Local Foods

Stacia Nordin

I appreciate Zlotkin and colleagues' years of work on the Sprinkle product, and it sounds like the product is much improved from the pill form of micronutrient treatments [1]. I'm not at all opposed to Sprinkle-type products or other nutrient pills for treatment (or in other special situations), but as ten years of international work experience on food and nutrition security issues has shown me, few programmes are supporting local solutions to problems. Once again, a message is being sent that nutrition comes from a pill or packet, made by a foreigner, and requires money.

In the case of Sprinkles, the product could support local solutions by including a message on each sachet about the importance of eating a wide variety of local foods—or a picture of local fruits, vegetables, and legumes. Instead ofjust sprinkling a packet onto a bulky carbohydrate food, use the Sprinkles as treatment along with instruction about planting and eating less of that bulky carbohydrate in the first place. Even better would be to take all that research, time, energy, and money to teach people (or local manufacturers) how to make their own Sprinkles from local nuts, fruits, greens, oilseeds, insects, fish, and the like.

The results could be just as immediate and dramatic, but with an impact that could last for generations to come. The organisations that support this type of permanent intervention could be mentioned during every teaching session along with big banners and flyers that announce them as the inventors and/or supporters. Just imagine a nice sprinkle powder that everyone can have on hand to improve their own nutrition without relying on a packet from an outside source that is manufactured with machines and jetted in with thousands of litres of petrol (or trucked across the country, if it is made in country).

I'm sure that pre-packaged, imported products have their place in wars, tsunamis, a few cities, and other disasters, but for the majority of the 750 million children in the developing world, their own indigenous foods would have just as much effect, with a longer-term impact on the society's nutritional health.

I saw Zlotkin's presentation on Sprinkles at the International Congress of Dietetics conference in Chicago, Illinois, in 2004, and he did include a sentence about diversifying diets as part of the whole project, but it was strongly overshadowed by discussion of bringing in external resources and experts. When I asked him about using the same resources that went into developing, manufacturing, and transporting Sprinkles to create a local sprinkle product with an emphasis on local diversified diets, he immediately responded that it wouldn't work.

How do we know, if no one really puts the effort into it at the level that products like Sprinkles get?

I've posted this message to several food and nutrition listservs and magazines, and I am now beginning to learn of some small projects working towards local sprinkle products. Zlotkin and team could assist these projects to research the work and scale it up to other countries with other local foods. ■

Stacia Nordin

Lilongwe, Malawi E-mail:


1. Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur M, et al. (2005) Micronutrient Sprinkles to Control Childhood Anaemia. PLoS Med 2: el. DOI: 10.1371/journal.pmed.0020001

Citation: Nordin S (2005) Sustainable super-sprinkle: Powdered local foods. PLoS Med 2(7): e188.

Copyright: © 2005 Stacia Nordin. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Competing Interests: The author has declared that no competing interests exist. DOI: 10.1371/journal.pmed.0020188

Authors' Reply: Sprinkles as a Home Fortification Strategy to Improve the Quality of Complementary Foods

We are writing in response to the letter by Stacia Nordin [1]. Independent of where a child is born in the world, the most appropriate feeding regimen is breast milk until six months of age, followed by a weaning or complementary food [2]. It is known that breast milk provides all the essential nutrients for a growing infant, except for vitamin D. It is also known that complementary foods should contribute to providing all of the essential nutrients when breast milk is no longer the sole source of nutrition after the first few months of life. However, as early as 1930, it was realized that typical complementary foods were generally poor sources of micronutrients (minerals and vitamins) and were often not sufficient to meet the micronutrient needs of growing children. For example, per 100 g, rice-based complementary foods contain about 1 mg of iron, and wheat-based complementary foods contain about 0.8 mg of iron [3]. Even a meat-based complementary food, such as commercial "toddler beef stew", contains only 1.2 mg of iron in each 170-g jar. Since the recommended dietary allowance for iron is 11 mg/day (for ages 7-12 months) [4], clearly a rice- or wheat-based complementary food, or even a dilute meat-based stew, would not provide an adequate amount of iron for a growing infant.

Pablum, the first fortified baby food, was invented at the Hospital for Sick Children in Toronto, Canada, in the 1930s

[5]. Subsequently, by the early 1960s in North America, all commercially manufactured infant cereals were fortified with iron. Today, the major source of iron in the diet of a North American child is fortified commercial infant cereals. And, indeed, the low rates of iron-deficiency anaemia in Canada and the United States are thought to be partly a result of the widespread use of commercially available iron-fortified cereals

Another good example of a fortified food for young children in North America is fluid milk products, which are fortified with vitamin D in order to prevent the development of rickets. It is currently well accepted among nutritionists and pediatricians that most young children in North America depend on fortified foods to meet their micronutrient needs.

