Effect of iron-, iodine-, and beta-carotene-fortified biscuits on the micronutrient status of primary school children: a randomized controlled trial

Increased vs. Standard Dose of Iron in Ready-to-Use Therapeutic Foods for the Treatment of Severe Acute Malnutrition in a Community Setting: A Systematic Review and Meta-Analysis

The optimal dose of iron in ready-to-use therapeutic foods (RUTF) used to treat uncomplicated severe acute malnutrition (SAM) in community settings is not well established. The objective of this systematic review was to assess if an increased iron dose in RUTF, compared with the standard iron dose in the World Health Organization (WHO)-recommended peanut-based RUTF, improved outcomes in children aged six months or older. We searched multiple electronic databases and only included randomized controlled trials. We pooled the data in a meta-analysis to obtain relative risk (RR) and reported it with a 95% confidence interval (CI). Three studies, one each from Zambia, the Democratic Republic of Congo, and Malawi, were included. In all studies, the RUTF used in the intervention group was milk-free soya–maize–sorghum-based RUTF. The pooled results showed that, compared to the control group, a high iron content in RUTF may lead to increase in hemoglobin concentration (mean difference 0.33 g/dL, 95% CI: 0.02, 0.64, two studies, certainty of evidence: low) and a decrease in any anemia (RR 0.66, 95% CI: 0.48, 0.91, two studies, certainty of evidence: low), but also decrease recovery rates (RR 0.91, 95% CI: 0.84, 0.99, three studies, certainty of evidence: low) and increase mortality (RR 1.30, 95% CI: 0.87, 1.95, three studies, certainty of evidence: moderate). However, the CIs were imprecise for the latter outcome. Future studies with large sample sizes are needed to confirm the beneficial versus harmful effects of high iron content in RUTF in treating uncomplicated SAM in children aged 6-59 months in community settings.

Micronutrient Fortification of Commercially Available Biscuits Is Predicted to Have Minimal Impact on Prevalence of Inadequate Micronutrient Intakes: Modeling of National Dietary Data From Cameroon

BACKGROUND

Voluntarily fortified snack products are increasingly available but are not necessarily formulated to meet known dietary nutrient gaps, so potential impacts on population micronutrient intake adequacy are uncertain.

OBJECTIVES

We modeled the impacts of hypothetical micronutrient-fortified biscuits on inadequate micronutrient intake in children and women of reproductive age (WRA) in Cameroon.

METHODS

In a nationally representative survey stratified by macro-region (North, South, and Yaoundé/Douala), 24-h dietary recall data were collected from 883 children aged 12-59 mo and from 912 WRA. We estimated usual nutrient intake by the National Cancer Institute method for vitamin A, folate, vitamin B-12, zinc, and iron. We simulated the impact of biscuit fortification on prevalence of micronutrient intake below the estimated average requirement, given observed biscuit consumption, in the presence and absence of large-scale food fortification (LSFF) programs.

RESULTS

Biscuit consumption in the prior 24-h by children and WRA, respectively, ranged from 4.5% and 1.5% in the South, to 20.7% and 5.9% in Yaoundé/Douala. In the absence of LSFF programs, biscuits fortified with retinol (600 μg/100 g), folic acid (300 μg/100 g), and zinc (8 mg/100 g) were predicted to reduce the prevalence of inadequacy among children by 10.3 ± 4.4, 13.2 ± 4.2, and 12.0 ± 6.1 percentage points, respectively, in Yaoundé/Douala. However, when existing vitamin A-fortified oil, and folic acid-fortified and zinc-fortified wheat flour programs were considered, the additional impacts of fortified biscuits were reduced substantially. Micronutrient-fortified biscuits were predicted to have minimal impact on dietary inadequacy in WRA, with or without LSFF programs.

CONCLUSIONS

Given observed patterns of biscuit consumption in Cameroon, biscuit fortification is unlikely to reduce dietary inadequacy of studied micronutrients, except possibly for selected nutrients in children in urban areas in the absence of LSFF programs. As voluntary fortification becomes increasingly common, modeling studies could help guide efforts to ensure that fortified products align with public health goals.

The association of urine markers of iodine intake with development and growth among children in rural Uganda: a secondary analysis of a randomised education trial

OBJECTIVE

We examined associations of urine iodide excretion, proxy for iodine intake, with child development and growth.

DESIGN

This is a secondary analysis of a 1:1 cluster-randomised trial with a 6-month nutrition/stimulation/hygiene education intervention among mothers of children aged 6-8 months to improve child development and growth. Development was assessed using Bayley Scales of Infant and Toddler Development-III (BSID-III) and Ages and Stages Questionnaire (ASQ), whereas anthropometry was used to assess growth. Urine iodide concentration (UIC) and urine iodide/creatinine ratio (ICR) were measured.

SETTING

The current study was conducted in southern Uganda.

PARTICIPANTS

We randomly selected 155 children from the 511 enrolled into the original trial and analysed data when they were aged 20-24 and 36 months.

RESULTS

Median UIC for both study groups at 20-24 and 36 months were similar (P > 0·05) and within the normal range of 100-199 µg/l (0·79-1·60 µmol/l), whereas the intervention group had significantly higher ICR at 20-24 months. The BSID-III cognitive score was positively associated (P = 0·028) with ICR at 20-24 months in the intervention group. The ASQ gross motor score was negatively associated (P = 0·020) with ICR at 20-24 months among the controls. ICR was not significantly associated with anthropometry in the two study groups at either time-point.

CONCLUSIONS

Following the intervention, a positive association was noted between ICR and child's cognitive score at 20-24 months, whereas no positive association with ICR and growth was detected. Iodine sufficiency may be important for child's cognitive development in this setting.

Effectiveness of school-based nutrition interventions in sub-Saharan Africa: a systematic review

OBJECTIVE

To evaluate the effect of school-based nutrition interventions (SBNI) involving schoolchildren and adolescents in sub-Saharan Africa (SSA) on child nutrition status and nutrition-related knowledge, attitudes and behaviour.

DESIGN

A systematic review on published school nutrition intervention studies of randomised controlled trials, controlled clinical trials, controlled before-and-after studies or quasi-experimental designs with control. Nine electronic bibliographic databases were searched. To be included, interventions had to involve changes to the school's physical and social environments, to the school's nutrition policies, to teaching curriculum to incorporate nutrition education and/or to partnership with parents/community.

SETTING

Schools in SSA.

PARTICIPANTS

School-aged children and adolescents, aged 5-19 years.

RESULTS

Fourteen studies met our inclusion criteria. While there are few existing studies of SBNI in SSA, the evidence shows that food supplementation/fortification is very effective in reducing micronutrient deficiencies and can improve nutrition status. Secondly, school nutrition education can improve nutrition knowledge, but this may not necessarily translate into healthy nutrition behaviour, indicating that nutrition knowledge may have little impact without a facilitating environment. Results regarding anthropometry were inconclusive; however, there is evidence for the effectiveness of SBNI in improving cognitive abilities.

CONCLUSIONS

There is enough evidence to warrant further trials of SBNI in SSA. Future research should consider investigating the impact of SBNI on anthropometry and nutrition behaviour, focusing on the role of programme intensity and/or duration. To address the high incidence of micronutrient deficiencies in low- and middle-income countries, food supplementation strategies currently available to schoolchildren should be expanded.

Can School Feeding Programs Reduce Malnutrition in Rural China?

BACKGROUND

Childhood malnutrition is commonplace among poor rural communities in China. In 2012, China launched its first nationwide school-feeding program (SFP) to address this problem. This study examines the prevalence of malnutrition before and after the SFP and identifies possible reasons for the trends observed.

METHODS

Ordinary least squares regression and propensity score matching were used to analyze data from 2 cross-sectional surveys of 100 rural primary schools in northwestern China. Participants were fourth-and fifth-grade students. Outcome measures include anemia rates, hemoglobin levels, body mass index, and height for age Z scores.

RESULTS

Three years after implementation of the SFP, malnutrition rates among sample students had not fallen. The SFP had no statistically significant effect on either anemia rates or BMI, but was linked to an increase in the proportion of students with below normal height for age Z scores. Meals provided to students fell far short of national recommendations that the SPF should provide 40% of the recommended daily allowance of micronutrients.

CONCLUSIONS

Despite significant budgetary outlays between 2012 and 2015, China's SFP has not reduced the prevalence of malnutrition among sample students. To make the SFP more effective, funding and human resources both need to be increased.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Systematic review and meta-analysis of the effect of iron-fortified flour on iron status of populations worldwide

Objective:

Assess the effectiveness of iron-fortified flour on iron status.

