PAN Recommends

2019 : Nutrition and Physical Activity for Longevity

This session aimed to collectively put together statements/ recommendations of an important and urgent nutrition and related policy, strategy and/or program recommendation that will contribute to the improvement of the current nutrition situation of Filipinos – particularly of the population groups in most need. Implementation of the PAN Recommends is a partnership by and among government agencies, local government units, nongovernment organizations, business sector, media and all other entities. The PAN Recommends targets policy makers, program planners and managers, field program personnel and local government officials who are in a position to initiate, support, and cause the implementation of urgently needed measures and actions.

In the past years, PAN Recommends focused on identified significant health and/or nutrition issues:

  • 2003 – Iron supplementation
  • 2004 – Biotechnology
  • 2005 – LGUs as prime movers
  • 2006 – Nutrition friendly schools
  • 2007 – Adolescent health
  • 2017 – Healthy lifestyle
  • 2018 – Home and school gardening

For 2019, PAN Recommends focuses on Nutrition and Physical Activity for Longevity. Initially, PAN Recommends Committee was created. The Committee consisted of Dr. Talavera, Ms. Raval and Ms. Gonzales. The Committee reviewed relevant evidences on the importance of nutrition and physical activity for longevity. These were eventually validated and a set of recommendations were crafted through consensus. The recommendations were subsequently presented/ disseminated in the convention. Collectively put together, PAN Recommends the following actions for different concerned agencies/ groups:

  1. National agencies
    • National Economic and Development Authority (NEDA)
      • Convene a multi-sectoral group (i.e., DepEd, DA, DENR, DOST, DOH) to develop an Action Plan that will enable the shift to a sustainable healthy diet consistent with SDG2: Zero Hunger
    • Department of Agriculture (DA)
      • Continue to pursue sustainable agriculture and food system through community gardens
    • Department of Education (DepEd)
      • Continue agriculture program in schools through Gulayan sa Paaralan
    • Department of Health (DOH)
      • Commission a study to analyze the existing food systems and identify recommendations for the action plan
      • Lead the promotion of healthy diet and physical activity anchored on the WHO global action plan to create active Filipino society and enabling environment
      • Strengthen food laws and food safety laws
    • Department of Environment and Natural Resources (DENR) – Office of Bureau of Fisheries
      • Intensify policies on protecting the marine resources to sustain food security
    • Department of Interior and Local Government (DILG)
      • Strengthen support for nutrition programs
  2. Local Government Units (LGUs)
    • Issue ordinances to promote healthy diet and physical activity, and to build safe infrastructure for an active environment
    • Invest, scale up and sustain local initiatives in implementing physical activities and improving health
  3. Food industry/ private sector
    • Gradually shift to production of healthy food products
    • Implement labeling on food allergens
    • Scale up initiatives on biofortification/ food fortification
    • Intensify promotion of consumption of healthy diets
    • Strengthen food labeling
  4. Community nutrition workers
    • Encourage families to eat healthy diet, increase physical activity, produce food, and reduce food waste throughout the life course

2018 : Home and school gardening

This session aimed to collectively put together recommendations for sustainable home and community food gardens based on the research, evidence, technologies and identified gaps, challenges and opportunities presented in the preceding sessions. Dr. Tuazon facilitated the discussion and a panel of reactors from the LGU (Ms. Sabado), academe (Dr. Belino), NNC (Dr. Dayanghirang) and PAN, Inc. (Dr.

Panlasigui) were invited to provide significant inputs and comments in the set of PAN Recommends.

The identified social, economic, health and nutritional contributions of home and community gardens were as follows:

  1. Improvement of household nutrition/ dietary diversity
  2. Empowering women for better nutrition and healthier children
  3. Income improvement and rural employment
  4. May be associated with lower risk to overweight/ obesity
    • Macronutrient intake defines enterotype
    • Diets with higher fiber are associated with enterotype that may be linked with lower risk of overweight/ obesity
  5. Fosters community mobilization and participation
  6. Collectively put together, PAN (strongly) Recommends the continued promotion of sustainable home, school and community home (food) gardens through the following:
    • Strengthening of functional multi-stakeholder and multi-sectoral platforms, alliances/ partnerships that will increase access of households/ communities to land, capital, market and technical support, including coordinating mechanism from national to local levels
      • Active engagement of LGUs through appropriate legislations and institutionalization
      • Community mobilization for ownership and sustainability
      • Provision of national and regional institutional government support
      • Establishment of an entrepreneural ecosystem throughout the supply value chain
      • Engagement of private sector, CSOs, NGOs and professional organizations
      • Involvement of academe in capacity building, provision of technical assistance and MOE
      • Integration of gardening in primary, secondary and tertiary education
    • Ensure the integration of nutrition education/ Social Behavior Change Communication as an integral/ complementary component
    • Recognition of women as important stakeholders of home gardens
    • Safeguard consumer welfare through adoption of good agricultural practices / food safety measures
    • The adoption and dissemination of component of technologies/ success stories that may be adapted such as:
      • BIG, School+Home Garden Projects, Sigla-Pack, Gawad Kalinga Enchanted Farm, Good Food Grocer – These technologies integrate agriculture, nutrition, livelihood, etc.
      • Best practices: agricultural diversification and intensification in home gardens using climate-smart technologies, post-production with value-adding phase, food banking, among others
    • Capacity building of agricultural extension workers, local leaders, parents and other stakeholders on nutrition-sensitive gardens
    • Establish a built-in participatory monitoring and evaluation system

2007 : Adolescent health

…. that youth groups be supported as agents of change for adolescent health.

This can be achieved by ….

  • Organizing youth groups in  schools and communities;
  • Promoting networking of youth groups in health and nutrition directed activities;

By ….

  • Providing a one-stop resource for organized youth groups seeking advise for activities and inputs;
  • Inviting youth groups to participate as advocates for a healthy lifestyle.

Why are we concerned with adolescent health?

The burden of adolescence:

  • Many Filipino adolescents are either underweight or overweight, causing health and psycho-social problems; most are suffering from iron deficiency anemia, sapping  their energy and productivity.
  • Today’s adolescents face direct threats to their health with the increase in unhealthy practices: poor eating habits, smoking, alcoholism, intake of prohibited drugs;
  • A substantial proportion of adolescents are directly at risk because of unplanned pregnancy. Moreover, early pregnancy is likely to result in low birth weight and malnourished infants.
  • Non-communicable diseases are increasingly prevalent even among the young; NCDs can be addressed by promoting healthy lifestyle starting at a young age.

Thus ….

  • Investment on adolescent health has far-reaching benefits to the youth of today as well as benefits that can be felt when today’s adolescence move to adulthood

Why are we recommending that the youth be an agent of change?

The youth occupies a major segment of the Philippine population, constituting a powerful, largely untapped, social and intellectual force.

  • They are filled with fresh ideas and hopeful dreams, beaming with enthusiasm, and all too eager to voice their aspirations.
  • They are in best position to understand their own problems, think of what is best for them, and decide on what they should do.
  • They are at the doorstep of adulthood, eager to contribute to the welfare of society when called upon. What should we do together to support youth groups as agents of change for adolescent health?

What should we do…?

  • National government agencies concerned with adolescents:  DOH, DepEd, DSWD, etc integrate adolescent health & nutrition into their programs
  • Local governments at provincial, municipal & barangay level
    • Include youth groups into their nutrition action committees 
    • Integrate adolescent health into their programs 

What can we do…?

  • Sangunian Kabataan include strategies for improving adolescent health
  • NGOs, private sector and civil society lead in establishing youth groups in their areas; and facilitate the planning/and implementing health programs for adolescents
  • …together with the PHILIPPINE ASSOCIATION OF NUTRITION lending its technical resources.

What can the PAN do?

  • Lend its technical resource at the central and local level;
  • Organize adolescent health symposia, seminars and workshops
  • Facilitate networking among youth groups.

Let us mobilize the youth as agents of change for adolescent health!

2006 : Nutrition friendly schools

…. that, elementary school aim to be nutrition-friendly schools.

The PAN recommends that five-point criteria, measured by specified indicators, may be used to identify nutrition-friendly schools.  We believe that nutrition-friendly schools are those that:

  1. Implement the systematic and comprehensive integration of Nutrition, Physical Activity, and factors affecting nutrition (infection, food security. Horticulture) into the curriculum of elementary school children;
  2. Establish a comprehensive school-specific plan on health and nutrition for schoolchildren and teachers;
  3. Promote physical activity and physical fitness;
  4. Promote and facilitate access and availability of a healthy and nutritious diet for schoolchildren; and
  5. Promote and facilitate the delivery of essential health interventions critical to nutrition in the schools and in the communities.