In most developing countries, access to commercially processed baby foods (fortified with iron) is very limited

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mainly because of their high cost and limited availability [7]. It is noteworthy that recent research has demonstrated that even if dietary diversification and modification (such as soaking, fermentation, and germination) strategies are used at the household level, they may not be sufficient to overcome the deficits in iron and other micronutrients [3]. As a result, other options need to be considered for young children living in developing and poor countries to ensure that all of their nutrient requirements are met [8]. The use of Sprinkles is one such option [9,10]. One of the greatest advantages of the Sprinkles concept is its emphasis on complementary food consumption because Sprinkles have to be mixed with food. When educating caregivers about anaemia and the use of Sprinkles, healthy weaning practices can be concurrently promoted to ensure the timely introduction of complementary foods at six months of age in addition to continued breast feeding (as recommended by the World Health Organization) [2]. This is an important benefit, as it is well known that in many developing countries poor weaning practices are common [3]. As a home fortificant, Sprinkles ensure that the food eaten contains adequate amounts of essential micronutrients. Indeed, Sprinkles are meant to improve the nutritional value of homemade baby foods, which are otherwise poor in micronutrient content. Sprinkles can enrich foods not only with iron but also with other essential micronutrients such as zinc, folic acid, and vitamins A and C. In addition, since Sprinkles can be easily mixed with any homemade semisolid foods, their use does not require any change in food practices; thus, they can be easily accepted in diverse cultural settings.

With anaemia rates as high as 80% in young children in some developing countries, current food-based strategies alone are clearly not effective. All children should have the right to eat foods that meet their nutritional needs. The use of Sprinkles is one way to help these children meet their nutrient requirements. Unfortunately, a food-based strategy alone, using locally available unfortified foods, in most circumstances, is simply inadequate and may further predispose a growing child to various micronutrient deficiencies [8]. ■

Stanley H. Zlotkin (

Hospital for Sick Children and University of Toronto Toronto, Ontario, Canada

Claudia Schauer Anna Christofides Waseem Sharieff Melody C. Tondeur S. M. Ziauddin Hyder

Hospital for Sick Children Toronto, Ontario, Canada


1. Nordin S (2005) Sustainable super-sprinkle: Powdered local foods. PLoS Med 2: e188.

2. World Health Organization (2000) Nutrition for health and development: A global agenda for combating malnutrition. Geneva: World Health Organization. Available: 2000.pdf. Accessed 10 June 2005.

3. Gibson RS, Ferguson EL, Lehrfeld J (1998) Complementary foods for infants feeding in developing countries: Their nutrient adequacy and improvement. Eur J Clin Nutr 52: 764-770.

4. Food and Nutrition Board, Institute of Medicine (2000) Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper,

iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington (DC): National Academy Press. Available: http://www.nap. edu/books/0309072794/html/. Accessed 1 June 2005.

5. Tisdall FF, Drake TGH, Summerfeldt P, Brown A (1930) A new whole wheat irradiated biscuit containing vitamins and mineral elements. Can Med Assoc J 22: 166-170.

6. Ramakrishnam U, Yip R (2002) Experiences and challenges in industrialized countries: Control of iron deficiency in industrialized countries. J Nutr 132: 820S-824S.

7. Yip R, Ramakrishnam U (2002) Experiences and challenges in developing countries. J Nutr 132: 827S-830S.

8. Dewey KG, Brown KH (2003) Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull 24: 5-28.

9. Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur MC, et al. (2005) Micronutrient Sprinkles to control childhood anaemia. PLoS Med 2: e1. DOI: 10.1371/journal.pmed.0020001

10. Zlotkin SH, Christofides AL, Hyder SM, Schauer CS, Tondeur MC, et al. (2004) Controlling iron deficiency anemia through the use of home-fortified complementary foods. Indian J Pediatr 71: 1015-1019.

Citation: Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur MC, et al. (2005) Authors' reply: Sprinkles as a home fortification strategy to improve the quality of complementary foods. PLoS Med 2(7): e202.

Copyright: © 2005 Zlotkin et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Competing Interests: SHZ is an occasional consultant to Bristol-Myers Squibb, and Mead Johnson. He owns the intellectual property rights to Sprinkles. The H. J. Heinz Company is supporting the technical development of Sprinkles on a cost-recovery basis. Any profit from royalty fees on the technology transfer of Sprinkles is currently donated to the Hospital for Sick Children Foundation.

DOI: 10.1371/journal.pmed.0020202

Bold Suggestion by Smith

David Cohen

Richard Smith's key suggestion [1] is that medical journals "should stop publishing trials" and concentrate on "critically evaluating them." This bold and radical suggestion deserves wide debate. It's obvious that many medical journals are losing relevance as vehicles for scientific information, but it's unclear what will save them. Even as journals strive to better enforce their conflicts-of-interest disclosure rules, drug companies will strive to find or create other publication outlets that can communicate to physicians precisely what advertisers wish to communicate. In sum, an unanticipated effect of purging clinical trial reports from medical journals might be an even larger proliferation of frank advertising outlets and messages that might more effectively catch doctors' attentions. ■

David Cohen

Florida International University Miami, Florida, United States of America E-mail:


1. Smith R (2005) Medical journals are an extension of the marketing arm of pharmaceutical companies. PLoS Med 2: e138. DOI: 10.1371/journal. pmed.0020138

Citation: Cohen D (2005) Bold suggestion by Smith. PLoS Med 2(7): e226.

Copyright: © 2005 David Cohen. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Competing Interests: DC is a former editor of Ethical Human Sciences and Services, which published several articles critical of the drug industry, and has authored articles critical of drug industry sponsorship and influence on clinical psychopharmacology trials.

DOI: 10.1371/journal.pmed.0020226

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