The impact of an integrated community-based micronutrient and health programme on anaemia in non-pregnant Malawian women

Exploring the Complementarity of Fortification and Dietary Diversification to Combat Micronutrient Deficiencies: A Scoping Review

Achieving a balanced and diverse diet remains a challenge for many people, contributing to an ongoing burden of micronutrient deficiencies, particularly in low-income settings. Fortification or dietary diversification are common food-based approaches. We conducted a scoping review to: 1) find evidence on whether combined food-based strategies are more effective than single strategies, and 2) understand how strategies implemented together could complement each other to achieve optimal nutritional impact on populations. Peer-reviewed articles selected (n = 21) included interventions or observational studies (n = 13) and reviews (n = 8). We found little evidence of an added nutritional impact. On the other hand, it is apparent that fortification and dietary diversification target different types of settings (urban compared with rural) and foods (that is, low priced compared with highly priced). Further research is needed to understand the complementarity of these approaches and establish evidence of the effectiveness of combined strategies to foster policy adoption.

Anemia among Women of Reproductive Age: An Overview of Global Burden, Trends, Determinants, and Drivers of Progress in Low- and Middle-Income Countries

Relatively little progress has been made in reducing anemia prevalence among women of reproductive age (WRA anemia). Interventions, policies and programs aimed at reducing WRA anemia have the potential to improve overall not only women’s, but also children’s health and nutrition outcomes. To our knowledge, this is the first review that aimed to compile evidence on the determinants and drivers of WRA anemia reduction in low- and middle-income countries (LMICs). We synthesized the available evidence on the determinants and drivers, including government policies and programs, of WRA anemia and their mitigation strategies across a wide range of countries and geographies, thus contributing to the complex and multifactorial etiology of anemia. We carried out a systematic review of published peer-reviewed and grey literature assessing national or subnational decline in WRA anemia prevalence and the associated drivers in LMICs. Among the 21 studies meeting our inclusion criteria, proximal determinants of healthcare utilization, especially during pregnancy and with the use of contraceptives, were strong drivers of WRA anemia reduction. Changes in other maternal characteristics, such as an increase in age at first pregnancy, BMI, birth spacing, and reduction in parity, were associated with modest improvements in anemia prevalence. Access to fortified foods, especially iron-fortified flour, was also a predictor of a decrease in WRA anemia. Of the intermediate determinants, an increase in household wealth, educational attainment and access to improved sanitation contributed significantly to WRA anemia reduction. Although several common determinants emerged at the proximal and intermediate levels, the set of anemia determinants and the strength of the association between each driver and WRA anemia reduction were unique in each setting included in this review. Further research is needed to provide targeted recommendations for each country and region where WRA anemia prevalence remains high.

Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis

BACKGROUND

Micronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts.

OBJECTIVES

The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs.

METHODS

All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs.

RESULTS

LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential.

CONCLUSIONS

Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.

Evaluating environmental and social influences on iron and zinc status of pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi

Micronutrient deficiency affects over 4.5 billion people worldwide, the majority in developing countries. Deficiencies of iron (and associated anaemia) and zinc in pregnancy are associated with complications, maternal and neonatal mortality, and developmental disorders in the foetus and growing child. We report the results of pilot study which used an interdisciplinary approach to explore environmental and sociocultural factors influencing the micronutrient status in the soil-plant-human transfer for pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi. It evaluated micronutrient status in soil and the staple crop and explored the context for their transfer to pregnant women. Scientific and social science methods were used to collect data, following full sensitisation of the communities. A total of 99 participants were recruited from Chiradzulu (plateau) and Chikwawa (floodplain). Soil, maize and blood samples were collected, along with food frequency and health behaviour questionnaires and anthropological observation. Statistical analysis revealed that soil iron was significantly higher in Chiradzulu than in Chikwawa; total iron concentration is not deemed to be deficient in either area. Soil zinc was not significantly different between areas. Maize concentrations of iron and zinc were not significantly different between areas, and were not deficient relative to improved cultivars. Blood iron deficiency and associated anaemia were problematic in both areas, but more so in Chikwawa than in Chiradzulu, and zinc deficiency was similar in both areas. The study has identified a significant difference in the blood iron status of the participants of the two communities, and has shown that this difference is not accounted for by the staple crop maize. Socio-geographical factors appear to play a significant role in the micronutrient health of the populations. The findings lend support to multifaceted community intervention studies which educate communities on strategies to tackle micronutrient deficiencies.

Soil-type influences human selenium status and underlies widespread selenium deficiency risks in Malawi

Selenium (Se) is an essential human micronutrient with critical roles in immune functioning and antioxidant defence. Estimates of dietary Se intakes and status are scarce for Africa although crop surveys indicate deficiency is probably widespread in Malawi. Here we show that Se deficiency is likely endemic in Malawi based on the Se status of adults consuming food from contrasting soil types. These data are consistent with food balance sheets and composition tables revealing that >80% of the Malawi population is at risk of dietary Se inadequacy. Risk of dietary Se inadequacy is >60% in seven other countries in Southern Africa, and 22% across Africa as a whole. Given that most Malawi soils cannot supply sufficient Se to crops for adequate human nutrition, the cost and benefits of interventions to alleviate Se deficiency should be determined; for example, Se-enriched nitrogen fertilisers could be adopted as in Finland.