Complementary feeding diets in low‐ and middle‐income countries are generally inadequate to meet requirements for growth and development. Food‐based interventions may prevent nutrient inadequacies ...provided that they do not displace other nutrient‐rich foods. We conducted a randomized controlled trial in rural Malawi in which 660 children aged 6 to 9 months were provided an egg a day for 6 months or assigned to a control group. Dietary intake of complementary foods and drinks was assessed at baseline, 3‐month midline and 6‐month endline visits using a tablet‐based multipass 24‐h recall. Up to two repeat recalls were collected at each time point in a subsample of 100 children per treatment group. At midline and endline, usual energy intake from eggs was about 30 kcal/day higher in the egg group compared with controls (p < 0.0001). Compared with controls, children in the egg group were over nine times more likely to consume eggs at midline and endline. There was a comparable, but nonsignificant, greater total usual energy intake from complementary foods of 30 kcal/day at midline (p = 0.128) and 36 kcal/day at endline (p = 0.087). There also was a displacement of 7 kcal/day in legumes and nuts in children at endline (p = 0.059). At midline and endline, more than 80% of children in the egg group consumed a minimally diverse diet compared with 53% at midline and 60% at endline in the control group. This study illustrates that mothers in the egg group fed eggs to young children on a regular basis without substantial displacement of other complementary foods.
Background:
Detailed dietary intake data in low-income populations are needed for research and program evaluation. However, collection of such data by paper-based 24-hour recall imposes substantial ...demands for staff time and expertise, training, materials, and data entry.
Objective:
To describe our development and use of a tablet-based 24-hour recall tool for conducting dietary intake surveys in remote settings.
Methods:
We designed a 24-hour recall tool using Open Data Kit software on an Android tablet platform. The tool contains a list of local foods, questions on portion size, cooking method, ingredients, and food source and prompts to guide interviewers. We used this tool to interview caregivers on dietary intakes of children participating in an efficacy trial of provitamin A-biofortified maize conducted in Mkushi, a rural district in central Zambia. Participants were children aged 4 to 8 years not yet enrolled in school (n = 938). Dietary intake data were converted to nutrient intakes using local food composition and recipe tables.
Results:
We developed a tablet-based 24-hour recall tool and used it to collect dietary data among 928 children. The majority of foods consumed were maize, leafy vegetable, or small fish dishes. Median daily energy intake was 6416 kJ (1469 kcal).
Conclusions:
Food and nutrient intakes assessed using the tablet-based tool were consistent with those reported in prior research. The tool was easily used by interviewers without prior nutrition training or computing experience. Challenges remain to improve programming, but the tool is an innovation that enables efficient collection of 24-hour recall data in remote settings.
Young children with diets lacking diversity with low consumption of animal source foods are at risk of iron deficiency anemia (IDA).
Our objectives were to determine the impact of supplementing diets ...with 1 egg/d on 1) plasma ferritin, soluble transferrin receptor (sTfR), body iron index (BII), and hemoglobin concentrations and 2) the prevalence of iron deficiency (ID), anemia, and IDA.
Malawian 6–9-mo-old infants in the Mazira trial (clinicaltrials.gov; NCT03385252) were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329). In this secondary analysis, hemoglobin, plasma ferritin, sTfR, C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) were measured at enrollment and 6-mo follow-up. Iron biomarkers were corrected for inflammation. Ferritin, sTfR, BII, and hemoglobin were compared between groups using linear regression. Prevalence ratios (PRs) for anemia (hemoglobin <11 g/dL) and ID (ferritin <12 µg/L, sTfR >8.3 mg/L, or BII <0 mg/kg) between groups were compared using log binomial or modified Poisson regression.
A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the total prevalence of anemia was 61% and did not differ between groups. At 6-mo follow-up, groups did not differ in geometric mean concentration of hemoglobin mean (95% CI); Egg: 10.9 (10.7, 11.1) g/dL; Control: 11.1 (10.9, 11.2) g/dL and inflammation-adjusted ferritin Egg: 6.52 (5.98, 7.10) µg/L; Control: 6.82 (6.27, 7.42) µg/L, sTfR Egg: 11.34 (10.92, 11.78) mg/L; Control: 11.46 (11.04, 11.89) mg/L or BII Egg: 0.07 (0.06, 0.09) mg/kg; Control: 0.07 (0.05, 0.08) mg/kg. There were also no group differences in anemia Egg: 46%; Control 40%; PR: 1.15 (95% CI: 0.96, 1.38), ID PR: 0.99 (0.94, 1.05), or IDA PR: 1.12 (0.92, 1.36).
