High-Energy, Nutrient-Dense Emergency Relief Food Product (2002) / Chapter Skim
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2 Nutrient Content and Special Considerations
2 Nutrient Content and Special Considerations
Pages 17-96
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From page 17... ...
This report assumes that emergency relief agencies will provide potable water supplies as a top priority. This assumption is based on assurances provided by the United States Agency for International Development.
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From page 18... ...
If a nutritionally complete food ration is divided among two or more different foods, or if foods are targeted to specific individuals such as children or pregnant women, then certain foods are more likely to be exchanged. This type of exchange can deprive the population of a portion of the profile of nutrients provided by the emergency food ration and increase the risk of malnutrition.
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From page 19... ...
. Individuals in the target population are of smaller stature and body mass than similarly aged groups in the North American population (this is the same premise used in an earlier report from the Food and Nutrition Board, Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations [IOM, 1995bl)
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From page 20... ...
Furthermore, because the EFP is a single food meant to support a heterogeneous population, nutrient content must be determined on an energy density basis. Estimating Energy Requirements of the Population A potential basis for calculating the energy requirements for a refugee population is provided in the Institute of Medicine report, Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations (IOM, 1995b)
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From page 21... ...
If energy intake is less than expected, the nutrient density will be too low to meet the micronutrient requirements. Second, the life stage and gender groups do not correspond to the current groups used in the Dietary Reference Intake (DRI)
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From page 22... ...
(representing the 1- through 3-year-old group) were calculated according to the formula of Butte and coworkers (2000~: Energy requirements (MJ/d)
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From page 23... ...
Estimating Energy Requirements for Pregnancy and Lactation. Although adequate nutrition during pregnancy and lactation are of concern in refugee populations, the EFP is designed to meet energy requirements based on the assumption that pregnant or lactating women as well as others with higher energy needs (i.e., due to physical activity or rapid growth)
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From page 24... ...
CHARACTERISTICS OF THE EMERGENCY RELIEF FOOD PRODUCT Given the estimated energy requirements (Table 2-3) , the proposed energy density for the EFP is 4 to 5 kcal (17 to 21 kJ)
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From page 25... ...
and Canadian populations for which it is recommended. For some required nutrients, it was not possible to establish an intake at which half of a life stage and gender group would be adequately nourished, while the other half would demonstrate signs of inadequacy.
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From page 26... ...
. Determination of a Minimal Nutrient Density At the population level, there are a number of individual minimal nutrient densities for each nutrient.
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From page 27... ...
for other groups in the population. Additional assumptions used in setting the minimal nutrient density include: The relief food is the only food consumed.
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From page 28... ...
28 EMERGENCY RELIEF FOOD PRODUCT TABLE 2-4 Unadjusted Baseline Minimal Nutrient Density Values Using Recommended Intakes Baseline per Basis for Recommended Nutrient Limiting Group 1,000 koala Intake Fat N/A 39-50 g Providing an energy density of 4-5 kcal/g Proteinb 51+ yr, men 34 g Balance studies Carbohydrate N/A 100-125 g Seven to 12Ofthe23-35gof total carbohydrate should be from sugars for adequate palatability SodiumC 2-5 yr, children 1.3 g Maximum level of intake PotassiumC 2-5 yr, children 1.7 g Level estimated to meet minimum requirements ChlorideC 2-5 yr, children 2.0 g Level estimated to be equimolar to sodium Calcium 9-13 yr, children 768 mg Based on maximal calcium retention Phosphorus 9-13 yr, children 740 mg Based on factorial approach Magnesium 14-18 yr, boys 190 mg Amount needed to maintain magnesium balance Chromium 13.5 fig Based on amounts in well balanced diets/l,OOO kcal Copper 51+ yr, women 470 fig Biochemical indicators of copper status Iodine 1-3 yr, children 105 fig Balance studies Irons 19-50 yr, women 9 mg Based on iron requirement (estimated basal losses, increase in hemoglobin mass, increase in nonstorage iron, increase in storage iron) plus assumed iron absorption Manganese 1-3 yr, children 1.4 mg Average intake in healthy population Selenium 14-18 yr, girls 28 fig Maximizing plasma glutathione peroxidase activity Zinc 14-18 yr, boys 5.2 mg Level needed to match exogenous losses Vitamin A 14-18 yr, boys 420 fig RAE Level needed to maintain adequate stores Vitamin D 51-70 yr, women 5.2 fig Maintain serum 25~0H)
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From page 29... ...