The evidence is clear:

  • Hidden hunger, short-term hunger and malnutrition are pervasive problems among school children.
  • Infection leads to and worsens malnutrition.
  • Obesity is a growing problem that must be addressed.
  • Good nutrition improves learning.
  • Health lifestyle and dietary habits can be prevent both undernutrition and obesity.
  • Basic, time-tested and efficacious intervention strategies are at hand.

What can we do together?

To this end, we recommend that the government, through Department of Education as the lead agency, initiate public-private partnership to enact policies that would support the goal of achieving nutrition-friendly schools.  By achieving this goal, we could have a generation of children who are physically, mentally and socially fit through the practice of healthy lifestyle as they grow to adulthood, free from the double burden of under- and over-nutrition.

How can this be achieved and measured?

CriteriaSuggested Activities and MessagesIndicators
Enhanced CurriculumIncorporate key nutritional messages into the curriculum (detailed below)Implementation of TCP Further integration of nutrition and physical activity in the curriculum
Comprehensive Health and Nutrition PlanDivision or school-specific health and nutrition priority settingSchool-specific plan with set priority activities
Regular Physical Activity ProgramIncorporation into the curriculumPromotion of regular physical fitness activitiesInclusion of physical fitness activities as part of the school curriculum Regular physical fitness activities being conducted
Provision of Health Diet Options in SchoolPromotion of healthy food choices in the school canteenPromotion of Food Guide Pyramid for FilipinosAvailability of health nutritious choices in school canteenActivities and IEC materials to promote consumption of fruits and vegetables
Essential Health InterventionsTargeted Food Supplementation ProgramsIron Supplementation Deworming programs for intestinal worms and schistosomiasisAdvocacy programs promoting the use of insecticide-treated nets in malaria-endemic areasTreatment of MDR-TB+ (multi-drug resistant tuberculosis) teachersInitiate supplementary feeding programsInitiate school-based iron supplementation programsImplementation of school-based control programs for endemic parasitic diseaseIdentification and completed treatment of MDR-TB + teachers 

Among the key messages to be integrated into the curriculum are:

  • Attain and maintain proper weight and height
  • Do not miss breakfast; it is the most important meal of the day
  • Eat fruit and vegetables every day
  • Eat foods rich in calcium to build strong bones
  • Include “grow” foods in the daily diet
  • Fatty and empty calorie foods should be taken sparingly
  • Prepare and keep foods safely.
  • Observe healthy options when eating outside the home.
  • Use the Food Guide Pyramid for Filipinos as a simple guide to proper nutrition

Together with

  • Regular physical activities in and outside the classroom.

2005 : LGUs as prime movers

LGUs as prime movers for improved nutrition

An appeal to all Barangay Chairmen, City and Municipal Mayors, Provincial Governors, Congressmen and the National Nutrition Council to participate in the urgent need for immediate action for nutritional improvement.

PAN call upon official and national agencies to:

  • Intensify implementation of PPAN impact programs at the barangay level especially in identified provinces, municipalities and cities;
  • Focus on priority barangay and families; and, 
  • Establish and sustain the barangay plan and program of action for nutrition through a barangay- and family- driven approach. 

The local government units at the provincial and municipal levels and in particular, at the barangay, are the key to effective strategy to address the needed urgent call for action in nutritional improvement.

LGUs have the authority and responsibility to plan, implement, monitor and evaluate, and most importantly, allocate needed resources for local nutrition programs through a barangay and family- driven approach.

LGUs have the power and accountability as well, to bring about improved nutrition for its constituents and their families by integrating the barangay plan and program of action for nutrition into the local development plan in all levels.

