A sprinkle a day keeps anaemia at bay

Stanley Zlotkin, the Canadian scientist who developed Sprinkles, a nutritional supplement to reduce anaemia in infants and young children, recalls the moment in Mongolia when he decided to take the idea global.

"I was in the middle of nowhere, in an isolated herder's tent (yert), and there was a mother feeding Sprinkles to her child, telling me that the child is more talkative, walking better, and in better general health."

It was 1991 and Mongolia was one of the first countries where pilot studies on the supplement's effectiveness were done. "It was moving; it was motivating, and I have never looked back or questioned my mission since that moment."

Supplements in sachets

Sprinkles are a blend of powdered micronutrients packed in sachets - like small packets of sugar - that are easily sprinkled onto foods. "Any homemade food can be instantly fortified by adding Sprinkles: coating the iron prevents changes to the taste, colour or texture of the food to which Sprinkles are added," he explained to IRIN.

Distribution is typically done through ‘clusters’ or partnerships. Each cluster includes a licensed private-sector producer, one or more implementing agencies, such as an international non-governmental organisation or local NGO, and may include social marketing agencies, social franchise organisations, women’s income generation projects, a UN agency - usually the UN Children's Agency (UNICEF) and the local and/or national government.

"We have active distribution programmes at varying stages of development in more than 18 countries - it is likely that we will come close to reaching our goal of distributing Sprinkles to two million children this year. Our goal for the next three to five years is to reach 50 million children with Sprinkles," Zlotkin said.

Halving anaemia

Recently-published research by the New York-based Cornell University Division of Nutritional Sciences and the Washington-based International Food Policy Research Institute (IFPRI) has shown that Sprinkles can halve the incidence of anaemia in infants and young children.

The study which began in 2005 in rural Haiti, where at least two thirds of children under three are anaemic, is the first to show that Sprinkles are effective in reducing anaemia when included in an ongoing fortified food aid programme, in real-life conditions in developing countries.

Assessments showed that over a two-month period, anaemia rates were reduced from 54 to 24 percent in the group receiving Sprinkles. Anaemia was further reduced to 14 percent, nine months after the children first received the two-month dose of Sprinkles.

Community-based studies with anaemic as well as non-anaemic children have been completed in northern Canada, China, Cambodia, Bangladesh, India, Pakistan, Ghana, Bolivia and Haiti. Pilot projects have also been undertaken in Bangladesh, Mongolia and Pakistan.

"Cure rates of anaemia ranged from 50 to 90 percent [in the community-based studies], depending on the confounding presence of other factors that also lead to anaemia, such as malaria," said Zlotkin.

Kitchen beginnings

Zlotkin, a senior scientist in the Research Institute of the Hospital for Sick Children (SickKids), affiliated to the University of Toronto, Canada, started making Sprinkles in the hospital kitchen at night, where he worked as a clinician-nutritionist.

Sprinkles are available in two formulations: one aimed at anaemic children which contains iron, zinc, folic acid, with vitamins A and C; and the other a multi-micronutrient powder which besides iron, zinc, copper, iodine, niacin and folic aid contains other vitamins such as A, D, E, B2, B6 and B12.

The iron in the powder is encapsulated by a thin lipid layer that prevents interaction with the food to which it is added so it does not significantly change the taste, colour or texture of food. 

The numbers are staggering: two billion people - over 30 percent of the world's population - are anaemic, many due to iron deficiency, and in resource-poor areas this is frequently exacerbated by infectious diseases

Two billion iron deficient

"Vitamin and mineral deficiencies (VMD) - also known as hidden hunger - are widely recognised as a serious public health problem. Over 750 million children worldwide ... suffer from VMD, with roughly half of child deaths associated with malnutrition," he said.

Iron deficiency is the most common and widespread nutritional disorder in the world, according to the World Health Organisation (WHO).

WHO estimates that every second pregnant woman, and about 40 percent of pre-school children in developing countries, is anaemic. "The numbers are staggering: two billion people - over 30 percent of the world's population - are anaemic, many due to iron deficiency, and in resource-poor areas this is frequently exacerbated by infectious diseases. Also, WHO reports that it is the only nutrient deficiency which is "significantly prevalent in industrialised countries."

Micronutrient deficiencies increase the general risk of infectious illness and of dying from diarrhoea, measles, malaria and pneumonia. These conditions are among the ten leading causes of disease in the world today, according to the UN health body.

Fortification

Foods fortified with vitamins and minerals have been around for decades. The level of fortification in foods usually provided by food aid programmes, like wheat-soy blend and corn-soy blend, is adequate for adults, but too low for infants and young children, who have particularly high requirements for their size and cannot consume large amounts of the product, said Marie Ruel, director of IFPRI's Food Consumption and Nutrition Division.

"They [young children] would need to consume at least 100g of the dry powder each day, and 6- to 12-month-old children - who are the groups at highest risk of iron deficiency - often cannot consume that much in one day, let alone consume it every day."

In developing countries, especially those in Africa, poor populations do not always have access to special fortified products for babies, such as cereals, which are usually expensive and often unavailable. "Syrups and drops have extremely low compliance, and tablets are not safe for use in infants and very young children," Zlotkin pointed out.

WHO, UNICEF and the World Food Programme have acknowledged that foods fortified with micronutrients may not meet fully the needs of certain nutritionally-vulnerable groups such as pregnant and lactating women, or young children, particularly during an emergency. The agencies, in a joint position, say that when livelihoods and food crops are lost; food supplies are interrupted; diarrhoeal diseases break out, resulting in malabsorption and nutrient losses; and infectious diseases suppress the appetite - micronutrients are needed more.

In those instances, the agencies support the use of multiple micronutrient powders such as Sprinkles.

Cheap supplement

Photo: Sprinkles Global Health Initiative

Sprinkles are a blend of powdered micronutrients packed in sachets

Sprinkles, can be used on small quantities of semi-solid or solid food and eaten at home. The formulation is also cheap: "Between US$0.01 and $0.03 per day, and our study showed that two months of Sprinkles were sufficient to reduce anaemia from 54 percent to 14 percent. So the total cost per child would be between $0.60 to $1.80," Ruel said.

A global rollout means setting up local production to reduce costs further, and an effective distribution system. "Our study highlighted a very feasible and effective distribution system: i.e. linking the distribution of Sprinkles to monthly distribution of take-home food rations, in the context of a food-assisted development programme targeted to mothers and young children," Ruel said.

Sprinkles have been widely and effectively used in emergencies in Haiti and for post-tsunami relief in Indonesia, according to Zlotkin.

He said the Sprinkles Global Health Initiative aims to target children in Indonesia (12 million), India (20 million), Pakistan (10 million) and Bangladesh (7 million). "We already have established pilot projects in each of these countries and working 'clusters' in Indonesia, Pakistan and Bangladesh."

The initiative is using a number of distribution models including public sector free distribution, NGO-operated subsidised distribution and social marketing through public-private partnerships.

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