Design:

Systematic review and meta-analysis.

Setting:

Argentina, Australia, Azerbaijan, Bangladesh, Brazil, Cameroon, Chile, China, Costa Rica, Côte d’Ivoire, Denmark, India, Iran, Jordan, Kazakhstan, Kenya, Kuwait, Mongolia, Morocco, Norway, South Africa, Sri Lanka, Tajikistan, Thailand, UK, USA, Uzbekistan, Venezuela, Vietnam, and Zambia.

Participants:

Fifty-two articles (ninety-four trials) were examined. The main target groups were women, children, and infants/toddlers. The effects of different types of iron-fortified flour (wheat, maize, rice, soy, and beans) on iron status were examined.

Results:

A random effects analysis of before–after studies showed that iron-fortified flour led to significant increases of mean haemoglobin level (3·360 g/l; 95 % CI: 0·980, 5·730) and mean serum ferritin level (4·518 µg/l; 95 % CI: 2·367, 6·669); significant decreases of anaemia (−6·7 %; 95 % CI: −9·8 %, −3·6 %) and iron deficiency (ID) (−10·4 %; 95 % CI: −14·3 %, −6·5 %); but had no significant effect on iron deficiency anaemia (IDA). A random effects analysis of controlled trials indicated that iron-fortified flour led to significant increases of mean haemoglobin level (2·630 g/l; 95 % CI: 1·310, 3·950) and mean ferritin level (8·544 µg/l; 95 % CI: 6·767, 10·320); and significant decreases of anaemia (−8·1 %; 95 % CI: −11·7 %, −4·4 %), ID (−12·0 %; 95 % CI: −18·9 %, −5·1 %), and IDA (−20·9 %; 95 % CI: −38·4 %, −3·4 %).

Conclusions:

Flour fortification with iron is an effective public health strategy that improves iron status of populations worldwide.

Fortification of staple foods with vitamin A for vitamin A deficiency

BACKGROUND

Vitamin A deficiency is a significant public health problem in many low- and middle-income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups.

OBJECTIVES

To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health-related outcomes in the general population older than two years of age.

SEARCH METHODS

We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI-exp and CPCI-SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus - AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018.

SELECTION CRITERIA

We included individually or cluster-randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review.

MAIN RESULTS

We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low- and upper-middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest.Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention.The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non-governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results.Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI -0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low-certainty evidence). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low-certainty evidence). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency.It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low-certainty evidence). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias.Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison.Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI -0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low-certainty evidence). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias.In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate-certainty evidence). The certainty of the evidence was mainly affected by serious risk of bias.Staple foods fortified with vitamin A plus other micronutrients versus no interventionFortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low-certainty evidence). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low-certainty evidence) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias.No trials reported on the outcomes of all-cause morbidity, all-cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women).

AUTHORS' CONCLUSIONS

Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency.Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low.It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes.The type of funding source for the studies did not appear to distort the results from the analysis.

School Feeding Reduces Anemia Prevalence in Adolescent Girls and Other Vulnerable Household Members in a Cluster Randomized Controlled Trial in Uganda

BACKGROUND

Food for education (FFE) programs that include school meals are widely used to improve school participation and performance, but evidence on nutritional benefits is limited.

OBJECTIVE

This study tested whether food fortified with multiple micronutrients provided in FFE programs reduced anemia prevalence of primary-school-age adolescent girls, adult women, and preschool children.

METHODS

Through the use of a cluster randomized controlled trial with individual-level repeated cross-sectional data, we measured impacts on anemia prevalence from 2 FFE programs, a school feeding program (SFP) providing multiple-micronutrient-fortified meals and a nutritionally equivalent take-home ration (THR). Camps for internally displaced people (IDP) (n = 31) in Northern Uganda were randomly assigned to SFP, THR, or a control group with no FFE. Rations were provided for 15 mo at SFP and THR schools. A survey of households (n = 627) with children aged 6-17 y was conducted (baseline and 18 mo later). Analyses used difference-in-differences by intent to treat.

RESULTS

Adolescent girls aged 10-13 y in FFE schools experienced a significant (P < 0.05) 25.7 percentage point reduction (95% CI: -0.43, -0.08) in prevalence of any anemia [hemoglobin (Hb) <11.5 g/dL, age 10-11 y; Hb <12 g/dL, age 12-13 y] and a significant 19.5 percentage point reduction (95% CI: -0.35, -0.04) in moderate-to-severe anemia (Hb <11 g/dL) relative to the control group, with no difference in impact between SFP and THR. The THR reduced moderate-to-severe anemia prevalence (Hb <11g/dL) of adult women aged ≥18 y (12.8 percentage points, 95% CI: -0.24, -0.02). All IDP camps initially received micronutrient-fortified rations through a separate humanitarian program; in one district where most households stopped receiving these rations, SFP reduced moderate-to-severe anemia of children aged 6-59 mo by 22.1 percentage points (95% CI: -0.42, -0.02).

CONCLUSIONS

FFE programs reduced any anemia and moderate-to-severe anemia in primary-school-age adolescent girls and reduced moderate-to-severe anemia for adult women and preschool children. This study was registered with clinicaltrials.gov as NCT01261182.

Iodine-fortified toddler milk improves dietary iodine intakes and iodine status in toddlers: a randomised controlled trial

PURPOSE

We aimed to evaluate the effectiveness of consuming iodine-fortified toddler milk for improving dietary iodine intakes and biochemical iodine status in toddlers.

METHODS

In a 20-week parallel randomised controlled trial, healthy 12-20-month-old children were assigned to: Fortified Milk [n = 45; iodine-fortified (21.1 µg iodine/100 g prepared drink) cow's milk], or Non-Fortified Milk (n = 90; non-fortified cow's milk). Food and nutrient intakes were assessed with 3-day weighed food records at baseline, and weeks 4 and 20. Urinary iodine concentration (UIC) was measured at baseline and 20 weeks.

RESULTS

At baseline, toddlers' median milk intake was 429 g/day. There was no evidence that milk intakes changed within or between the groups during the intervention. Toddlers' baseline geometric mean iodine intake was 46.9 µg/day, and the median UIC of 43 µg/L in the Fortified Milk group and 55 µg/L in the Non-Fortified Milk group indicated moderate and mild iodine deficiency, respectively, with this difference due to chance. During the intervention, iodine intakes increased by 136% (p < 0.001) and UIC increased by 85 µg/L (p < 0.001) in the Fortified Milk group compared to the Non-Fortified Milk group. The 20-week median UIC was 91 µg/L in the Fortified Milk group and 49 µg/L in the Non-Fortified Milk group.

CONCLUSIONS

Consumption of ≈ 1.7 cups of iodine-fortified toddler milk per day for 20 weeks can increase dietary iodine intakes and UIC in healthy iodine-deficient toddlers. This strategy alone is unlikely to provide sufficient intake to ensure adequate iodine status in toddlers at risk of mild-to-moderate iodine deficiency.

Iodine fortification of foods and condiments, other than salt, for preventing iodine deficiency disorders

BACKGROUND

Iodine deficiency disorders (IDD) affect close to 1.9 billion people worldwide, and are a major public health concern in many countries. Among children, iodine deficiency is the main cause of potentially preventable deficits of central nervous system development and impairment of cognitive function, as well as goitre and hypothyroidism in people of all ages. Salt iodisation is the preferred strategy for IDD prevention and control, however, in some instances where salt is not the major condiment, alternate vehicles for iodine fortification have been considered.

OBJECTIVES

To assess the effects of fortifying foods, beverages, condiments, or seasonings other than salt with iodine alone or in conjunction with other micronutrients, on iodine status and health-related outcomes in all populations.

SEARCH METHODS

Studies were identified through systematic searches of the following databases from their start date to January 2018: Cochrane Public Health Group Specialised Register; CENTRAL; MEDLINE; MEDLINE in Process; Embase; Web of Science; CINAHL; POPLINE; AGRICOLA; BIOSIS; Food Science and Technology Abstracts; OpenGrey; Bibliomap and TRoPHI; AGRIS; IBECS; Scielo; Global Index Medicus-AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched reference list of relevant articles, conference proceedings, and databases of ongoing trials, and contacted experts and relevant organisations to identify any unpublished work. We applied no language or date restrictions.