What LGUs must do

  1. Focused targeting or giving priority and immediate attention to:
  • Families with underweight preschool children and/or pregnant and lactating women in target barangay
  • All cities and municipalities with the highest prevalence of underweight preschool children, and in these cities and municipalities, all barangays with the highest prevalence of underweight school children, as primary targets.
  1. Convergence of basic nutrition, health and related services to targeted families
  1. Planning, implementing, monitoring and, mobilizing and allocating resources to nutrition impact programs including:
  • Growth Monitoring
  • Nutrition Information and Education
  • Community and Home Food Production and Livelihood
  • Micronutrient Supplementation – vitamin A, iron, iodine
  • Promotion of Breastfeeding and Adequate Complementary Feeding
  • Promotion and Consumption of Fortified Foods
  1. Capacity development of nutrition workers, families and barangays by:
  • Revitalizing nutrition committees in all levels particularly at the barangay level through intensive advocacy and training led by the National Nutrition Council and its Regional Offices
  • Strengthening barangay program planning and management capacity of barangay nutrition workers.
  • Enabling families to plan, implement and monitor a nutrition improvement program at home and in their barangays.

Nutrition Situation in the Philippines

Over the last three decades of nutrition program implementation, nutritional improvement has been slow among Filipino households particularly infants and young children, pregnant and lactating women.

There is a high prevalence of undernutrition among children 0-5 years.  Provinces have been identified where prevalence of protein-energy malnutrition is high.

In 2003:

  • 57 out of 100 households are still below 100% of their dietary energy requirement.
  • 28 out of 100 children aged 0-5 years are underweight due to current malnutrition.
  • 30 out of 100 children aged 0-5 years are underheight due to chronic malnutrition.

About five to six out of 100 children aged 0-5 years are wasted in body due to severe malnutrition.

From 1988-90 to 2001:

  • A low 0.35 percent annual average reduction in the prevalence of underweight preschoolers

Between 1998 and 2003

  • A low 0.88 percent reduction in the prevalence of underweight preschoolers per year compared with the target of four percent.
  • The 2003 survey show increasing prevalence of diet related diseases, such as obesity, cardiovascular diseases and diabetes across socio-economic groups. 

Achieving Good Nutrition:  A Critical Development Issue

People are the country’s key human resource capital.  Their quality determines to an immeasurable extent the state of national development.

Nutrition tells heavily on the mental performance, physical endurance and socio-psychological adaptability of men, women, and children.

Global examples show the very close relation between good nutrition and national economic and social development.  Poor nutrition holds back economic and social progress.

Achieving good nutrition, adequate food in quality and quantity, for a continually growing population such as the Philippines is a huge challenge.

Good Nutrition Begins in the Home and in the Barangay

A barangay plan and program of action for nutrition emanating from the Philippine Plan of Action for Nutrition (PPAN) has been successfully demonstrated by the Nutrition Center of the Philippines.

In 1999-2000, 43 selected barangays in 17 municipalities in Luzon and the Visayas implemented the barangay plan and program of action for nutrition resulting in:

  • Reduced number of underweight preschool children
  • Increased demand for fortified foods and iodized salt at the household level
  • Improved coverage of vitamin A and iron supplementation.
  • Introduced Pabasa sa Nutrisyon, and interactive nutrition education strategy
  • Improved nutrition committee organization and management of the nutrition program.

Micronutrient malnutrition trends to reside mostly in families with children suffering from protein-energy malnutrition.  Reaching families with underweight preschool children will most likely target children with micronutrient malnutrition as well. 

PAN Recommends . . . . . . . . .

  • A statement urging immediate action for a nutrition and related policy, strategy, program or measure to hasten nutritional improvement particularly among the children, women and other vulnerable groups.
  • Based on research and scientific investigations, international commitments and national priorities.
  • PAN Recommend No. 1, 2003 urged the Department of Health (DOH) to provide weekly iron supplementation for 1-5 year old children.
  • PAN Recommend No. 2, 2004 Judicious application of biotechnology for nutritional and dietary improvement. 

2004 : Biotechnology

The judicious use of modern biotechnology in the search for foods of improved nutritional quality in terms of their nutritional content, nutrient bioavailability, functional properties and acceptability, and in enhancing the efficiency of food production for the growing population, for as long as utmost regard is accorded to their safety to health and environment.

More particularly, PAN urges the continuing development of: 

  • Varieties of rice and other cereals with high iron and zinc content of acceptable bioavailability; 
  • Sweet potato and other tubers with increased beta-carotene and iron content; 
  • Tomatoes with higher beta-carotene and lycopene content;
  • Green leafy vegetables with high iodine content even when grown in iodine-poor soils;
  • Cereals, beans and legumes with improved amino acid profile;
  • Crops of lower content of absorption inhibitors and other anti-nutritional factors such as phytates, tannin, trypsin inhibitors, etc. 
  • Vegetables, fruits and other plant foods with enhanced phytochemicals of potential benefit to health; 
  • New food products of high nutritional value, functional properties and acceptable organoleptic quality.

