A multiple-micronutrient-fortified beverage affects hemoglobin, iron, and vitamin A status and growth in adolescent girls in rural Bangladesh

Small Fish Big Impact: Improving Nutrition during Pregnancy and Lactation, and Empowerment for Marginalized Women

Undernutrition and micronutrient deficiencies such as anemia are considered significant public health challenges in Bangladesh, which enhancing fish consumption is a well-established food-based intervention to address these. This paper documents the establishment of community-based fish chutney production and reports the impact of its consumption on mid-upper arm circumference (MUAC) and hemoglobin (Hb) levels among targeted 150 pregnant and lactating women (PLW) in rural Bangladesh. A fish chutney was developed using locally available ingredients followed by a series of laboratory tests, including nutrient composition, shelf-life and food safety. A community-based fish chutney production process was designed to: (1) supply locally available ingredients for processing; (2) establish two fish drying sites; (3) initiate a community-based production site; and (4) distribute fish chutney to PLW for one year by six women nutrition field facilitators. Then a pre- and post-intervention study was designed for a selected 150 PLW to receive 30 g of fish chutney daily for 12 months. Differences in mean MUAC and Hb levels pre- and post-consumption were analyzed using one-way analysis of variance. Consumption of 30 g of fish-chutney resulted in significant increases of the mean values of Hb levels and MUAC among the targeted PLW.

Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

Social and ecological disparities in anaemia among adolescent girls 15-19 years old in Nepal

OBJECTIVE

Adolescent girls are at risk of anaemia due to increased nutrient demands because of growth, menstrual blood loss and possible pregnancies. Sociocultural and household conditions influence their anaemia risk. We aimed to identify the sociocultural and economic factors associated with anaemia among adolescent girls in Nepal.

DESIGN

The Nepal Demographic and Health Surveys (NDHS) conducted in 2006, 2011 and 2016 were pooled for secondary analysis. We used data on haemoglobin measurements for anaemia and conducted bivariate and multivariable logistic regression analyses to identify factors associated with anaemia.

SETTING

Nationally representative NDHS households with adolescent girls 15-19 years of age.

PARTICIPANTS

Non-pregnant adolescent girls 15-19 years, with a haemoglobin measurement (n = 3731).

RESULTS

The overall prevalence of anaemia among adolescent girls was 39·6 %. Adolescents from socially disadvantaged caste/ethnicity groups were 1·42 times (95 % CI: 1·13, 1·78) more likely to have anaemia compared with those from Brahmin/Chhetri households. We found a counter-intuitive association between socio-economic status and anaemia where adolescents from the middle (adjusted OR (aOR) 1·37, 95 % CI: 1·01, 1·85) and highest (aOR 1·74, 95 % CI: 1·18, 2·56) quintiles were at increased odds of anaemia. Relative geographical inequality was observed where adolescents from the Terai region had 3·5 times (95 % CI: 2·32, 5·33) higher odds of anaemia.

CONCLUSIONS

The disparities in the distribution of anaemia among adolescents by caste/ethnicity groups, wealth quintiles and geographical regions are evident. Reducing the anaemia burden will require addressing the social determinants of anaemia by allocating resources and expanding anaemia prevention programmes to target adolescents at higher risk.

Factors affecting the micronutrient status of adolescent girls living in complex agro-aquatic ecological zones of Bangladesh

Inadequate intake of both macro and micronutrients is the major determinant of micronutrient deficiencies in adolescent girls. This study assessed multiple micronutrient status including vitamin D, iron, vitamin A, and urinary iodine concentration among adolescent girls through two seasonal cross-sectional surveys conducted during dry and wet seasons. Mixed-effects linear and logistic regression analysis were conducted to assess associations between micronutrient status, salinity and seasonality. The mean age of the girls was 14 years. Vitamin (OH)D insufficiency was significantly higher in freshwater areas in wet season compared to dry season (wet season: 58% and dry season: 30%, P < 0.001). In wet season, risk of vitamin (OH)D insufficiency was three times higher compared to dry season (AOR: 3.03, 95% CI 1.71, 5.37, P < 0.001). The odds of vitamin (OH)D insufficiency was 11 times higher in fresh water areas compared to high saline areas (AOR: 11.51, 95% CI 3.40, 38.93, P < 0.001). The girls had higher risk of iron deficiency in wet season. Despite the environment being enriched with micronutrient-contained aquatic food, adolescent girls in coastal areas experience different micronutrient deficiencies. The high prevalence of vitamin (OH)D insufficiency in freshwater locations and seasonal iron deficiency in high saline areas needs attention.