and estimated energy expenditure from Table 2-3. c Values based on estimated requirements, desirable intakes, or maximal intakes (NRC,1989~.
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From page 30... ...
The nutrient content of the EFP is based on this assumption. NUTRIENTS INCLUDED IN THE EMERGENCY RELIEF FOOD PRODUCT SPECIFICATIONS For each nutrient or nutrient group that follows, the assumptions, including the minimal nutrient density, the limiting groups, and how the RDA, AI, or other values were utilized are discussed.
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From page 31... ...
Furthermore, infants and young children have comparatively high energy requirements per kilogram of body weight (Koletzko, 1999) and have limited capacities to consume food.
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From page 32... ...
The greatest concern in developing the EFP regarding type of fat is to include fats/oils that will provide the greatest stability in terms of storage of the finished product, without the inclusion of fat of animal origin. For long-term health, other aspects of dietary fat, such as the proportion of essential fatty acids or the inclusion of long chain polyunsaturated fatty acids (LC-PUFAs)
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From page 33... ...
Protein and Amino Acid Requirements Protein is essential for all physiological functions. Although two structural proteins, collagen and elastin, comprise about half of the proteins in the adult body, the protein associated with muscle, visceral organs, and blood is the most dynamic and most affected by poor nutritional status (Crim and Munro, 1994~.
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From page 34... ...
The EFP target populations may have reduced energy intakes and low protein intakes, resulting in negative energy and nitrogen balances (Fjeld et al., 1989) , reduced growth and/or lactation volume, and loss of body weight and muscle mass (Golden, 1994, Golden et al., 1977, Rice et al., 2000, Young and Jaspars, 1995~.
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From page 35... ...
Thus, the amount of protein recommended for the EFP is a compromise. Although the pattern of amino acids will meet the essential amino acid needs of the young child, the total protein may be limiting.
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From page 36... ...
have proven to be most acceptable for a wide spectrum of cultures during various emergencies where relief food products have been used, although compressed food bars such as the Norwegian BP-5 were also acceptable (Grobler-Tanner, 2001~. The only flavor found to be acceptable to widely diverse populations was sweetness (Drewnowski, 1997, Young et al., 1985~.
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From page 37... ...
Therefore, the emergency food product should provide glucose and sodium in quantities that will optimize intestinal absorption when consumed with ample water, yet not be so high as to be malabsorbed (Santosham et al., 1987~. Ability to absorb glucose in the small intestine and transport it with sodium remains intact during acute diarrhea (Hirschhorn, 1980~.
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From page 38... ...
would receive approximately 14.5 g/day or ~5 g/meal episode. This amount of lactose would allow milk solids to provide about one-third of the specified content of protein (34 g/1,000 kcal)
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From page 39... ...
to meet the needs of all age groups in the population, and to facilitate ease of transport and distribution. Consequently, although the EFP will contain some fiber because of its grain and legume constituents, the level of fiber should be limited to provide maximal energy density.
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From page 40... ...
. Because of concerns over possible water shortages, the EFP is designed to contribute minimally to osmotic load, while providing essential nutrients and energy to meet the needs of most individuals in emergency situations for a short period of time.
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From page 41... ...
However, a ration that contained 30 percent protein approximately doubled the obligatory urine volume when the caloric content increased from 500 to 2,000 kcal (Calloway and Spector, 1954~. Based on these calculations and considering the renal dynamics discussed in the previous paragraph, it appears that the 2,000 kcal diet was optimal in terms of osmotic load when it contained 7.5 percent protein (approximately 40 g of protein)
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From page 42... ...