Towards this end, PAN strongly supports increased human resources and financial support for research and development in modern biotechnology, particularly towards the development of foods of improved nutritional quality.

Furthermore, the PAN Recommends  that government exert every effort and means to ensure safety of foods derived from modern biotechnology, the provision of adequate regulatory and monitoring system of such foods, and the development of a comprehensive program to educate the public on the benefits of modern biotechnology and on what the government as well as the private sector are doing to ensure safety to health and environment. 

On its part, the PAN and all its members throughout the country should contribute to public understanding of the benefits of modern biotechnology together with the measures being implemented in ensuring its safety to health and environment.

2003 : Iron supplementation

Weekly iron supplementation for 1 to 5 year-old children, an economical and effective intervention for anemia prevention.

Philippines, the overall prevalence of iron deficiency anemia (IDA) is 30.6%, with a prevalence of 29.6% among children aged 1-5 years. Iron supplementation and food fortification have been identified as impact programs to address IDA. However, the existing guidelines on iron supplementation contained in the Department of Health Administrative Order 3-A s. 2000 does not include universal iron supplementation of 1-5 year-old children although routine supplementation of 2-5 year old children daily for about 2 months is indicated. Food fortification, on the other hand, is still not fully implemented. In addition, when hookworm infection is one of the underlying causes of IDA, both iron supplementation and food fortification will be less effective. Thus, the strategy for IDA in hookworm-endemic areas should include addressing hookworm infection concurrently.

In 2000, the Early Childhood Development Project of the Department of Social Welfare and Development (ECD-DSWD) called for the conduct of the study on the “Cost-effectiveness of deworming and weekly iron supplementation in the reduction of anemia among preschoolers: a field test”. The Nutrition Center of the Philippines (NCP) responded to this call and was subsequently selected to conduct the study. The project was In the conducted from September 2001 to May 2003. The study showed that weekly iron  supplementation for 4 months, with or without deworming, was effective in improving the iron status of 1-5 year-old children. Based on this finding, the Philippine Association of Nutrition recommends weekly iron supplementation for 1-5 year-old children. A summary of the study, taken from the final report by the NCP, is presented below.

Title:   Cost-effectiveness of deworming and weekly iron supplementation in the reduction of anemia among preschoolers: a field test 

Objective:   This study aimed to determine the cost-effectiveness of the combined strategy of deworming and weekly iron supplementation (DIS) versus weekly iron supplementation alone (IS) in reducing the prevalence of anemia among preschoolers. 

Methods:   This randomized field trial was conducted among 2,082 preschoolers (aged 12-71 months) in 

8 rural villages in the municipalities of Barili and Dalaguete in Cebu Province. After the baseline data collection, the children were randomized to DIS group (experimental) or the IS group (control). The children in the DIS group were dewormed before the iron supplements were given. Children aged 1-2 years old were given 200 mg of albendazole while those aged 3-5 years old were given 400 mg of albendazole. All the children were given iron supplements weekly for 4 months as follows: 1.2 ml of ferrous sulfate drops for age 1-2 years; 7.5 ml of ferrous sulfate syrup for age 3-4 years; and, 12.0 ml of ferrous sulfate syrup for age 5 years.

Results:   At baseline, the characteristics of the children in the DIS and IS groups did not differ significantly except for Trichuris infection and mixed infection. After the intervention, the hemoglobin, zinc protoporphyrin and serum ferritin levels increased in both groups, with no significant differences observed between groups. Overall, the prevalence of anemia was reduced by 43%, iron deficiency (using serum ferritin) by 65%, iron deficiency (using zinc protoporphyrin) by 50%, IDA (using hemoglobin and serum ferritin) by 73% and IDA (using hemoglobin and zinc protoporphyrin) by 70%. The prevalence of infection for all helminths was similar to baseline levels after 4 months, although the prevalence and intensity of infection was significantly lower in the DIS group. The prevalence of stunting decreased while that of underweight and wasting increased slightly but not significantly. The average cost of administering DIS to a child is PHP 77.57 and PHP 45.52 for IS. The cost of drugs comprised 68.2% of total costs for DIS and 62.5% for IS. Significant additional mild anemia cases prevented were observed for IS while for DIS, significant reductions in hookworm and Ascaris infections were noted. DIS prevented less number of mild anemia cases and is more costly than IS. DIS was effective in reducing hookworm, Ascaris and Trichuris infection. As expected, IS did not have any considerable effect on geohelminthic infections. 