SELECTION CRITERIA

Studies were eligible if they were randomised or quasi-randomised controlled trials (RCT) with randomisation at either the individual or cluster level (including cross-over trials), non-randomised RCTs, or prospective observational studies with a control group, such as cohort studies, controlled before-and-after studies, and interrupted time series. We included studies that examined the effects of fortification of food, beverage, condiment, or seasoning with iodine alone, or in combination with other micronutrients versus the same unfortified food, or no intervention. We considered the following measures: death (all-cause), goitre, physical development, mental development, cognitive function and motor skill development, cretinism, hypothyroidism, adverse effects (any reported by trialists), urinary iodine concentration, thyroid-stimulating hormone (TSH) concentration, and serum thyroglobulin concentration. We included all populations, including pregnant women, from any country.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias of included studies.We used random-effects meta-analyses to combine data and generate an overall estimate of treatment effect, when more than one study examined the same outcome measure. The overall effect estimate was calculated as the mean difference (MD) or standardised mean difference (SMD) between the intervention group and the comparison group for continuous outcomes, and as odds ratio (OR) for dichotomous outcomes. We assessed the level of heterogeneity through the I² statistic. We conducted post-hoc subgroup analyses to explore possible sources of heterogeneity, and sensitivity analyses to check the robustness of the findings from the primary analyses. We assessed the quality of the evidence for each outcome using the GRADE framework.Where it was not possible to pool the results in a meta-analysis, we provided a narrative summary of the outcomes.

MAIN RESULTS

Eleven studies met the criteria, providing 14 comparisons, and capturing data on 4317 participants. Seven studies were RCTs, three were cluster non-RCTs, and one was a randomised cross-over design. Seven studies were carried out among school children (N = 3636), three among women of reproductive age (N = 648), and one among infants (N = 33). The studies used diverse types of food as vehicle for iodine delivery: biscuits, milk, fish sauce, drinking water, yoghourt, fruit beverage, seasoning powder, and infant formula milk. Daily amounts of iodine provided ranged from 35 µg/day to 220 µg/day; trial duration ranged from 11 days to 48 weeks. Five studies examined the effect of iodine fortification alone, two against the same unfortified food, and three against no intervention. Six studies evaluated the effect of cofortification of iodine with other micronutrients versus the same food without iodine but with different levels of other micronutrients. We assessed one study to be at low risk of bias for all bias domains, three at low risk of bias for all domains apart from selective reporting, and seven at an overall rating of high risk of bias.No study assessed the primary outcomes of death, mental development, cognitive function, cretinism, or hypothyroidism, or secondary outcomes of TSH or serum thyroglobulin concentration. Two studies reported the effects on goitre, one on physical development measures, and one on adverse effects. All studies assessed urinary iodine concentration.The effects of iodine fortification compared to control on goitre prevalence (OR 1.60, 95% CI 0.60 to 4.31; 1 non-RCT, 83 participants; very low-quality evidence), and five physical development measures were uncertain (1 non-RCT, 83 participants; very low-quality evidence): weight (MD 0.23 kg, 95% CI -6.30 to 6.77); height (MD -0.66 cm, 95% CI -4.64 to 3.33); weight-for-age (MD 0.05, 95% CI -0.59 to 0.69); height-for-age (MD -0.30, 95% CI -0.75 to 0.15); and weight-for-height (MD -0.21, 95% CI -0.51 to 0.10). One study reported that there were no adverse events observed during the cross-over trial (low-quality evidence).Pooled results from RCTs showed that urinary iodine concentration significantly increased following iodine fortification (SMD 0.59, 95% CI 0.37 to 0.81; 6 RCTs, 2032 participants; moderate-quality evidence). This is equivalent to an increase of 38.32 µg/L (95% CI 24.03 to 52.61 µg/L). This effect was not observed in the meta-analysis of non-RCTs (SMD 0.25, 95% CI -0.16 to 0.66; 3 non-RCTs, 262 participants; very low-quality evidence). Sensitivity analyses did not change the effect observed in the primary analyses.

AUTHORS' CONCLUSIONS

The evidence on the effect of iodine fortification of foods, beverages, condiments, or seasonings other than salt on reducing goitre, improving physical development measures, and any adverse effects is uncertain. However, our findings suggest that the intervention likely increases urinary iodine concentration. Additional, adequately powered, high-quality studies on the effects of iodine fortification of foods on these, and other important outcomes, as well as its efficacy and safety, are required.

Health effects of micronutrient fortified dairy products and cereal food for children and adolescents: A systematic review

INTRODUCTION

Micronutrient (MN) deficiencies cause a considerable burden of disease for children in many countries. Dairy products or cereals are an important food component during adolescence. Fortification of dairy products or cereals with MN may be an effective strategy to overcome MN deficiencies, but their specific impact on health in this age group is poorly documented.

METHODS

We performed a systematic review and meta-analysis (registration number CRD42016039554) to assess the impact of MN fortified dairy products and cereal food on the health of children and adolescents (aged 5-15 years) compared with non-fortified food. We reviewed randomised controlled trials (RCT) using electronic databases (MEDLINE, EMBASE, Cochrane library; latest search: January 2018), reference list screening and citation searches. Three pairs of reviewers assessed 2048 studies for eligibility and extracted data. We assessed the risk of bias and applied GRADE to rate quality of evidence.

RESULTS

We included 24 RCT (often multi MN fortification) with 30 pair-wise comparisons mainly from low- and middle income countries. A very small and non-significant increase of haemoglobin values emerged (0.09 g/dl [95%-CI: -0.01 to 0.18]; 13 RCT with iron fortification; very low quality of evidence). No significant difference was found on anaemia risk (risk ratio 0.87 [95%-CI: 0.76 to 1.01]; 12 RCT; very low quality), but a significant difference in iron deficiency anaemia favouring fortified food was found (risk ratio 0.38 [95%-CI: 0.18 to 0.81]; 5 RCT; very low quality). Similar effects were seen for fortified dairy products and cereals and different fortification strategies (mono- vs. dual- vs. multi-MN). Follow-up periods were often short and the impact on anthropometric measures was weak (low quality of evidence) Very low quality of evidence emerged for the improvement of cognitive performance, functional measures and morbidity.

CONCLUSIONS

Fortification of dairy products and cereal food had only marginal health effects in our sample population from 5-15 years. Further evidence is needed to better understand the health impact of fortified dairy products and cereals in this age group.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 26 May 2016 (registration number CRD42016039554).

WITHDRAWN: Iodine supplementation for preventing iodine deficiency disorders in children

BACKGROUND

Iodine deficiency is the main cause of potentially preventable mental retardation in childhood, as well as causing goitre and hypothyroidism in people of all ages. It is still prevalent in large parts of the world.

OBJECTIVES

To assess the effects of iodine supplementation overall, and of different forms and dosages of iodine supplementation separately, in the prevention of iodine deficiency disorders in children.

SEARCH METHODS

The Cochrane Library, MEDLINE, EMBASE and reference lists, databases of ongoing trials and the Internet were searched.

SELECTION CRITERIA

We included randomised controlled trials and prospective controlled trials not using randomisation of iodine supplementation in children living in areas of iodine deficiency.

DATA COLLECTION AND ANALYSIS

Two reviewers did the initial data selection and quality assessment of trials independently. As the studies identified were not sufficiently similar and not of sufficient quality, we did not do a meta-analysis but summarised the data in a narrative format.

MAIN RESULTS

Twenty-six prospective controlled trials were related to our question, assessing a total of 29613 children. Twenty of them were classified as being of low quality, six of moderate quality. Most studies used iodised oil as a supplement, but other supplements were also used. The intervention groups were compared to a non-supplemented control group, different doses or different forms of iodine supplementation.There was a clear tendency towards goitre reduction with iodine supplementation; this was significant in several studies. Significant differences in physical development were not seen, except in one study. Results for differences in cognitive and psychomotor measures were mixed, with only few studies showing a positive intervention effect. One study suggested that infant mortality was lowered after iodine supplementation.Most studies showed a significant increase in urinary iodine excretion and levels recommended by the WHO were reached in most cases after supplementation. Thyroid-stimulating hormone (TSH) levels were significantly reduced in one study. In 1.8% of the children investigated, adverse effects were found, most of them were minor and transient.

AUTHORS' CONCLUSIONS

Despite most of the included studies being of low quality, the results suggest that iodine supplementation, especially iodised oil, is an effective means of decreasing goitre rates and improving iodine status in children. Indications of positive effects on physical and mental development and mortality were seen, although results were not always significant. Adverse effects were generally minor and transient. Insufficient evidence was available on non-oil supplements. High quality controlled studies investigating relevant long term outcome measures are needed to address the question of the best form of iodine supplementation in different population groups and settings.

