The World Health Organization (WHO) recommends intake of free sugars to not exceed 10% of energy in children. The objectives of this study are to (1) estimate the proportion of infants in rural ...Malawi who exceed the recommended intake of free sugars and (2) describe the sources of free sugars in infant diets.
Among children enrolled in a randomized controlled trial of an egg feeding intervention, a secondary analysis was conducted using endline dietary data from a single 24-hour recall among 12- to 15-month-old children (n = 590). Free sugars in home-prepared foods were estimated using the gram weight of table sugar and honey in standardized local recipes. Free sugars from commercial foods were estimated using food composition data from the Nutrition Data System for Research. Foods and beverages containing free sugars were classified into seven food categories: maize porridge, sweetened tea, sweetened dairy, candy or table sugar, juice or soda, pastries, and cookies. The total grams of free sugars and grams of free sugars by food category and by commercial or home preparation were summed for each child. Breastmilk intake was not directly assessed, so total energy intake was assumed equal to the estimated energy requirement when assessing proportion of energy intake from free sugars.
The mean intake of free sugars was 10.7 ± 13.1 g (6% of estimated energy requirement), and 22% of children exceeded recommended energy intake from free sugars. The majority of free sugars were consumed in maize porridge (5.1 g, 48% of total free sugars) followed by sweetened tea (2.0 g, 18%), sweetened dairy (1.7 g, 16%), candy or table sugar (1.0 g, 9%), juice or soda (0.3 g, 3%), pastries (0.3 g, 3%), and cookies (0.3 g, 3%). The average intake of free sugars from commercial foods or beverages was 3.5 ± 8.5 g (33% of total free sugar intake), whereas the average intake from home-prepared foods or beverages was 7.1 ± 9.4 g (67%).
Free sugar consumption exceeded WHO recommendations in approximately one-fifth of this sample of rural Malawian children. This data suggests the greatest opportunity for reducing free sugar consumption among young children in rural villages is by targeting sugars added to home-prepared foods and beverages.
Bill and Melinda Gates Foundation.
Adequate protein quantity and quality are necessary for child health, growth and development, but may be lacking in complementary feeding diets with limited variety and few animal source foods. We ...assessed the impact of an egg feeding intervention on protein quality and quantity among rural Malawian children aged 9 to 15 months.
We enrolled 660 children into a 6-month trial to test the effect of eggs on child growth. Children were randomly assigned to the egg group (n = 331), who received one egg per day, or the control group (n = 329). Dietary intake data were collected at 3-month midline (9–12 months old) and 6-month endline visits (12–15 months old) by 24-hour recall interview with the primary caregiver. Repeat recalls were collected in a subsample at each timepoint. Crude protein intakes were calculated using local recipe and food composition tables. Breast milk intake was estimated as the difference between the estimated energy requirement and energy intake from complementary diet. Protein intakes were adjusted using the Digestible Indispensible Amino Acid Score (DIAAS), which weighs crude amino acid intakes against amino acid requirements. Treatment group differences in DIAAS were tested with ANCOVA. Group differences in adjusted total protein intakes from complementary diet and breastfeeding were tested using the National Cancer Institute method for estimating usual mean intakes with bootstrap standard errors. Adequacy was assessed using World Health Organization protein requirements.
The egg intervention improved protein quality of the complementary feeding diet (DIAAS of 79 egg v 61 control at midline, 86 v 72 at endline, P < .0001). Inclusion of breast milk in the DIAAS increased mean scores in both groups; total protein quality remained higher in the egg group. Total quality-adjusted protein intakes were 15.4 ± 0.3 g (mean ± standard error) in the egg group v 12.7 ± 0.3 g in the control group at midline and 17.1 ± 0.3 g egg group v 14.6 ± 0.3 g control at endline (P < .0001). Inadequacy of protein intake was lower in the egg group than the control group at midline (2% v 15%, P < 0.01) and very low in both groups at endline (<1% egg v 2% control, P > 0.05).
The egg intervention increased quantity and quality of protein intakes among young Malawian children, though protein inadequacy was uncommon.
The Bill and Melinda Gates Foundation.