........... l 500 1000 1500 2000 Ration Kcal Content Ration Nitrogen as% of Kcal ~0 ·7.5 let 15 ~130 FIGURE 2-2 Influence of caloric and protein content of emergency rations on urine volume.
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From page 43... ...
Western dietary guidelines suggest sodium intakes of no more than 2.4 g/day (NRC, 1989~. Given that the EFP may be used during periods of sustained physical activity or in high ambient temperatures, the EFP should contain a minimum of 1.3 g/1,000 kcal, which is equivalent to 300 mg/EFP bar.
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From page 44... ...
Chloride is the principal inorganic anion in extracellular fluid, and is essential for maintaining fluid and electrolyte balance (NRC, 1989~. Although chloride deficiency is rarely observed, its loss mirrors sodium loss with the exception of that due to vomiting, so it is also important to ensure adequate intakes of chloride for refugee populations, particularly when consuming a single-source food product.
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From page 45... ...
, however, the individual minimal nutrient density for magnesium (Table 2-4) , based on adolescent boys, is actually slightly greater than that derived for pregnancy assuming an additional 200-kcal intake.
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From page 46... ...
Although the EFP may provide the only source of nutrients for a very short period of time, the addition of calcium is essential to provide as nutritionally complete a diet as possible. The minimal nutrient density for calcium is 768 mg/1,000 kcal, which is derived from the AI for children ages 9 through 13 years of 1,300 mg/day (IOM, 1997a)
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From page 47... ...
. The phosphorus content of the EFP is set based on the minimal nutrient density of 740 mg/1,000 kcal, which is derived from the RDA of 1,250 mg for boys and girls 9 to 13 years of age based on their estimated energy needs (Table 2-3~.
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From page 48... ...
This value is higher than the 1.04 ,ug/1,000 kcal recommended by the Sphere Project as the desirable nutrient density for refugee diets (Sphere Project, 2001~. While there is a lack of evidence of deficiency or toxicity and difficulties in analyzing chromium levels in foods, it is important that a single-source food
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From page 49... ...
Factorial analysis as well as indicators such as plasma copper concentrations, serum cerul opt asmin concentration, erythro cyte sup eroxi de di smutase activity, and platelet copper concentration, are the basis for determining recommended intakes for copper (IOM, 2001~. The minimal nutrient density value for copper was calculated (see Table 24)
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From page 50... ...
The minimal nutrient density value for iodine is based on the subgroup of children 1 to 3 years of age and is 105 ,ug/1,000 kcal. Assuming that iodized table salt will be used in the EFP and provide at least 50 percent of the specified sodium content, the EFP will provide more than adequate levels of iodine to prevent IDD.
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From page 51... ...
, which results in a maximum content of 230,ug/1,000 kcal (specified content + 115 percent)
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From page 52... ...
oral iron supplementation in malarious regions may carry up to a 50 percent increased risk of clinical malaria if given in therapeutic doses at times of malaria transmission, and (3) oral iron supplementation in therapeutic doses to older immunized children and adults in malarious regions may also carry up to a 50 percent increased risk of other infectious disease.
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From page 53... ...
Using the recommended intake for adult women during their reproductive years (18 mg/day) , the minimal nutrient density (Table 2-4)
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From page 54... ...
The minimal nutrient density value is based on the AI for children ages 1 to 3 years (1.2 mg/day) and is 1.4 mg of manganese/1,000 kcal (see Table 2-4~.
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From page 55... ...
report are considerably lower. Based on the limiting minimal nutrient density (see Table 2-4)
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From page 56... ...
Evidence for the existence of inadequate zinc intakes has come largely from zinc supplementation trials (Hotz and Brown, 2001~. Consumption of plant-based diets, especially those having a high content of physic acid, is considered a major factor contributing to zinc deficiency (Gibson et al., 1997, Hambidge et al., 1998~.