Efficacy Trials of a Micronutrient Dietary Supplement in Schoolchildren and Pregnant Women in Tanzania

Traditionally, the main strategies used to control micronutrient deficiencies have been food diversification, consumption of medicinal supplements, and food fortification. In Tanzania, we conducted efficacy trials using a dietary supplement as a fourth approach. These were randomized, double-blind, placebo-controlled efficacy trials conducted separately first in children and later in pregnant women. The dietary supplement was a powder used to prepare an orange-flavored beverage. In the school trial, children consumed 25 g per school day attended. In the pregnancy trial, women consumed the contents of two 25-g sachets per day with meals. This dietary supplement, unlike most medicinal supplements, provided 11 micronutrients, including iron and vitamin A, in physiologic amounts. In both trials we compared changes in subjects consuming either the fortified or the nonfortified supplement. Measures of iron and vitamin A status were similar in the groups at the baseline examination, but significantly different at follow-up, always in favor of the fortified groups. Children receiving the fortified supplement had significantly improved anthropometric measures when compared with controls. At four weeks postpartum, the breast milk of a supplemented group of women had significantly higher mean retinol content than did the milk of mothers consuming the nonfortified supplement. The advantages of using a fortified dietary supplement, compared with other approaches, include its ability to control several micronutrient deficiencies simultaneously; the use of physiologic amounts of nutrients, rather than megadoses that require medical supervision; and the likelihood of better compliance than with the use of pills because subjects liked the beverage used in these trials.

Effect of a Multiple-Micronutrient-Fortified Fruit Powder Beverage on the Nutrition Status, Physical Fitness, and Cognitive Performance of Schoolchildren in the Philippines

This study aimed to determine the effect of a multiple-micronutrient-fortified beverage on the micronutrient status, physical fitness, and cognitive performance of schoolchildren. The study was a randomized, double-blind, placebo-controlled trial of schoolchildren assigned to receive either the fortified or nonfortified beverage with or without anthelmintic therapy. Data on hemoglobin level, urinary iodine excretion (UIE) level, physical fitness, and cognitive performance were collected at baseline and at 16 weeks post-intervention. The fortified beverage significantly improved iron status among the subjects that had hemoglobin levels < 11 g/dl at baseline. The proportion of children who remained moderately to severely anemic was significantly lower among those given the fortified beverage. In the groups that received the fortified product, the median UIE level increased, whereas among those who received the placebo beverage, the median UIE level was reduced significantly. Iron- and/or iodine-deficient subjects who received the fortified beverage showed significant improvements in fitness (post-exercise reduction of heart rate) and cognitive performance (nonverbal mental ability score). The study showed that consumption of a multiple-micronutrient-fortified beverage for 16 weeks had significant effects on iron status, iodine status, physical fitness, and cognitive performance among iron- and/or iodine-deficient Filipino schoolchildren. Anthelmintic therapy improved iron status of anemic children and iodine status of the iron-adequate children at baseline but it had no effect on physical fitness and cognitive performance. The results from the clinical study showed that a multiple-micronutrient-fortified beverage could play an important role in preventing and controlling micronutrient deficiencies.

Improved absorption of β-carotene by encapsulation in an oil-in-water nanoemulsion containing tea polyphenols in the aqueous phase

β-Carotene (BC) serves as an important source of provitamin A and natural edible pigment, but the application is limited because of its instability and low oral-bioavailability. A tea polyphenols-β-carotene (TP-BC) oil-in-water (O/W) nanoemulsion was prepared with the core oil phase containing BC and the water phase containing TP. During storage at three different temperatures (4, 25 and 35 °C), the TP-BC nanoemulsion had a better stability and higher retention rate of BC than BC nanoemulsion. An in vitro simulated digestion assay indicated that the BC recovery rates of TP-BC nanoemulsion at digestion phases I and II were significantly increased compared to the BC nanoemulsion. An in vivo absorption study showed that TP-BC nanoemulsion had higher conversion efficiency on vitamin A compared to the BC nanoemulsion. These results suggested that tea polyphenols are effective ingredients for improving the oral-bioavailability of BC.

Sanitation, Disease Externalities and Anaemia: Evidence From Nepal

Anaemia impairs physical and cognitive development in children and reduces human capital accumulation. The prior economics literature has focused on the role of inadequate nutrition in causing anaemia. This article is the first to show that sanitation, a public good, significantly contributes to preventing anaemia. We identify effects by exploiting rapid and differential improvement in sanitation across regions of Nepal between 2006 and 2011. Within regions over time, cohorts of children exposed to better community sanitation developed higher haemoglobin levels. Our results highlight a previously undocumented externality of open defaecation, which is today practiced by over a billion people worldwide.

A Randomized, Double-Blind Study Assessing Changes in Cognitive Function in Indian School Children Receiving a Combination of Bacopa monnieri and Micronutrient Supplementation vs. Placebo

Several studies have indicated a chronic cognitive enhancing effect of Bacopa monnieri across different ages and cognitive impairment associated with vitamin and mineral deficiencies in children. Therefore, we investigated the effects of 4-month supplementation with a combination of B. monnieri extract and multiple micronutrients on cognitive functions in Indian school children aged 7–12 years. This was a randomized, double-blind, parallel design, single-center study in which 300 children were randomized to receive a beverage either fortified with B. monnieri and multiple micronutrients (“fortified”) or a non-fortified isocaloric equivalent (“control”) twice-daily for 4 months. Cognitive function was assessed by the Cambridge Neuropsychological Automated Test Battery (CANTAB) administered at baseline, Day 60 and Day 121. The primary endpoint was change in short-term memory (working memory) from baseline in subjects receiving “fortified” vs. “control” beverages after 4 months. Secondary endpoints included sustained attention, episodic memory, and executive function. The “fortified” beverage did not significantly improve short-term memory or any of the secondary outcomes tested relative to the “control” beverage. However, the spatial working memory “strategy” score showed significant improvement on Day 60 (difference between groups in change from baseline: −0.55; p < 0.05), but not on Day 121 due to the active intervention. Study products were well-tolerated. Reasons for these unexpected findings are discussed.

Locally Sustainable School Lunch Intervention Improves Hemoglobin and Hematocrit Levels and Body Mass Index among Elementary Schoolchildren in Rural West Java, Indonesia

School lunch is not provided in public elementary schools in Indonesia, and students frequently buy and eat snacks at school. We hypothesized that providing a traditional Sundanese meal as school lunch would be beneficial for children in rural West Java. To test this hypothesis, we evaluated the effect of a 1-month school lunch intervention aiming at sustainability and based on children’s nutritional intake, hemoglobin and hematocrit levels, and body mass index (BMI). A lunch (including rice, vegetable dish, animal protein dish, plant protein dish, and fruit) containing one-third of the recommended daily allowance of energy was offered every school day for 1 month, targeting 68 fourth-grade elementary schoolchildren. At baseline, the prevalence of anemia was 33.3%. The prevalence of stunting and underweight were 32.4% and 2.9%, respectively, whereas that of overweight and obesity combined was 17.6%, indicating a double burden of malnutrition among the subjects. During the intervention, intakes of protein (p < 0.05), calcium (p < 0.05), and vitamin C (p < 0.001) significantly increased, while that of fat significantly decreased (p < 0.001). After the intervention, hemoglobin (p < 0.05) and hematocrit (p < 0.05) levels were significantly improved, thereby almost halving the rate of anemia. These changes were significantly larger in the baseline anemic group than the non-anemic group (p < 0.01). BMI significantly increased in the baseline underweight/normal group (p < 0.001) but not in the overweight/obese group. The school lunch intervention significantly improved nutritional intakes and health statuses, implying its potential for reducing anemia and resolving the double burden of malnutrition among rural Indonesian schoolchildren.

Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh

BACKGROUND

Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group.

OBJECTIVE

We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.

METHODS

We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities.

RESULTS

Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels.

CONCLUSIONS

This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.