Our objective was to assess whether fish and meat consumption over 6mo was associated with plasma ferritin, soluble transferrin receptor (sTfR), hemoglobin (Hb), iron deficiency (ID), and anemia in a ...population of young Malawian children with a high (>50%) prevalence of iron deficiency anemia.
This secondary data analysis includes 585 Malawian infants, age 6–9mo, from a 6mo egg feeding trial. At enrollment and 6mo follow-up, 24hr dietary recalls and blood draws were conducted. Days with any small fish, large fish, or meat consumption were reported weekly in 7-day food frequency questionnaires. The % of days with flesh food consumption were totaled for each child. Plasma ferritin, sTfR, and Hb were assessed for associations with the % of days with small fish, large fish, and meat intake using linear regression. Prevalence ratios (PR) of ID (ferritin < 12μg/L or sTfR > 8.3 mg/L) and anemia (Hb< 11g/dL) were compared for each flesh food category using log binomial or modified Poisson regression.
The % of children with observed intake of small fish (4%), large fish (1%), and meat (2%) from 24-hr recalls at enrollment increased to 40%, 12%, and 9%, respectively, at the 6mo follow-up. Over 6mo, children averaged consumption of small fish, large fish, and meat on 25%, 8%, and 6% of days, respectively. More frequent intake of small fish was associated with higher Hb geometric mean ratio (95% CI) per 10 percentage point difference: 1.01 g/dL (1.00, 1.01) and lower sTfR 0.98 mg/L (0.96, 1.00) but was not associated with ferritin concentration 1.03 μg/L (0.99, 1.07); nor was it associated with the prevalence of ID PR (95% CI): 0.99 (0.97, 1.01) or anemia 0.94 (0.88, 1.01). More frequent consumption of large fish was associated with a higher prevalence of anemia 1.09 per 10 percentage point difference in frequency, (1.00, 1.18) but was not associated with ID 0.96 (0.92, 1.00). Meat consumption was predominantly chicken and not associated with iron or anemia indices.
Small fish are a primary contributor to total flesh food intake of young Malawian children and may provide modest improvements to iron status and hemoglobin. Meat and large fish were infrequently consumed and not associated with ID.
Bill & Melinda Gates Foundation.
Young children with complementary feeding diets that lack diversity and have low micronutrient density are at risk of iron deficiency anemia. Our objectives were to determine the impact of ...supplementing diets with 1 egg/day on: (1) plasma ferritin, soluble transferrin receptor (sTfR), and hemoglobin (Hb) concentrations; and (2) the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA).
Children age 6–9mo in the Mangochi District of Malawi were individually randomized to receive 1 egg/day for 6mo (n = 331) or continue their usual diet (n = 329). Venous blood samples were collected at enrollment and a 6mo follow-up by assessors masked to group assignment. Plasma ferritin, sTfR, c-reactive protein (CRP), and α1-acid glycoprotein (AGP) were assessed using ELISA and hemoglobin was measured using Hemocue analyzers. Ferritin and sTfR were corrected for inflammation using CRP and AGP in linear regression models. Ferritin, sTfR, and hemoglobin concentrations were compared between groups using linear regression models, adjusting for baseline values. The prevalence ratios (PR) of ID (fer < 12μg/L, sTfR >8.3mg/L, or total body iron< 0mg/kg), anemia (Hb< 11g/dL), and IDA (Hb < 11g/dL and ID) were compared between egg and control groups using binomial or Poisson regression models.
A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the prevalence of anemia and IDA was 61% and 55%. At the 6mo follow-up, there was no difference between groups in inflammation-adjusted ferritin (geometric mean 95% CI; Egg: 6.52μg/L 5.98,7.10; Control: 6.82 6.27, 7.42) or sTfR (Egg: 11.34mg/L 10.92,11.78; Control: 11.46 11.04,11.89) concentrations. There was also no difference in mean hemoglobin concentration between groups (mean 95%CI; Egg: 11.0g/L 10.8,11.1; Control:11.1 11.0,11.3). Overall, 43% of children had anemia, 89% had ID, and 40% had IDA. No group-level differences were observed in the prevalence of anemia 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).