Providing eggs daily for 6 mo did not affect iron status or anemia prevalence in this context. Other interventions are needed to address the high prevalence of ID and anemia among young Malawian children. This trial is registered at http://www.clinicaltrials.gov as NCT03385252.
The egg intervention did not impact children's iron status or prevalence of anemia. Young children in rural Malawi remain at high risk of iron deficiency and anemia.
Vitamin A deficiency (VAD) is common in populations with limited dietary diversity and access to vitamin A-rich foods.
This analysis aimed to determine the impact of supplementing children’s diets ...with 1 egg/d on the concentration of plasma retinol and RBP and the prevalence of VAD.
Children age 6–9 mo living in the Mangochi district of Malawi were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329) in the Mazira trial (clinicaltrials.gov; NCT03385252). This secondary analysis measured plasma retinol by HPLC and RBP, CRP, and α-1-acid glycoprotein (AGP) by ELISA techniques at enrollment and 6 mo follow-up. Retinol and RBP were adjusted for inflammation, and mean concentrations were compared between groups using linear regression models. In addition, prevalence ratios of VAD (retinol <0.7 μmol/L) were compared between groups using log-binomial or modified Poisson regression models.
After 6 mo of study participation, 489 were assessed for retinol (egg: n = 238; control: n = 251), and 575 (egg: n = 281; control: n = 294) were assessed for RBP. Prevalence of inflammation (CRP >5 mg/L or AGP >1 g/L: 62%) and inflammation-adjusted VAD (7%) at enrollment did not differ between groups. At follow-up, the egg intervention group did not differ from the control in inflammation-adjusted retinol geometric mean (95% CI); egg: 1.10 μmol/L (1.07, 1.13); control: 1.08 (1.05, 1.12), RBP egg: 0.99 μmol/L (0.96, 1.02); control: 0.97 (0.94, 1.00), or prevalence of VAD egg: 6%; control: 3%; prevalence ratio: 1.87 (0.83, 4.24).
Provision of 1 egg/d did not impact VAD, plasma retinol, or RBP among young children in rural Malawi, where the prevalence of VAD was low. Curr Dev Nutr 2023;x:xx.
This trial was registered at clinicaltrials.gov as NCT03385252.
Eggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of 1 egg/d in young children in Ecuador, an egg intervention led to ...significant improvements in growth, which were partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development.
We aimed to evaluate the effect of 1 egg/d for 6 mo on plasma choline concentrations in Malawian children enrolled in a randomized trial.
Infants aged 6–9 mo in rural Malawi were randomly assigned to receive 1 egg/d (n = 331) or serve as a nonintervention control (n = 329) for 6 mo. Anthropometric, developmental, and dietary data were collected at baseline and 6-mo follow-up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trimethylamine N-oxide (TMAO), and DHA were measured at both time points using ultrahigh performance liquid chromatography–tandem MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 mo of intervention.
Plasma choline, betaine, dimethylglycine, and DHA concentrations did not differ between groups at 6-mo follow-up. Plasma TMAO was significantly (26%; 95% CI: 7%, 48%) higher in the egg intervention group in a fully adjusted model.
Provision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO. This could partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population.
Provision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO, in this randomized trial of young Malawian children.
Stunted growth is a significant public health problem in many low-income countries.
The aim of this study was to evaluate the impact of 1 egg per day on child growth in rural Malawi.
We conducted an ...individually randomized controlled trial in which 660 children aged 6–9 mo were equally allocated into an intervention (1 egg/d) or control group. Eggs were provided during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. Assessors blinded to intervention group measured length, weight, head circumference, and midupper arm circumference at baseline and the 6-mo follow-up visit. To assess adherence, multipass 24-h dietary recalls were administered at baseline, 3-mo, and 6-mo visits.
Between February and July 2018, 660 children were randomly assigned into the intervention (n = 331) and control (n = 329) groups. Losses to follow-up totaled 10%. In the intervention group, egg consumption increased from 3.9% at baseline to 84.5% and 70.3% at the 3-mo and 6-mo visits, whereas in the control group, it remained below 8% at all study visits. The baseline prevalence of stunting was 14%, underweight was 8%, and wasting was 1% and did not differ by group. There was no intervention effect on length-for-age, weight-for-age, or weight-for-length z scores. There was a significantly higher head circumference for age z score of 0.18 (95% CI: 0.01, 0.34) in the egg group compared with the control group. There was a significant interaction with maternal education (P = 0.024), with an effect on length-for-age z score only among children whose mothers had higher education.
