Background: 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.
Objective: 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.
Design: 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-km2 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.
Results: 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.
Conclusion: 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.
Fortified blended foods (FBFs) are widely used to prevent undernutrition in early childhood in food-insecure settings. We field tested enhanced Wheat Soy Blend (WSB++)—a FBF fortified with ...micronutrients, milk powder, sugar, and oil—in preparation for a complementary food supplement (CFS) trial in rural northwestern Bangladesh. Formative work was conducted to determine the optimal delivery method (cooked vs. not) for this CFS, to examine mothers’ child feeding practices with and acceptance of the WSB++, and to identify potential barriers to adherence. Our results suggest WSB++ is an acceptable CFS in rural Bangladesh and the requirement for mothers to cook WSB++ at home is unlikely to be a barrier to its daily use as a CFS in this population.
Growth faltering in relation to the WHO reference is common in the first 2 years of life in South Asia. Stunting, defined as an attained height/length-for-age (H/LA) < -2 Z, is limited in its ability ...to capture this dynamic process. Our aims were to (1) reveal distributions of growth faltering by age in a cohort of preschool Nepali children, and (2) propose a definition of growth faltering that represents early or continued deviated growth that precedes a child reaching < -2 H/LAZ.
We conducted a mixed longitudinal study in 21 wards of 7 randomly selected sub-districts across the Tarai (plains) of Nepal. Mid-year anthropometry was measured annually from 2013–2016 in children < 71 months (mo) of age. Children with paired data over a ∼1-year interval contributed to any of 6 age groups: < 6 mo n = 645, 6–11 mo n = 998, 12–23 mo n = 744, 24–35 mo n = 691, 36–47 mo n = 730 and 48–59 mo n = 637, reflecting age at the outset of the interval. Sex-specific, annualized growth velocities and incidence rates of growth faltering were calculated for each age. Growth faltering was provisionally defined as an annualized decrement (-△) in H/LA of >0.5 Z, corresponding to a ∼ >1 cm/year slower rate of linear growth than an estimated median velocity on the WHO referent growth curve for children < 6 months at the outset. A -0.5 △H/LAZ cutoff was applied to all ages.
Annualized △H/LAZ mean (SD) was -1.3 (1.2), -0.8 (1.2), -0.3(0.8), 0.0 (0.7), 0.1(0.6), 0.1 (0.5) at each age specified above. Incidence of growth faltering was 79.8%, 66.3%, 40.4%, 11.7%, 4.9%, 2.1% at each respective age. Among infants < 6 mo whose initial LAZ was -1 < x < + 1 (excluding extrema), a △LAZ of < -0.5 or >0 (acceleration) was observed in 85.8% and 3.6%, respectively.
Growth faltering, expressed as an annualized decrement in HAZ >0.5 likely reflects biologically relevant deceleration before children reach < -2 H/LAZ. Two-thirds to 80% of infants in the Tarai of Nepal exhibit growth faltering the year after assessment. By 36 months and older, linear growth, parallels the WHO median attained HA on average, with < 5% appearing to falter, an age at which WHO growth velocity standard curves are lacking.
The study was funded by USAID via a subaward from Tufts University under the Feed the Future Innovation Lab for Nutrition. Additional assistance was received from Sight and Life and the Gates Foundation.
To investigate national trends in the prevalence of anemia among children and the stability of factors associated with anemia in Nepal.
A series of nationally representative mid-year surveys was ...conducted in the same 63 wards across the mountains, hills, and Tarai of Nepal in 2013, 2014, and 2016. Each survey collected data on community, household, and individual factors to explore associations with agricultural practices and nutritional outcomes. Data were collected from consenting households that had children under 5 years, among whom a random sample was selected each year for anemia assessment using a Hb 201 + hemoglobinometer (HemoCue AB, Angelholm, Sweden), with n = 861, 794, and 837 children in each survey, respectively. Odds ratios were estimated and prevalence for 2014 and 2016 was standardized to the 2013 national surveyed population distribution.
The national prevalence of anemia among children aged 0–59 months significantly decreased from 64.6% (95% CI: 61.3%, 67.8%) in 2013 to 51.8% (95% CI: 48.2%, 55.3%) in 2014 and then increased to 58.7% (95% CI: 55.2%, 62.0%) in 2016. Across all years, the prevalence was highest in the Tarai (57.9–70.7%) followed by the mountains (50.4–61.0%) and hills (37.6–52.0%). Within each region, the trend in prevalence followed that of the national prevalence, decreasing significantly from 2013 to 2014 and increasing in 2016. Nationally and across time, univariate analysis revealed child age <24 months, diarrhea, low dietary diversity, low dietary intake of meat, maternal hemoglobin, and lack of household access to an improved toilet to be strong and stable risk factors for anemia. Our presented paper will include findings from multivariable adjusted analysis.