Using the School Feeding System as a Vehicle for Micronutrient Fortification: Experience from South Africa

School-age children are often a neglected group in terms of micronutrient interventions because they are not reached by the intervention strategies aimed at preschool children or pregnant women. School feeding, however, offers an excellent opportunity for targeted intervention in this age group, especially with regard to fortification. This paper first gives a brief overview of the school-feeding program in South Africa, and second reports on a number of trials conducted in South African schools by the South Africa Medical Research Council that examined the feasibility of using school feeding as a vehicle for micronutrient fortification. Various food items, such as biscuits, bread spread, and soup, are evaluated as potential carriers for micronutrients with positive effects on outcomes such as micronutrient status, growth, morbidity and cognitive function. For schoolchildren to realize their full mental and physical potential and to perform optimally at school, both short-term hunger and hidden hunger (micronutrient deficiencies) need to be addressed. School feeding has the potential to contribute toward alleviating both of these conditions and should therefore be fully utilized.

Can the Provision of Breakfast Benefit School Performance?

Studies of an association between school performance (enrollment, attendance, achievement, classroom behavior, and school drop-out) and nutritional status are discussed and the evidence of an effect of school meals evaluated. Many studies have shown associations between hunger, poor dietary intakes, stunting, underweight, and poor school performance after controlling for socioeconomic conditions. However, it remains possible that unmeasured socioeconomic variables could explain the relationship. Rigorous short-term studies of missing breakfast have generally found detrimental effects on children's cognition whereas studies of providing breakfast have shown benefits particularly in malnourished children. Classroom conditions may modify the effects of breakfast on behavior. There are extremely few longer term studies of the effects of giving school meals. Nearly all involved breakfast and very few had randomized controlled designs. Studies comparing participants with non-participants or comparing matched schools have found benefits (but bias due to self-selection) of receiving breakfast; inadequate matching of schools also remains possible. One longer term randomized controlled trial found benefits associated with attendance and arithmetic performance. In conclusion, most studies of giving breakfast have found benefits to school performance but many had serious design problems, were short-term, and were not conducted in the poorest countries. In order to advise policy makers correctly, there is an urgent need to run long-term randomized controlled trials of giving school meals in poor countries and to determine the effects of age and nutrition status of the children, the quality of the school, and the timing of the meal. The special needs of orphans should also be considered.

Efficacy Trials of a Micronutrient Dietary Supplement in Schoolchildren and Pregnant Women in Tanzania

Traditionally, the main strategies used to control micronutrient deficiencies have been food diversification, consumption of medicinal supplements, and food fortification. In Tanzania, we conducted efficacy trials using a dietary supplement as a fourth approach. These were randomized, double-blind, placebo-controlled efficacy trials conducted separately first in children and later in pregnant women. The dietary supplement was a powder used to prepare an orange-flavored beverage. In the school trial, children consumed 25 g per school day attended. In the pregnancy trial, women consumed the contents of two 25-g sachets per day with meals. This dietary supplement, unlike most medicinal supplements, provided 11 micronutrients, including iron and vitamin A, in physiologic amounts. In both trials we compared changes in subjects consuming either the fortified or the nonfortified supplement. Measures of iron and vitamin A status were similar in the groups at the baseline examination, but significantly different at follow-up, always in favor of the fortified groups. Children receiving the fortified supplement had significantly improved anthropometric measures when compared with controls. At four weeks postpartum, the breast milk of a supplemented group of women had significantly higher mean retinol content than did the milk of mothers consuming the nonfortified supplement. The advantages of using a fortified dietary supplement, compared with other approaches, include its ability to control several micronutrient deficiencies simultaneously; the use of physiologic amounts of nutrients, rather than megadoses that require medical supervision; and the likelihood of better compliance than with the use of pills because subjects liked the beverage used in these trials.

Effect of a Multiple-Micronutrient-Fortified Fruit Powder Beverage on the Nutrition Status, Physical Fitness, and Cognitive Performance of Schoolchildren in the Philippines

This study aimed to determine the effect of a multiple-micronutrient-fortified beverage on the micronutrient status, physical fitness, and cognitive performance of schoolchildren. The study was a randomized, double-blind, placebo-controlled trial of schoolchildren assigned to receive either the fortified or nonfortified beverage with or without anthelmintic therapy. Data on hemoglobin level, urinary iodine excretion (UIE) level, physical fitness, and cognitive performance were collected at baseline and at 16 weeks post-intervention. The fortified beverage significantly improved iron status among the subjects that had hemoglobin levels < 11 g/dl at baseline. The proportion of children who remained moderately to severely anemic was significantly lower among those given the fortified beverage. In the groups that received the fortified product, the median UIE level increased, whereas among those who received the placebo beverage, the median UIE level was reduced significantly. Iron- and/or iodine-deficient subjects who received the fortified beverage showed significant improvements in fitness (post-exercise reduction of heart rate) and cognitive performance (nonverbal mental ability score). The study showed that consumption of a multiple-micronutrient-fortified beverage for 16 weeks had significant effects on iron status, iodine status, physical fitness, and cognitive performance among iron- and/or iodine-deficient Filipino schoolchildren. Anthelmintic therapy improved iron status of anemic children and iodine status of the iron-adequate children at baseline but it had no effect on physical fitness and cognitive performance. The results from the clinical study showed that a multiple-micronutrient-fortified beverage could play an important role in preventing and controlling micronutrient deficiencies.

Red Palm Oil in the Maternal Diet Improves the Vitamin A Status of Lactating Mothers and Their Infants

Improvement of the vitamin A status of lactating mothers and their nursing infants following maternal palm oil consumption was comparable to that following supplementation with purified β-carotene. Mothers who consumed β-carotene as red palm oil had 2.1- and 2.5-fold increases in their serum and milk β-carotene concentrations, respectively, and 2.8- and 3.2-fold increases in their serum and milk α-carotene concentrations, respectively. Infant serum retinol concentrations were significantly increased following maternal supplementation with red palm oil or β-carotene. Maternal intake of red palm oil or β-carotene supplements did not alter infant serum carotenoids, maternal serum retinol, or milk retinol. Because the local diet includes foods prepared with oil, the possibility that red palm oil could provide a significant source of provitamin A carotenoids for Honduran women and children should be further investigated.

South African Experience with the Use of Red Palm Oil to Improve the Vitamin A Status of Primary Schoolchildren

A randomized, controlled, three-month trial compared the effect of biscuits containing red palm oil as a source of β-carotene and biscuits containing synthetic β-carotene on the vitamin A status of primary schoolchildren. Children consuming either type of fortified biscuit had a significant improvement in serum retinol concentrations compared with control children who received an unfortified biscuit. Using a red palm oil shortening in the biscuit has several other advantages. Unlike the commercial fat normally used in the baking industry, red palm oil contains no trans fatty acids. Because of its high carotenoid and vitamin E contents, the need to add synthetic β-carotene and antioxidant to the baking mix is eliminated. Quality control is simplified. Production costs for the red palm oil biscuit are slightly lower than those for the synthetic β-carotene biscuit. Red palm oil is thus ideally suited for use as a source of β-carotene in food fortification in the baking industry.

Double-blind cluster randomised controlled trial of wheat flour chapatti fortified with micronutrients on the status of vitamin A and iron in school-aged children in rural Bangladesh

Food fortification is a cost-effective and sustainable strategy to prevent or correct micronutrient deficiencies. A double-blind cluster (bari) randomised controlled trial was conducted in a rural community in Bangladesh to evaluate the impact of consumption of chapatti made of micronutrient-fortified wheat flour for 6 months by school-aged children on their vitamin A, haemoglobin and iron status. A total of 43 baris (group of households) were randomly selected. The baris were randomly assigned to either intervention or control group. The intervention group received wheat flour fortified with added micronutrients (including 66 mg hydrogen-reduced elemental iron and 3030 μg retinol equivalent as retinyl palmitate per kilogram of flour), while the control group received wheat flour without added micronutrients. A total of 352 children were enrolled in the trial, 203 in the intervention group and 149 in the control group. Analyses were carried out on children who completed the study (191 in the intervention group and 143 in the control group). Micronutrient-fortified wheat flour chapatti significantly increased serum retinol concentration at 6 months by 0.12 μmol L(-1) [95% confidence interval (CI): 0.06, 0.19; P < 0.01]. The odds of vitamin A deficiency was significantly lower for children in the intervention group at 3 months [odds ratio (OR) = 0.26; 95% confidence interval (CI): 0.07, 0.89; P < 0.05] and 6 months (OR = 0.21; 95% CI: 0.06, 0.68; P < 0.01). No demonstrable effect of fortified chapatti consumption on iron status, haemoglobin levels or anaemia was observed. Consumption of fortified chapattis demonstrated a significant improvement in the vitamin A status, but not in iron, haemoglobin or anaemia status.