The provision of 1 egg per day to children in rural Malawi had no overall effect on linear growth. A background diet rich in animal source foods and low prevalence of stunting at baseline may have limited the potential impact. This trial was registered at clinicaltrials.gov as NCT03385252.
Abstract only
In resource‐limited settings, we generally assume that household food insecurity (HFI) status is static over time, ranging from a period of a few months to a few years. Longitudinal HFI ...measures are required to test the validity of this assumption. We assessed HFI on a monthly basis in the context of an efficacy trial of biofortified maize conducted in rural Zambia from October 2012 to March 2013. This period is mostly characterized as the lean season, which peaks in ~April in this setting. The trial included two intervention arms and a parallel non‐intervened group for the purposes of background dietary and food security measures. A total of 907 households were enrolled at baseline; however, the present analysis includes longitudinal data from 157 households in the non‐intervened arm. At each of the six monthly visits, HFI was assessed using a validated 8‐item perception‐based Likert scale with a one month recall period. We calculated a HFI index by summing scores over the Likert scale (ranging from 0 to 32). The median (IQR) HFI index was 7 (4–11), 8 (5–11), 7 (4–10), 6 (4–9), 6 (4–9) and 7 (4–9) at the six monthly visits, respectively. The correlation between HFI index between visits ranged from 0.3 to 0.4. A random effect model was fit on the index as a function of visit clustered at household level. Results from the model showed that the HFI index decreased on average by 0.25 points per visit. Within and between household variation in the index was 10.6 and 8.8, respectively. Within‐household variability of the HFI index did not show a clear pattern in relation to the household mean score. Because our repeated HFI measurements were conducted in one single season, the small change in mean monthly HFI index suggested that seasonal assessments may be sufficient for population monitoring purposes in similar settings. However, higher variation within some households suggests that household characteristics—as opposed to seasonal impacts on food security—may explain the differences in variation in response to the repeated scale.
Support or Funding Information
HarvestPlus (grant 8251) and Sight and Life Global Nutrition Research Institute at Johns Hopkins University
Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to improve vitamin ...A status in maize-consuming populations.
We evaluated the efficacy of regular provitamin A carotenoid-biofortified "orange" maizemeal (∼15 μg β-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children.
This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ∼400-km(2) area were identified and grouped by proximity into clusters of ∼15-25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, β-carotene, C-reactive protein, and α1-acid glycoprotein.
Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 μmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum β-carotene was 0.14 μmol/L (95% CI: 0.09, 0.20 μmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 μmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms.
In this marginally nourished population, regular biofortified maizemeal consumption increased serum β-carotene concentrations but did not improve serum retinol. This trial was registered at clinicaltrials.gov as NCT01695148.
Choline is an essential nutrient which may be important for child growth and development; however, data on intake among children in low and middle income countries are scarce. We aimed to describe ...choline intake among Malawian children age 6–9 and 12–15 months enrolled in an egg intervention trial.
The Mazira Project was a randomized controlled trial of the effect of daily egg consumption on growth and development in Malawian children. Children 6–9 months old were randomized to the intervention group, which received one egg/day for 6 months, or to the control group, which did not receive eggs. Data on children’s complementary food intake were collected by 24-hour recall interview with the primary caregiver at baseline (6–9 months of age; n = 659) and at endline (12–15 months of age; n = 595). Choline from complementary foods was calculated based on local recipe and food composition tables. Breastmilk intake was approximated as the child’s estimated energy requirement minus energy from complementary foods, and then multiplied by an assumed choline concentration. Total choline intake was compared to the Adequate Intake (AI) level. Contribution to choline intake by food source was calculated at each time point. Since eggs are high in choline, analysis was stratified by group at endline.
The median (IQR) total choline intake at 6–9 months was 98.2 (77.7–120.6) mg. Breastmilk was the top contributor (80% of total choline), followed by maize (10%). At 12–15 months, median (IQR) choline intake in the egg group was 126.2 (91.9–166.2) mg and the main contributors were breastmilk (40%), eggs (29%) and maize (10%). Choline intake in the control group was lower, at 94.3 (63.3–118.1) mg, and was mainly from breastmilk (53%) and maize (15%). Median intake was below the AI at both ages; however, at 12–15 months, median intake was 65% of the AI in the egg group and only 47% in the control group.
Choline intake is low among the Malawian children in this sample, potentially putting them at risk for poor development. The egg intervention increased choline intake, specifically from eggs, but the median intake in this group was still below the AI.
The Bill and Melinda Gates Foundation, Egg Nutrition Center.
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