Conclusions: The combined intervention of DIS did not significantly impact on IDA among preschoolers possibly due to the low prevalence of IDA and hookworm infection in this study population. 

IS alone for 4 months was effective in reducing anemia. IS alone has a potential of cost savings compared to the combined strategy in preventing cases of mild anemia, because of more cases of mild anemia prevented at a lower cost. 

Deworming alone is also cheaper than the combined strategy in preventing geohelminthic infections in this population of preschoolers.

Recommendations and Policy Implications: As weekly iron supplementation for 4 months was proven effective in reducing anemia, it is recommended that this be implemented as a national program of the government. However, the duration of the iron supplementation must be for at least 1 year to prevent iron deficiency, improve iron stores and consequently prevent anemia. If the resources of the government are limited, iron supplementation can be targeted only among preschoolers who are anemic. If assessment of anemia is not feasible due to budget constraints, the child’s nutritional status can be used as surrogate indicator for anemia. As this study has shown, it is more likely that underweight, stunted or wasted children are anemic.

It is recommended that weekly iron supplementation for 1-5 year-old children should be considered as a policy. Although this study did not assess the effect of daily iron supplementation, studies conducted elsewhere has proven that daily and weekly iron supplementation produce the same effect on iron status.

While iron supplementation in itself is highly effective in reducing anemia, food-based strategies as food fortification and dietary diversification through nutrition education are still more recommended as long-term interventions to address the malnutrition problem in the country. The evident inadequate energy and nutrient intake of children in this population is expected to be found in other poor communities in the country. 

An effectiveness trial in other communities with higher prevalence and intensity of geohelminthiases and/or other areas with multiple parasitic infections (for example, soil-transmitted helminths plus malaria or schistosomiasis) should be conducted. An efficacy trial on a subset of preschool children diagnosed with anemia and helminthiases may also be done. It is important that the frequency, timing and duration of deworming children be studied and instituted as a national program.

Authors:

Florentino S. Solon, M.D., M.P.H.; Liberty Fajutrao, M.D., M.P.H.; Juan Antonio A. Solon, M.D., M.Sc.; Jesus N. Sarol, Jr., Ph.D.; Lorena S. Wambangco-Tengco, R.N.D.; and, Liza S. Fermin, M.Sc., R.N.D.

Funder: Early Childhood Development Project-Department of Social Welfare and Development

Studies on the efficacy of weekly iron supplementation

1. Beaton GH, McCabe GP (1999) Efficacy of intermittent iron supplementation in the control of iron deficiency anemia in developing countries. An analysis of experience: Final report to the Micronutrient Initiative. Canada: Micronutrient Initiative.

2. Monteiro CA, Szarfarc SC, Brunken GS, Gross R, Conde WL (2001) Long-term preventive mass prescription of weekly doses of iron sulfate may be highly effective to reduce endemic child anemia. Food Nutr Bull 1:53-61. 

3. Liu X-N, Kang J, Zhao L, Viteri FE (1995) Intermittent iron supplementation in Chinese children is efficient and safe. Food Nutr Bull 16:139-46.

4. Palupi L, Schultink W, Achadi E, Gross R (1997) Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation Am J Clin Nutr 65:1057-61. 

5. Schultink W, Gross R, Gliwitzki M, Karyadi D, Matulessi P (1995) Effect of daily vs. twice weekly iron supplementation in Indonesian preschool children with low iron status. Am J Clin Nutr 61:111-15.

6. Soemantri AG, Pollitt E, Kim I (1985) Iron deficiency anemia and educational achievement Am J Clin Nutr 42:1221-8.

7. Thu BD, Schultink W, Dillon D, Gross R, Leswara ND, Kha HH (1999) Effect of daily and weekly micronutrient supplementation on micronutrient deficiencies and growth in young Vietnamese children. Am J Clin Nutr 69:80-6.