The risk factors associated with anemia among children suggest the need for multi-sectoral interventions with a focus on improving diet, reducing gastrointestinal infection, and promoting hygienic and sanitary practices. Research is needed to examine why the prevalence of anemia fluctuates from year to year given that, across this period of time, many of the household and individual risk factors remain stably associated with anemia.
U.S. Agency for International Development (USAID), Washington DC, assisted by Sight and Life and the Gates Foundation.
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This study describes dietary patterns of women in Nepal and how dietary patterns vary by under-and-overweight, socioeconomic status (SES), and agro-ecological zone.
In 2016, a national mid-year ...nutrition and health survey was conducted in Nepal. In each zone (mountains, hills and Tarai) 7 sub-districts (village development communities, VDCs) were systematically selected after a random start (N = 21). Within each VDC, 3/9 wards (N = 63) were sampled in proportion to population and all households were enumerated. In all, 5380 women, married <2 years or having >1 child <72 mo of age, were assessed for weight, height, caste, SES, & food security among other factors. Diet was assessed by a 7-day food frequency questionnaire with 48 items. Latent class analysis was used to generate dietary patterns, consolidated into 12 food groups. Goodness-of-fit indicators supported a 7 class (dietary pattern) model. Chi2 tests were used to test statistically significant differences in dietary patterns by characteristics.
National median IQR intake frequencies for key foods by women were: fruits 3 1,7, vegetables 12 7,20, meat 1 0.3, eggs 0 0,1, and dairy 6 0,14. Only 10% of women consumed fruits or vegetables 5 times per week. Dietary patterns (% of women) identified included: 1) Most diverse (18%); 2) Diverse no egg no alcohol (17%); 3) Diverse orange fruit, veg and milk (4%); 4) Moderate (13%); 5) Non-diverse meat and alcohol (10%); 6) Low moderate diversity with oil and fat (22%); and 7) Monotonous (17%). Patterns 2 and 6 were distinct of the Tarai and pattern 3 more evident in the Hills. Significant variation was evident by wealth quintile, food security status, caste, zone, and body mass index (BMI). Women whose intakes aligned with Pattern 1 had the highest prevalence of BMI >25.0 kg/m2 (26.7%) and those eating pattern 3, the lowest (1.4%). Pattern 1 had the lowest prevalence of BMI <18.5 kg/m2 (12.6%), and pattern 6 the highest (28.8%).
Dietary patterns of women in Nepal are heterogeneous, vary by SES, agro-ecological and cultural factors, and are associated with risk of over and underweight.
Supported by USAID through the Feed the Future Nutrition Innovation Lab, with additional assistance from Sight and Life and the Bill & Melinda Gates Foundation.
Background: Tocopherols were discovered for their role in animal reproduction, but little is known about the contribution of deficiencies of vitamin E to human pregnancy loss.
Objective: We sought to ...determine whether higher first-trimester concentrations of α-tocopherol and γ-tocopherol were associated with reduced odds of miscarriage (pregnancy losses <24 wk of gestation) in women in rural Bangladesh.
Design: A case-cohort study in 1605 pregnant Bangladeshi women median (IQR) gestational age: 10 wk (8–13 wk) who participated in a placebo-controlled vitamin A– or β-carotene–supplementation trial was done to assess ORs of miscarriage in women with low α-tocopherol (<12.0 μmol/L) and γ-tocopherol (<0.81 μmol/L; upper tertile cutoff of the γ-tocopherol distribution in women who did not miscarry).
Results: In all women, plasma α- and γ-tocopherol concentrations were low median (IQR): 10.04 μmol/L (8.07–12.35 μmol/L) and 0.66 μmol/L (0.50–0.95 μmol/L), respectively. In a logistic regression analysis that was adjusted for cholesterol and the other tocopherol, low α-tocopherol was associated with an OR of 1.83 (95% CI: 1.04, 3.20), whereas a low γ-tocopherol concentration was associated with an OR of 0.62 (95% CI: 0.41, 0.93) for miscarriage. Subgroup analyses revealed that opposing ORs were evident only in women with BMI (in kg/m2) ≥18.5 and serum ferritin concentration ≤150 μg/L, although low BMI and elevated ferritin conferred stronger risk of miscarriage.