Association between household unavailability of iodized salt and child growth: evidence from 89 demographic and health surveys

BACKGROUND

Although a strong biological basis exists for a role of iodine in somatic growth failure in childhood, this relation has not been previously studied on a large scale to our knowledge.

OBJECTIVE

We investigated if a general association exists between the household unavailability of iodized salt and child growth across countries.

DESIGN

We used 89 nationally representative, repeated, cross-sectional and mutually comparable demographic and health surveys that were conducted between 1994 and 2012 across 46 low- and middle-income countries. We analyzed the data for the outcome variables of stunting (low height-for-age), underweight (low weight-for-age), wasting (low weight-for-height), and low birth weight in children aged between 0 and 59 mo at the time of the interview with the use of logistic regression models. Our samples consisted of 390,328 children for the stunting analysis, 397,080 children for the underweight analysis, 384,163 children for the wasting analysis, and 187,744 children for the low-birth-weight analysis. Models were adjusted for individual, maternal, and household covariates and fixed effects on the level of the primary sampling unit.

RESULTS

In the fully adjusted models, the unavailability of iodized salt was associated with 3% higher odds of being stunted (95% CI of ORs: 1.00, 1.06; P = 0.04), 5% higher odds of being underweight (95% CI: 1.02, 1.09; P < 0.01), and 9% higher odds of low birth weight (95% CI: 1.02, 1.17; P = 0.01). When India was excluded from the sample, the association was only statistically significant (P = 0.05) for low birth weight.

CONCLUSION

Although we did not establish causality in our analysis, the findings might indicate that the causal effect of iodized salt on child growth, if it exists, is most profound in utero and is not universally effective across all countries with respect to longer-run child-growth outcomes such as stunting and underweight.

Fortified Iodine Milk Improves Iodine Status and Cognitive Abilities in Schoolchildren Aged 7-9 Years Living in a Rural Mountainous Area of Morocco

Iodine is required for the production of the thyroid hormones essential for the growth and development of the brain. All forms of iodine deficiency (ID) affect the mental development of the child. Our study aims to assess the impact of ID on the intellectual development of Moroccan schoolchildren and to evaluate the effect of consumption of fortified milk on reducing ID. In a double-blind controlled trial conducted on schoolchildren, children were divided into two groups to receive fortified milk (30% of cover of RDI iodine) or nonfortified milk for 9 months. Urinary iodine was analyzed using the Sandell-Kolthoff reaction, a dynamic cognitive test using Raven's Standard Progressive Matrices to assess learning potential was performed at baseline and end line, and anthropometric assessment was done only at baseline. The study included schoolchildren who were severely iodine deficient. The prevalence of malnutrition was high in both groups; in this study, we found improvements in iodine status and in cognitive abilities among Moroccan schoolchildren. Our study showed that the consumption of fortified milk led to a clear improvement in iodine status and also appeared to have a favorable effect on the cognitive ability of Moroccan schoolchildren in a rural mountainous region.

Ready-to-use supplementary food increases fat mass and BMI in Haitian school-aged children

BACKGROUND

In Haiti and other countries, large-scale investments in school feeding programs have been made with marginal evidence of nutrition outcomes.

OBJECTIVE

We aimed to examine the effectiveness of a fortified ready-to-use supplementary food (RUSF), Mamba, on reduced anemia and improved body composition in school-aged children compared to an unfortified cereal bar, Tablet Yo, and control groups.

METHODS

A cluster, randomized trial with children ages 3-13 y (n = 1167) was conducted in the north of Haiti. Six schools were matched and randomized to the control group, Tablet Yo group (42 g, 165 kcal), or Mamba group (50 g, 260 kcal, and >75% of the RDA for critical micronutrients). Children in the supplementation groups received the snack daily for 100 d, and all were followed longitudinally for hemoglobin concentrations, anthropometry, and bioelectrical impedance measures: baseline (December 2012), midline (March 2013), and endline (June 2013). Parent surveys were conducted at baseline and endline to examine secondary outcomes of morbidities and dietary intakes. Longitudinal regression modeling using generalized least squares and logit with random effects tested the main effects.

RESULTS

At baseline,14.0% of children were stunted, 14.5% underweight, 9.1% thin, and 73% anemic. Fat mass percentage (mean ± SD) was 8.1% ± 4.3% for boys and 12.5% ± 4.4% for girls. In longitudinal modeling, Mamba supplementation increased body mass index z score (regression coefficient ± SEE) 0.25 ± 0.06, fat mass 0.45 ± 0.14 kg, and percentage fat mass 1.28% ± 0.27% compared with control at each time point (P < 0.001). Among boys, Mamba increased fat mass (regression coefficient ± SEE) 0.73 ± 0.19 kg and fat-free mass 0.62 ± 0.34 kg compared with control (P < 0.001). Mamba reduced the odds of developing anemia by 28% compared to control (adjusted OR: 0.72; 95% CI: 0.57, 0.91; P < 0.001). No treatment effect was found for hemoglobin concentration.

CONCLUSION

To our knowledge, this is the first study to give evidence of body composition effects from an RUSF in school-aged children.

Effect of supplementation with iron fortified biscuits on the hemoglobin status of children in rural areas of Shimoga, Karnataka

OBJECTIVE

To assess the efficacy of iron fortified biscuits, in high and low dosages, on the hemoglobin levels of anemic school going children aged 6 to 12 y.

METHODS

The nutrition intervention was conducted in primary schools located in villages at Shimoga district, Karnataka. School children aged 6 to 12 y who were anemic, with hemoglobin level <11.5 g/dl were considered for the nutrition intervention. The sampling design undertaken was quasi experimental with pre and post stages of outcome. The children enrolled were divided into two groups. One group received high dosage of iron fortified biscuits (30 mg of elemental iron/6 biscuits) and the second group received a relatively lower dosage of iron fortified biscuits (1.8 mg of elemental iron/6 biscuits) for a period of 120 d. The hemoglobin levels were estimated pre and post fortified biscuit supplementation by cyanomethemoglobin method.

RESULTS

There was an increase in the mean hemoglobin level of children which was found to be higher in group I (high iron fortified biscuits) (1.06 g/dl) compared to group II (low iron fortified biscuits) (0.41 g/dl), significant at 0.01 level (t = 3.84**).

CONCLUSIONS

In the current nutrition intervention, both high and low iron fortified biscuits led to a significant enhancement in the body weight and hemoglobin status of anemic school children in a rural setup. The nutrition intervention clearly highlights biscuits as an ideal fortification vehicle for addressing anemia.

Assessment of a portable device to quantify vitamin A in fortified foods (flour, sugar, and milk) for quality control

BACKGROUND

Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification levels.

OBJECTIVE

To assess the capacity of a portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) to quantify retinyl palmitate in fortified milks, flours (wheat, maize), and sugar.

METHODS

The portable fluorometer was assessed in a three-step procedure to determine its working range and linearity, intra-assay precision, and interperson precision. Measurements were compared with the results obtained by high-performance liquid chromatography (HPLC), commonly regarded as the standard method for vitamin A analysis.

RESULTS

The portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) precisely determined the vitamin A contents in fortifed flours, sugar, and milks. Its working range was 1 to 10, 0.5 to 3.0, and 5 to 15 mg retinol equivalents (RE) kg(-1) for flours (wheat and corn), milks, and sugar, respectively; these values are in accordance with the World Health Organization recommendations for food fortification in least developed countries. The limits of detection are higher than those of HPLC but are all satisfactory (< 1.46 mg RE kg(-1)). The coefficients of variation within and between observers were satisfactory, especially for sugar and milk.

CONCLUSIONS

The linear relationship between the data from the portable fluorometer and the HPLC data confirms that the portable fluorometer provides a good determination of the vitamin A content of the fortified products in the tested range.