Effect of change in individual and household level characteristics on anemia prevalence among adolescent boys and girls in India

Background

Anemia is a significant public health challenge that affects the population of all nations. Anemia among adolescents emerged as an alarming public health issue as it harms an individual’s physical capacity and cognitive and work performance. The study aims to determine the effect of changes in individual and household level factors on the prevalence of anemia among adolescent boys and girls.

Method

The study utilized data from two waves of the “Understanding the lives of adolescent and young adults” (UDAYA) survey, conducted in Bihar and Uttar Pradesh during 2015–16 (wave-1) and 2018–19 (wave-2). The sample size for the present study was 4216 and 5974 unmarried adolescent boys and girls aged 10–19 years in both waves. We performed descriptive analysis to observe the characteristics of adolescents during 2015–16. Further, changes in selected independent variables from wave-1 to wave-2 were examined using the proportion test. Moreover, random-effect regression models were employed to examine the association of changes in individual and household level factors with anemia prevalence among adolescents.

Results

The prevalence of anemia decreased over time among adolescent boys (33 to 30%), whereas it increased among adolescent girls (59 to 63%). The results from the random-effect model show that adolescent boys who used shared toilets were more anemic than those who used a private restroom [β:0.05, 95% CI:(0.01, 0.08)]. Moreover, underweight [β:0.05, CI:(0.01, 0.09)] and thin [β:0.04, CI:(0.00, 0.07)] adolescent boys were more likely to be anemic compared to their normal counterparts. Additionally, boys who belonged to the poorest [β:0.08, CI:(0.02, 0.14)] households had a higher risk of anemia than the richest household.

Conclusion

The anemia prevalence was higher among adolescents aged 10–19 years in Uttar Pradesh and Bihar. This study has filled an information gap by providing state-level representative estimates indicating underweight status and thinness as the common factors behind the anemia prevalence among adolescent boys than in girls. Iron deficiency anemia is the most prevalent in certain age groups in India. Hence, Anemia prevention efforts and iron-folic acid (IFA) supplementation programs are currently being strengthened in India, targeting the high-risk population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13863-w.

Effects of Foods Fortified with Zinc, Alone or Cofortified with Multiple Micronutrients, on Health and Functional Outcomes: A Systematic Review and Meta-Analysis

Seventeen per cent of the world's population is estimated to be at risk of inadequate zinc intake, which could in part be addressed by zinc fortification of widely consumed foods. We conducted a review of efficacy and effectiveness studies to ascertain the effect of zinc fortification [postharvest fortification of an industrially produced food or beverage; alone or with multiple micronutrients (MMN)] on a range of health outcomes. Previous reviews have required that the effect of zinc be isolated; because zinc is always cofortified with MMN in existing fortification programs, we did not impose this condition. Outcomes assessed were zinc-related biomarkers (plasma or serum, hair or urine zinc concentrations, comet assay, plasma fatty acid concentrations, and the proportion of and total zinc absorbed in the intestine from the diet), child anthropometry, morbidity, mortality, cognition, plasma or serum iron and copper concentrations, and for observational studies, a change in consumption of the food vehicle. Fifty-nine studies were included in the review; 54 in meta-analyses, totaling 73 comparisons. Zinc fortification with and without MMN increased plasma zinc concentrations (efficacy, n = 27: 4.68 μg/dL; 95% CI: 2.62-6.75; effectiveness, n = 13: 6.28 μg/dL; 95% CI: 5.03-7.77 μg/dL) and reduced the prevalence of zinc deficiency (efficacy, n = 11: OR: 0.76, 95% CI: 0.60-0.96; effectiveness, n = 10: OR: 0.45, 95% CI: 0.31-0.64). There were statistically significant increases in child weight (efficacy, n = 11: 0.43 kg, 95% CI: 0.11-0.75 kg), improvements in short-term auditory memory (efficacy, n = 3: 0.32 point, 95% CI: 0.13-0.50 point), and decreased incidence of diarrhea (efficacy, n = 3: RR: 0.79, 95% CI: 0.68-0.92) and fever (efficacy, n = 2: RR: 0.85, 95% CI: 0.74-0.97). However, these effects cannot be solely attributed to zinc. Our review found that zinc fortification with or without MMN reduced the prevalence of zinc deficiency and may provide health and functional benefits, including a reduced incidence of diarrhea.