Conclusions: In pregnant women in rural Bangladesh, low plasma α-tocopherol was associated with increased risk of miscarriage, and low γ-tocopherol was associated with decreased risk of miscarriage. Maternal vitamin E status in the first trimester may influence risk of early pregnancy loss. The JiVitA-1 study, from which data for this report were derived, was registered at clinicaltrials.gov as NCT00198822.
The epidemiology of tornado‐related disasters in the developing world is poorly understood. An August 2005 post‐tornado cohort study in rural Bangladesh identified elevated levels of death and injury ...among the elderly (≥ 60 years of age) (adjusted odds ratio (AOR) = 8.9 (95 per cent confidence interval (CI): 3.9–20.2) and AOR = 1.6 (95 per cent CI: 1.4–1.8), respectively), as compared to 15–24 year‐olds, and among those outdoors versus indoors during the tornado (AOR = 10.4 (95 per cent CI: 5.5–19.9) and AOR = 6.6 (95 per cent CI: 5.8–7.5), respectively). Females were 1.24 times (95 per cent CI: 1.15–1.33) more likely to be injured than males. Elevated risk of injury was significantly associated with structural damage to the house and tin construction materials. Seeking treatment was protective against death among the injured, odds ratio = 0.08 (95 per cent CI: 0.03–0.21). Further research is needed to develop injury prevention strategies and to address disparities in risk between age groups and between men and women.
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Antenatal micronutrient deficiencies may impair fetal and infant health. We conducted a cluster‐randomized, double‐masked trial among 44,567 pregnant women and 28,516 infants to assess ...efficacy of daily MM vs IFA supplementation, from the 1
st
trimester to 12 wk postpartum, in improving fetal and infant viability. Groups were similar in sample size (N
mm
=22,162, N
IFA
=22,405), baseline SES, diet, maternal and gestational (GA) ages at enrollment, and supplement adherence median: ~94 (IQR: ~84–100)%. MM vs IFA supplementation was associated with the following relative risks (RR; 95% CI, adjusted for design effect): Still birth (.89; .81‐.99), low birth weight (.88; .85‐.91), preterm birth (.87; .82‐.92), SGA (.99; .96–1.01) and 6 (.95; .86–1.06) and 12 (.94; .85–1.04) mo mortality. Lower mortality occurred by ages 6 and 12 mo in girls (.87; .74–1.01 and .85; .73‐.97) but not boys (1.02; .89–1.17, both ages), with P
Interax
=.08 and .06, respectively. MM supplementation increased weight, length, arm, chest and head circumference by 55 g, .21 cm, .11 cm, .25 cm and .21 cm, respectively, explained by a 0.30 wk longer gestation in both sexes (all p<0.0001). In rural Bangladesh, antenatal MM reduced risk of still birth and lengthened gestation, lowering risk of preterm birth, increasing birth size, and reducing risk of low birth weight. Supported by The Bill and Melinda Gates Foundation (Grant GH614).
Background: Severe anemia (hemoglobin <70 g/L) in pregnancy may increase the risk of maternal and perinatal mortality.
Objectives: We assessed response to standard treatment with high-dose iron–folic ...acid for 90 d and single-dose (500 mg) mebendazole among severely anemic pregnant women in periurban Karachi, Pakistan. In addition, we evaluated the efficacy of 2 enhanced treatment regimens.
Design: We screened pregnant women (n = 6288) for severe anemia and provided them all with the standard treatment. To test the efficacy of 2 additional treatments, women were randomly assigned to standard treatment alone (control) or with 100 mg mebendazole twice daily for 3 d or 90 d of daily multivitamins or both using a 2 × 2 factorial design.
Results: Prevalence of severe anemia was high (10.5%) during pregnancy. Prevalence of geohelminths and malaria was low. Treatment response was defined as hemoglobin >100 g/L at the 90-d or ≥25 g/L at the 60-d follow-up visit. The standard-of-care treatment resulted in a response rate of 49% at follow-up, although an adherence of ≥85% elicited a higher response (67%). The effect of the additional treatments was weak. Although response was higher in the enhanced groups than for the standard treatment at the final assessment, the differences were not statistically significant. However, hemoglobin concentration increased significantly in all groups and was higher in the enhanced mebendazole group compared with the standard group (P < 0.05).
Conclusions: Iron deficiency was high in this population, and the standard-of-care treatment resulted in a treatment response of 50%, although better treatment adherence showed a higher response. Multivitamins and the enhanced mebendazole regimen had a modest benefit over and above the standard treatment.
Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. Under the auspices of “The Micronutrient Powders ...Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale‐up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale‐up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.
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