Vitamin A deficiency is associated with gastrointestinal and respiratory morbidity in school-age children

Infection is an important cause of morbidity throughout childhood. Poor micronutrient status is a risk factor for infection-related morbidity in young children, but it is not clear whether these associations persist during school-age years. We examined the relation between blood concentrations of micronutrient status biomarkers and risk of gastrointestinal and respiratory morbidity in a prospective study of 2774 children aged 5-12 y from public schools in Bogotá, Colombia. Retinol, zinc, ferritin, mean corpuscular volume, hemoglobin, erythrocyte folate, and vitamin B-12 concentrations were measured in blood at enrollment into the cohort. Children were followed for 1 academic year for incidence of morbidity, including diarrhea with vomiting, cough with fever, earache or ear discharge with fever, and doctor visits. Compared with adequate vitamin A status (≥30.0 μg/dL), vitamin A deficiency (<10.0 μg/dL) was associated with increased risk of diarrhea with vomiting [unadjusted incidence rate ratio (IRR): 2.17; 95% CI: 0.95, 4.96; P-trend = 0.03] and cough with fever (unadjusted IRR: 2.36; 95% CI: 1.30, 4.31; P-trend = 0.05). After adjustment for several sociodemographic characteristics and hemoglobin concentrations, every 10 μg/dL plasma retinol was associated with 18% fewer days of diarrhea with vomiting (P < 0.001), 10% fewer days of cough with fever (P < 0.001), and 6% fewer doctor visits (P = 0.01). Every 1 g/dL of hemoglobin was related to 17% fewer days with ear infection symptoms (P < 0.001) and 5% fewer doctor visits (P = 0.009) after controlling for sociodemographic factors and retinol concentrations. Zinc, ferritin, mean corpuscular volume, erythrocyte folate, and vitamin B-12 status were not associated with morbidity or doctor visits. Vitamin A and hemoglobin concentrations were inversely related to rates of morbidity in school-age children. Whether vitamin A supplementation reduces the risk or severity of infection in children over 5 y of age needs to be determined.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

BACKGROUND

Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies.

METHODS

A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1.

RESULTS

Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children.

CONCLUSION

Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

Early-stage primary school children attending a school in the Malawian School Feeding Program (SFP) have better reversal learning and lean muscle mass growth than those attending a non-SFP school

In developing countries, schoolchildren encounter a number of challenges, including failure to complete school, poor health and nutrition, and poor academic performance. Implementation of school feeding programs (SFPs) in less developed countries is increasing and yet there is mixed evidence regarding their positive effects on nutrition, education, and cognition at the population level. This study evaluated cognitive and anthropometric outcomes in entry-level primary school children in Malawi with the aim of generating evidence for the ongoing debate about SFPs in Malawi and other developing countries. A total of 226 schoolchildren aged 6-8 y in 2 rural Malawian public primary schools were followed for one school year. Children attending one school (SFP school) received a daily ration of corn-soy blend porridge, while those attending the other (non-SFP school) did not. Baseline and post-baseline outcomes included the Cambridge Neurological Test Automated Battery cognitive tests of paired associate learning, rapid visual information processing and intra-extra dimensional shift, and anthropometric measurements of weight, height, and mid-upper arm circumference (MUAC). At follow-up, the SFP subcohort had a greater reduction than the non-SFP subcohort in the number of intra-extra predimensional shift errors made (mean 18.5 and 24.9, respectively; P-interaction = 0.02) and also showed an increase in MUAC (from 16.3 to 17.0; P-interaction <0.0001). The results indicate that the SFP in Malawi is associated with an improvement in reversal learning and catch-up growth in lean muscle mass in children in the SFP school compared with children in the non-SFP school. These findings suggest that the Malawian SFP, if well managed and ration sizes are sustained, may have the potential to improve nutritional and cognitive indicators of the most disadvantaged children.

Effects of a multi-micronutrient-fortified beverage, with and without sugar, on growth and cognition in South African schoolchildren: a randomised, double-blind, controlled intervention

Little is known about the effects of combined micronutrient and sugar consumption on growth and cognition. In the present study, we investigated the effects of micronutrients and sugar, alone and in combination, in a beverage on growth and cognition in schoolchildren. In a 2 × 2 factorial design, children (n 414, 6-11 years) were randomly allocated to consume beverages containing (1) micronutrients with sugar, (2) micronutrients with a non-nutritive sweetener, (3) no micronutrients with sugar or (4) no micronutrients with a non-nutritive sweetener for 8.5 months. Growth was assessed and cognition was tested using the Kaufman Assessment Battery for Children version II (KABC-II) subtests and the Hopkins Verbal Learning Test (HVLT). Micronutrients decreased the OR for Fe deficiency at the endpoint (OR 0.19; 95% CI 0.07, 0.53). Micronutrients increased KABC Atlantis (intervention effect: 0.76; 95% CI 0.10, 1.42) and HVLT Discrimination Index (1.00; 95% CI 0.01, 2.00) scores. Sugar increased KABC Atlantis (0.71; 95% CI 0.05, 1.37) and Rover (0.72; 95% CI 0.08, 1.35) scores and HVLT Recall 3 (0.94; 95% CI 0.15, 1.72). Significant micronutrient × sugar interaction effects on the Atlantis, Number recall, Rover and Discrimination Index scores indicated that micronutrients and sugar in combination attenuated the beneficial effects of micronutrients or sugar alone. Micronutrients or sugar alone had a lowering effect on weight-for-age z-scores relative to controls (micronutrients - 0.08; 95% CI - 0.15, - 0.01; sugar - 0.07; 95% CI - 0.14, - 0.002), but in combination, this effect was attenuated. The beverages with micronutrients or added sugar alone had a beneficial effect on cognition, which was attenuated when provided in combination.

School food, politics and child health

OBJECTIVE

An analysis undertaken jointly in 2009 by the UN World Food Programme, The Partnership for Child Development and the World Bank was published as Rethinking School Feeding to provide guidance on how to develop and implement effective school feeding programmes as a productive safety net and as part of the efforts to achieve Education for All. The present paper reflects on how understanding of school feeding has changed since that analysis.

DESIGN

Data on school feeding programme outcomes were collected through a literature review. Regression models were used to analyse relationships between school feeding costs (from data that were collected), the per capita costs of primary education and Gross Domestic Product per capita. Data on the transition to national ownership, supply chains and country examples were collected through country case studies.

RESULTS

School feeding programmes increase school attendance, cognition and educational achievement, as well as provide a transfer of resources to households with possible benefits to local agricultural production and local market development. Low-income countries exhibit large variations in school feeding costs, with concomitant opportunities for cost containment. Countries are increasingly looking to transition from externally supported projects to national programmes.

CONCLUSIONS

School feeding is now clearly evident as a major social programme in most countries with a global turnover in excess of $US 100 billion. This argues for a continuing focus on the evidence base with a view to helping countries ensure that their programmes are as cost-effective as possible. Clear policy advice has never been more important.

Plasmodium falciparum, anaemia and cognitive and educational performance among school children in an area of moderate malaria transmission: baseline results of a cluster randomized trial on the coast of Kenya

OBJECTIVES

Studies have typically investigated health and educational consequences of malaria among school-aged children in areas of high malaria transmission, but few have investigated these issues in moderate transmission settings. This study investigates the patterns of and risks for Plasmodium falciparum and anaemia and their association with cognitive and education outcomes on the Kenyan coast, an area of moderate malaria transmission.

METHODS

As part of a cluster randomised trial, a baseline cross-sectional survey assessed the prevalence of and risk factors for P. falciparum infection and anaemia and the associations between health status and measures of cognition and educational achievement. Results are presented for 2400 randomly selected children who were enrolled in the 51 intervention schools.

RESULTS

The overall prevalence of P. falciparum infection and anaemia was 13.0% and 45.5%, respectively. There was marked heterogeneity in the prevalence of P. falciparum infection by school. In multivariable analysis, being male, younger age, not sleeping under a mosquito net and household crowding were adjusted risk factors for P. falciparum infection, whilst P. falciparum infection, being male and indicators of poor nutritional intake were risk factors for anaemia. No association was observed between either P. falciparum or anaemia and performance on tests of sustained attention, cognition, literacy or numeracy.

CONCLUSION

The results indicate that in this moderate malaria transmission setting, P. falciparum is strongly associated with anaemia, but there is no clear association between health status and education. Intervention studies are underway to investigate whether removing the burden of chronic asymptomatic P. falciparum and related anaemia can improve education outcomes.