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From page 57... ...
Although observational studies have produced strong associations between poor maternal zinc status and various indicators of poor pregnancy outcome, supplementation trials have not produced strong or consistent results in support of dietary zinc supplementation (Caulfield et al., 1998~. The minimal nutrient density value for zinc is 5.2 mg/1,000 kcal, based on boys 14 to 18 years of age (Table 2-4~.
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From page 58... ...
Vitamin A deficiency is also associated with increased risk for infectious diseases (Underwood and Arthur, 1996~. Conversely, infection may contribute to development of vitamin A deficiency as a result of decreased food intake as well as decreased absorption, increased utilization, and possibly increased excretion (Nalubola and Nestel, 1999~.
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From page 59... ...
showed a significantly increased risk for malformation of cranial structures originating from neural crest cells in the infants of women who consumed more than 4,500 ,ug/day of preformed vitamin A from food and supplements during the first trimester of pregnancy. The ULs for women 14 through 18 and 19 through 50 years of age are 2,800 and 3,000 ,ug/day of preformed vitamin A, respectively (IOM, 2001~.
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From page 60... ...
, 1,850 ,ug, and Unimix, 1,635 ,ug (Beaton, 1995~. The minimal nutrient density value calculated for vitamin A and based on the RDA (900 ,ug RAE/day tIOM, 20013)
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From page 61... ...
. The maximum content is 1,000 ,ug of preformed vitamin A/1,000 kc al (specified content + 100 percent)
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From page 62... ...
, based on the needs for those over 50 years of age, those over 70 years of age were thought to be too small a group within refugee populations to be used as the basis for the vitamin D content of the EFP. Little information is found concerning the bioavailability of vitamin D in malnourished individuals, so no adjustments were made in the recommendation.
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From page 63... ...
Assuming that a smaller percentage of the dietary vitamin E in the EFP will be absorbed due to possible malabsorption, and recognizing that girls 14 to 18 years of age have the greatest nutrient density need, 20 percent is added to the minimal nutrient density value estimated for this age group (Table 2-4) of 7.8 mg of d-oc-tocopherol/1,000 kcal, to provide the amount for the EFP of 9.4 mg/1,000 kcal (2.2 mg/EFP bar)
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From page 64... ...
Vitamin C also is known to enhance the absorption of nonheme iron, which is especially important in populations where iron deficiency is a major nutritional problem, particularly among women and children (IOM, 2000~. Outbreaks of scurvy have been reported in refugee populations during the past three decades, often in populations entirely dependent on emergency food rations found to provide less than 2 mg/day of vitamin C (IOM, 1997b)
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From page 65... ...
It is also possible that storage in higher heat conditions and possible oxidation may destroy some of the vitamin C present in the EFP. Therefore, it is recommended that the vitamin C content of the EFP be 2.5 times the baseline minimal nutrient density, or 100 mg/1,000 kcal (23.3 mg/EFP bar)
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From page 66... ...
, the minimal nutrient density necessary to meet recommended intakes is 0.6 mg/1,000 kcal (Table 2-4~. The thiamin content of the EFP should be the amount that conservatively meets nutritional requirements under adverse conditions.
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From page 67... ...
Diets of this type are common in developing countries, and are frequently found in refugee situations. The baseline minimal nutrient density value calculated for riboflavin and based on the RDA (1.3 mg/day tIOM, 19983)
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From page 68... ...
(Golden 2001~. The maximum content is 1.4 mg/1,000 kc al (specified content + 20 percent)
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From page 69... ...
Because niacin deficiency is likely to be highly prevalent in many refugee populations, the minimal nutrient density is increased by 50 percent to 11.2 mg NE/1,000 kcal (2.6 mg NE/EFP bar)
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From page 70... ...
The maximum content is 12.4 mg/1,000 kcal (specified content + 10 percent)
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From page 71... ...