Iron and anemia indices did not differ between the egg intervention group and control group. Other interventions are needed to address the high prevalence of iron deficiency and anemia among young, Malawian children.
Bill & Melinda Gates Foundation.
Choline has been positively associated with child growth and development, but few studies have been in areas of high stunting and low choline intake. This secondary analysis examines the association ...of plasma choline with growth/development in Malawian children enrolled in a randomized trial of 1 egg/day versus nonintervention control.
Venous blood, anthropometric, and developmental measures were collected at enrollment (at age 6–9 mos) and at endline 6 mos later. Plasma choline, betaine, dimethylglycine, and trimethylamine N-oxide were measured using untargeted metabolomics among 400 children. Length, weight, and head circumference were converted to z-scores using WHO Growth Standards. Developmental measures included fine and gross motor, personal social, and language skills (measured and normed using the Malawi Developmental Assessment Tool), memory (elicited imitation endline only and visual paired comparison tasks), and attention (Infant Orienting with Attention IOWA task). Generalized linear models, adjusted for covariates including group assignment, were used to examine the association of plasma choline with growth/developmental outcomes.
In cross-sectional models including both time points (baseline, endline) and adjusting for repeated measures, a 1 SD-unit increase in plasma choline was negatively associated with length-for-age z-score (–0.11 SD 95% CI: –0.20, –0.02) and positively associated with IOWA reaction time (8.8 ms 1.7, 16.0), meaning slower shifts in attention with higher plasma choline. In predictive models, higher baseline plasma choline predicted lower endline fine motor z-scores (–0.13 SD –0.22, –0.04). There were no associations of plasma choline with weight-for-age, head-circumference-for-age, weight-for-length, or the other developmental outcomes. Analysis of other biomarkers revealed few significant associations with growth/development.
Plasma choline was not strongly associated with growth or development in this sample of Malawian children. The few significant associations suggested poorer growth/development with higher plasma choline. Further research in various contexts is needed.
Bill and Melinda Gates Foundation; Egg Nutrition Center.
To characterize the nutritional composition of chicken eggs from a large-scale commercial producer and a small-scale household producer in rural Malawi.
A convenience sample of 28 large commercial ...and 32 village eggs from Malawi were hardboiled and measured for the weight in grams of the whole egg, peeled egg, egg white, and egg yolk. A separate convenience sample of 11 commercial and 17 village eggs were selected for nutrient analysis. Eggs were hardboiled for 4 minutes, refrigerated, and shipped to a nutrient analysis lab in the United States. Eggs from each source were pooled and analyzed for macronutrients, amino acids, fatty acids, vitamins, and minerals. Analytes were reported per 100 g sample and converted to nutrients per egg using the mean peeled egg weight.
The mean weight in grams of whole commercial eggs (59.4 ± 5.3) was 19 g greater than whole village eggs (40.4 ± 3.0). Commercial eggs had a 15 g greater mass of egg whites (37.0 ± 4.2) than village eggs (21.8 ± 2.5), but the mass of egg yolks only differed by one gram (commercial: 15.3 ± 1.0 and village: 14.1 ± 1.4). Per 100 g sample, commercial and village eggs had similar calories (143 kcals vs. 162kcals), protein (12.5 g vs. 12.5 g), water-soluble vitamins (1.61 μg vs. 1.92 μg Vitamin B-12; 63.5 μg vs. 59.9 μg folate, DFE) and minerals (1.7 mg vs. 2.1 mg iron; 21 μg vs. 24 μg selenium; 1.1 mg vs. 1.4 mg zinc). For fat-soluble nutrients, the 100 g sample of commercial eggs had a higher concentration of Vitamin A than the village eggs (150 μg vs. 102 μg RAE) but lower concentrations of Vitamin D3, α-tocopherol, and choline than the village eggs (0.8 μg vs. 2.9 μg Vitamin D3; 2.25 mg vs. 4.08 mg α-tocopherol; and 238 mg vs. 314 mg choline). However, when compared on a per egg basis, the fat-soluble nutrient content of the whole eggs was similar due to the smaller size of the village eggs.