Multi-micronutrient-fortified biscuits decreased the prevalence of anaemia and improved iron status, whereas weekly iron supplementation only improved iron status in Vietnamese school children

In Vietnam, nutrition interventions do not target school children despite a high prevalence of micronutrient deficiencies. The present randomised, placebo-controlled study evaluated the impact of providing school children (n 403) with daily multiple micronutrient-fortified biscuits (FB) or a weekly Fe supplement (SUP) on anaemia and Fe deficiency. Micronutrient status was assessed by concentrations of Hb, and plasma ferritin (PF), transferrin receptor (TfR), Zn and retinol. After 6 months of intervention, children receiving FB or SUP had a significantly better Fe status when compared with the control children (C), indicated by higher PF (FB: geometric mean 36·9 (95% CI 28·0, 55·4) μg/l; SUP: geometric mean 46·0 (95% CI 33·0, 71·7) μg/l; C: geometric mean 34·4 (95% CI 15·2, 51·2) μg/l; P < 0·001) and lower TfR concentrations (FB: geometric mean 5·7 (95% CI 4·8, 6·52) mg/l; SUP: geometric mean 5·5 (95% CI 4·9, 6·2) mg/l; C: geometric mean 5·9 (95% CI 5·1, 7·1) mg/l; P = 0·007). Consequently, body Fe was higher in children receiving FB (mean 5·6 (sd 2·2) mg/kg body weight) and SUP (mean 6·1 (sd 2·5) mg/kg body weight) compared with the C group (mean 4·2 (sd 3·3) mg/kg body weight, P < 0·001). However, anaemia prevalence was significantly lower only in the FB group (1·0%) compared with the C group (10·4%, P = 0·006), with the SUP group being intermediate (7·4%). Children receiving FB had better weight-for-height Z-scores after the intervention than children receiving the SUP (P = 0·009). Vitamin A deficiency at baseline modified the intervention effect, with higher Hb concentrations in vitamin A-deficient children receiving FB but not in those receiving the SUP. This indicates that vitamin A deficiency is implicated in the high prevalence of anaemia in Vietnamese school children, and that interventions should take other deficiencies besides Fe into account to improve Hb concentrations. Provision of biscuits fortified with multiple micronutrients is effective in reducing anaemia prevalence in school children.

Identifying potential programs and platforms to deliver multiple micronutrient interventions

This article reviews the potential of four broad types of platforms, health, agriculture, market-based, and social protection programs, to deliver multiple micronutrient (MMN) interventions (supplementation, fortification, and dietary modification). We assessed the platforms' potential based on seven performance criteria related to programs within these platforms: 1) targeting, 2) efficacy of interventions, 3) quality of implementation, 4) utilization, 5) impact, 6) coverage, and 7) sustainability. We highlight one type of program per platform to illustrate strengths and weaknesses for delivering MMN interventions, identify critical knowledge gaps, and highlight what is needed to increase effectiveness for delivering MMN interventions. We found that all four platforms have the potential to effectively deliver MMN interventions if the following key program elements are addressed: 1) strong behavior change communication strategies to increase demand and proper utilization of services/products; 2) supply side interventions to ensure consistent availability of high quality interventions, products, and well-trained staff; 3) rigorous evaluations of effectiveness, quality of delivery, and impact pathways to generate best practices for replication and scale-up; and 4) timely dissemination of evaluation results to ensure use by program implementers and policy makers. The diversification of delivery platforms, which simultaneously addresses multiple determinants of MMN deficiencies and expands coverage, is needed to accelerate progress in reducing MMN deficiencies.

The effect of a 1-year multiple micronutrient or n-3 fatty acid fortified food intervention on morbidity in Indian school children

BACKGROUND/OBJECTIVES

Few studies have shown that supplementation with micronutrients (MNs) or n-3 fatty acids may have health benefits such as reduced morbidity in schoolchildren. The effect of a combination of these nutrients has never been investigated. This study aimed to determine the effect of a combination of two different doses of MN and n-3 fatty acids on morbidity in schoolchildren in Bangalore, India.

SUBJECTS/METHODS

In all 598 children (6-10 years) received foods fortified with either high (100% recommended dietary allowance) or low (15% recommended dietary allowance) MN, combined with either high (900 mg α-linolenic acid (ALA) plus 100 mg docosahexaenoic acid) or low (140 mg ALA) n-3 fatty acids for 1 year. Morbidity was measured by weekly self-reports using a structured questionnaire. Poisson regression analyses of episodes/child/year and duration/episode adjusted for age and sex were performed on clusters of symptoms, including upper and lower respiratory tract infections (URTI and LRTI), gastrointestinal complaints (GI) and general symptoms of illness to observe MN and n-3 fatty acid treatment effects.

RESULTS

Children consuming high n-3 fatty acids had significantly fewer episodes of URTI/child/year (relative risk (RR)=0.88, 95% confidence interval (CI): 0.79, 0.97) and significantly shorter duration/episode of URTI (RR=0.81, 95% CI: 0.78, 0.85), LRTI (RR=0.91, 95% CI: 0.85, 0.97), GI complaints (RR=0.79, 95% CI: 0.74, 0.85) and general symptoms (RR=0.90, 95% CI: 0.82, 0.98) compared with children who received low n-3 fatty acid intervention. The high MN intervention reduced the duration of general symptoms (RR=0.89, 95% CI: 0.82, 0.98).

CONCLUSION

Although n-3 fatty acids may be beneficial for reducing illness in Indian schoolchildren, more research is needed to confirm presence of combined effect with MN.

Decreased parasite load and improved cognitive outcomes caused by deworming and consumption of multi-micronutrient fortified biscuits in rural Vietnamese schoolchildren

Micronutrient deficiencies are associated with impaired growth and cognitive function. A school-based fortification program might benefit schoolchildren but a high prevalence of parasite infestation might affect effectiveness. A randomized, double-blind, placebo-controlled 2 × 2 factorial trial was conducted to assess the efficacy of multi-micronutrient fortified biscuits with or without de-worming on growth, cognitive function, and parasite load in Vietnamese schoolchildren. Schoolchildren (n = 510), 6-8 years of age were randomly allocated to receive albendazole or placebo at baseline and four months of multi-micronutrient fortified biscuits (FB) or non-fortified biscuits. Children receiving FB for four months scored higher on two cognitive tests: Raven's Colored Progressive Matrices and the Digit Span Forward test. Children receiving albendazole plus FB had the lowest parasite load after four months. In children receiving FB, mid-upper arm circumference was slightly improved (+0.082 cm) but there were no differences in other indexes of anthropometry. Combining multi-micronutrient fortified biscuits with de-worming is an effective strategy.

The role of iodine in human growth and development

Iodine is an essential component of the hormones produced by the thyroid gland. Thyroid hormones, and therefore iodine, are essential for mammalian life. Iodine deficiency is a major public health problem; globally, it is estimated that two billion individuals have an insufficient iodine intake. Although goiter is the most visible sequelae of iodine deficiency, the major impact of hypothyroidism due to iodine deficiency is impaired neurodevelopment, particularly early in life. In the fetal brain, inadequate thyroid hormone impairs myelination, cell migration, differentiation and maturation. Moderate-to-severe iodine deficiency during pregnancy increases rates of spontaneous abortion, reduces birth weight, and increases infant mortality. Offspring of deficient mothers are at high risk for cognitive disability, with cretinism being the most severe manifestation. It remains unclear if development of the offspring is affected by mild maternal iodine deficiency. Moderate-to-severe iodine deficiency during childhood reduces somatic growth. Correction of mild-to-moderate iodine deficiency in primary school aged children improves cognitive and motor function. Iodine prophylaxis of deficient populations with periodic monitoring is an extremely cost effective approach to reduce the substantial adverse effects of iodine deficiency throughout the life cycle.

Dietary vitamin A intake and serum retinol concentrations of preschool children from different socio-economical levels in Izmir, Turkey

AIM

Vitamin A deficiency (VAD), especially in its subclinical form, is a world health problem in young children. The aim of this study was to determine the prevalence of VAD among preschool children in various socio-economic groups in Izmir, Turkey.

METHODS

One hundred and one children aged 24-59 months were selected for the study with cluster sampling method. A questionnaire was completed by the parents, and the dietary pattern was assessed by using a 3-day dietary record method.

RESULTS

Mean serum retinol concentration of the children was 28.3 ± 10.2 μg/dL. Serum vitamin A concentration of two children (2%) was below 10 μg/dL (VAD), whereas 18 (18%) children had vitamin A concentrations between 10 and 20 μg/dL (subclinical deficiency). We did not find any relationship between mean serum retinol concentrations and the independent variables such as socio-economical levels, age groups, birth weight and gestational age. However, there was a statistically significant positive correlation between serum retinol concentrations and weight-for-age and weight-for-height Z scores of the children (p < 0.05).

CONCLUSION

  Because one-fifth of the children under 5 years have VAD in Izmir, Turkey, nutrition education must be given to the families during well-child care visits, and routine vitamin supplementation should be considered especially in children with malnutrition.