, a minimal nutrient density value was calculated (see Table 2-4~. Under the assumptions of the method, the value required to prevent inadequate intake in almost all individuals in this life stage and gender group would be 0.8 mg of vitamin B6/1,000 kcal.
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From page 72... ...
The minimal nutrient density value is 207 ,ug of dietary folate equivalents (DFE) /1,000 kcal (IOM, 1998~.
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From page 73... ...
However, when low stores are combined with low intake or malabsorption, deficiency occurs more rapidly. In rural Mexico, where consumption of animal products is limited, increased incidence of low levels of vitamin BE in human milk and plasma and decreased holotranscobalamin II have been noted (Allen et al., 1995, Black et al., 1994~.
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From page 74... ...
Little information is available on consumption of high levels of vitamin By from either food or supplements and associated adverse effects, therefore data were inadequate to establish a UL for this vitamin (IOM, 1998~. The minimal nutrient density value for vitamin By is based on the RDA for girls 14 to 18 years of age (2.4 ,ug/day [IOM, 19983)
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From page 75... ...
The minimal nutrient density value for pantothenic acid is based on the AI for girls 14 to 18 years of age (5 mg/day [IOM, 19981) and is 2.6 mg/1,000 kc al (see Table 2-4~.
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From page 76... ...
As with other water-soluble vitamins, to cover the potential for reduced absorption due to gastrointestinal problems, the minimal nutrient density value is increased by 50 percent. Therefore, the minimum content is 366 mg/1,000 kcal (85 mg/EFP bar)
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From page 77... ...
In addition, levels of nutrients were frequently increased above the minimal nutrient densities to compensate for poor bioavailability, processing and storage losses, and reduced absorption due to mild diarrhea, infections, or parasites. However, as was described in the beginning of this chapter, the nutritional content is not the highest priority in the design of the ration in terms of importance, it comes after safety, palatability, ease of delivery, and ease of use.
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From page 78... ...
2000. Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6-36 month old Togolese children.
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From page 79... ...
1994. Use of nonhuman milks in the dietary management of young children with acute diarrhea: A meta-analysis of clinical trials.
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From page 80... ...
2000. Energy requirements derived from total energy expenditure and energy deposition during the first 2 y of life.
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From page 81... ...
1995. Milk composition in women from five different regions of China: The great diversity of milk fatty acids.
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From page 82... ...
1998. Decreased polyunsaturated fatty acids in sickle cell anaemia.
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From page 83... ...
1989. A new model for predicting energy requirements of children during catch-up growth developed using doubly labeled water.
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From page 84... ...
2001. A Study of Emergency Relief Foods for Refugees and Displaced Persons.
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From page 85... ...
1981. Essential fatty acid deficiency in malnourished children.
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From page 86... ...
1995b. Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations.
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From page 87... ...
1992. The fatty acid composition of human milk in Europe and Africa.
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From page 88... ...
1995. Polyunsaturated fatty acids in erythrocyte and plasma lipids of children with severe protein-energy malnutrition.
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From page 89... ...
1990. Evidence for a pathogenic role of omega 6 polyunsaturated fatty acid in the cutaneous manifestations of biotin deficiency.
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From page 90... ...
1996. Energy requirements of pregnant and lactating women.
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From page 91... ...
1992. Effect of dietary energy density on total ad-libitum energy consumption by recovering malnourished children.
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From page 92... ...
1997. Effects of malnutrition on the erythrocyte fatty acid composition and plasma vitamin E levels of Pakistani children.
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From page 93... ...
1996. Energy requirements and dietary energy recommendations for children and adolescents 1 to 18 years old.
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From page 94... ...
2000. Relationship between vitamin E requirement and polyunsaturated fatty acid intake in man: A review.
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From page 95... ...
1999. Composition of long chain polyunsaturated fatty acids in human milk and growth of young infants in rural areas of northern China.
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From page 96... ...
2000. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials.
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