On a per egg basis, eggs from small-scale households may deliver comparable amounts of fat-soluble nutrients but fewer calories, protein, and minerals compared to eggs from commercial producers; however, on a per 100 g basis, village eggs were a more nutrient-dense option.
The Bill and Melinda Gates Foundation, BLUM Center of UC Davis.
Complementary feeding diets in low- and middle-income countries are usually inadequate to meet requirements for healthy growth and development. Food-based interventions may prevent nutrient ...inadequacies provided they do not replace other nutrient-rich foods. They may also be more sustainable than manufactured food supplements. We describe the contribution of daily egg supplementation to usual energy intake, usual energy intake by food group, and minimum dietary diversity of rural Malawian infants and young children.
We conducted a randomized controlled trial in rural Malawi in which 660 children aged 6 to 9 months were randomly allocated to receive an egg a day for 6 months or to a control group. Dietary intake of foods and drinks was assessed at baseline, 3-month midline, and 6-month endline visits using a tablet-based mulitpass 24-hour recall. Up to two repeat recalls were collected at each timepoint in a subsample of 100 children per intervention group.
The intervention resulted in an increased usual energy intake in the intervention group of 30 kcal at midline (P = 0.128) and 36 kcal at endline (P = 0.087). It also resulted in a 7 kcal displacement of legumes and nuts in children at endline (P = 0.059). At midline and endline, usual energy intake from eggs was about 30 kcal higher in the egg group compared to controls (P < 0.0001). Compared to controls, children in the egg group were over 9 times more likely to consume eggs at midline and endline. At midline and endline more than 80% of children in the egg group consumed a minimally diverse diet compared to 53% at midline and 60% at endline in the control group.
Mothers in the egg group fed eggs to young children on a regular basis without substantial displacement of other nutrient-rich complementary foods. The intervention resulted in higher energy intake from eggs, greater dietary diversity, and an increased percentage of children meeting a minimum dietary diversity cutoff.
Bill & Melinda Gates Foundation.
Zambia introduced mandatory sugar fortification with vitamin A (VA) in 1998; however, regulatory monitoring and evaluation have been limited. We studied the contribution of VA-fortified sugar intake ...to dietary adequacy, and examined associations between usual sugar and VA intakes with plasma and breast milk retinol concentrations in lactating women in rural Zambia.
We conducted three 24-h dietary recalls among each of 255 lactating women enrolled in a randomized trial, at the time of baseline venous blood and breast milk collection. We measured retinol in biospecimens using high-performance liquid chromatography. We simulated VA intake under various sugar fortification scenarios: 3.1 and 8.8 mg/kg (measured median fortification levels of VA in sugar from previous studies), 10 mg/kg (minimum legal requirement) and 15 mg/kg (minimum legal requirement at factory level). Usual intake distributions, prevalence of inadequate VA intake (< Estimated Average Requirement of 900 μg RAE/d) and prevalence of retinol intake above the tolerable upper intake level (UL, >3000 μg/d) for each scenario were estimated using the National Cancer Institute (NCI) method. We applied the NCI’s “bivariate model” as a regression calibration tool to examine associations of usual intake of sugar and dietary VA with plasma and breast milk retinol concentrations.
In the absence of sugar fortification, the prevalence of VA inadequacy was predicted to be 83% (SE: 6). Fortification of sugar with VA at 3.1 mg/kg, 8.8 mg/kg, 10 mg/kg and 15 mg/kg would reduce the prevalence of VA inadequacy by 7 (SE:6), 24 (SE:14), 30 (SE:15) and 47 (SE:18) percentage points, respectively, without increasing the risk of retinol intake above the UL. Usual sugar intake and usual VA intake were not associated with plasma retinol or breastmilk retinol concentrations.
The sugar fortification program has the potential to reduce dietary VA inadequacy, but the impact is likely to be limited if actual fortification levels are lower than mandated levels. Even if target fortification levels are achieved (10 mg/kg), sugar fortification alone is unlikely to eliminate dietary VA inadequacy among lactating women in rural Zambia.
HarvestPlus and the Sight and Life Global Nutrition Research Institute at Johns Hopkins University.
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