Adolescent undernutrition in South Asia: a scoping review

Undernutrition is a growing public health challenge affecting growth and development during adolescence in many low- and middle-income countries. This scoping review maps the evidence on adolescent undernutrition (stunting, thinness and micronutrient deficiencies) in South Asia and highlights gaps in knowledge. Using Arksey and O'Malley's framework and the Joanna Briggs Institute Reviewers' Manual, the search included electronic bibliographic databases (Medline (OVID), Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Scopus) as well as various grey literature sources published up to March 2019. In total, 131 publications met the inclusion criteria of this review. All the included evidence used quantitative data and 115 publications used a cross-sectional design. Nearly 70% (n = 86) of the included publications were conducted in India. Prevalence of undernutrition was reported based on different growth references and cut-offs. Evidence is divided into publications that included an intervention component (n = 12) and publications that did not include an intervention component (n = 116), and presented in a narrative synthesis. This scoping review provides a wide range of publications on adolescent undernutrition in South Asia and identifies future research priorities in the field.

Ten2Twenty-Ghana: Study Design and Methods for an Innovative Randomized Controlled Trial with Multiple-Micronutrient-Fortified Biscuits among Adolescent Girls in Northeastern Ghana

Investing in adolescent girls' nutrition is vital for health and for breaking the intergenerational cycle of malnutrition and deprivation, but limited knowledge on the type, timing, and efficacy of interventions delays progress. We describe the design of a 26-wk randomized placebo-controlled trial with multiple-micronutrient-fortified biscuits (MMBs) among adolescent girls in northeastern Ghana. Apparently healthy, premenarche (n = 312) and postmenarche (n = 309) girls (10-17 y) were randomly assigned to receive the following for 5 d/wk: 1) MMBs (fortified with 11 vitamins and 7 minerals) or 2) unfortified biscuits. Data included plasma micronutrient status, anthropometry, body composition, cognitive function, psychosocial health, fertility, dietary intake, and sociodemographic and socioeconomic covariates, complemented with in-depth interviews (n = 30) and 4 focus group discussions. We hypothesized an increase in plasma ferritin and retinol-binding protein with a resultant increase in hemoglobin, cognition, vertical height, and psychosocial health. Our study seeks to investigate the efficacy and optimal timing of a multiple-micronutrient food intervention program for adolescent girls. The RCT was registered prospectively with the Netherlands Clinical Trials Register (NL7487).

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.

Anaemia among adolescents: assessing a public health concern in Lao PDR

BACKGROUND

Lao PDR has identified the need to target adolescent public health concerns. Adolescents suffering from poor health and nutrition during rapid growth and development may be at risk of anaemia due to high iron requirements and the rapid depletion of body iron stores.

OBJECTIVE

This study assessed the prevalence and severity of anaemia among school adolescents in Pholhong district, Vientiane province, Lao PDR.

METHODS

A school-based cross-sectional study was conducted among 405 randomly selected school adolescents across 8 high schools in a rural district of Vientiane province. Adolescents aged 10-18, both male and female, were recruited. Haemoglobin concentration from capillary blood was measured. Descriptive statistics were computed for prevalence of anaemia, anthropometric measurements, socio-economic and socio-demographic variables. Multivariate logistic regression analysis was performed to identify determinants of anaemia among subjects. Results were expressed as odds ratios and 95% confidence intervals.

RESULTS

The prevalence of anaemia among adolescents in the study area was 19.4%. There was no difference in the prevalence of anaemia between younger and older adolescents, but the prevalence of anaemia was higher in female adolescents than among males (crude OR = 3.91, 95% CI 2.20 to 6.96). On univariate analysis, coming from an ethnic minority household was found to be significantly associated with anaemia among these adolescents (p < 0.05). After adjusting for other variables, only the effect of sex remained significant. Other factors showing no significant association with anaemia included parents' employment status, family size, and living conditions.

CONCLUSIONS

The prevalence of anaemia in this population is of public health concern with adolescents of both sexes at risk of developing anaemia. The national nutrition programme to control and manage anaemia by distributing a weekly iron and folate supplement for adolescent girls together with a deworming programme twice per year appears to have partly successful but could be strengthened.

Effects of preventive nutrition interventions among adolescents on health and nutritional status in low- and middle-income countries: A systematic review

Background

Malnutrition is one of the most common causes of morbidity and mortality among children and adolescents and is now considered to be one of the largest risk factors responsible for the global burden of diseases along with poor diet.

Objectives

The objective of this review was to assess the impact of preventive nutrition interventions (including nutrition education and counselling; micronutrient supplementation/fortification and macronutrient supplementation) to improve the health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). The secondary objective of the review was to assess various contextual factors based on the World Health Organisation (WHO) health system building blocks framework that might potentially impact the effectiveness of these interventions for this age group.

Search Methods

The search was conducted on Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, the WHO nutrition databases, CAB Global Health, Social Science Citation Index, Scopus, WHO Global Health Index, ADOLEC and EPPI until February 5, 2019. We searched Google Scholar along with key nutrition agencies database such as Nutrition International, the Global Alliance for Improved Nutrition, the World Food Programme and HarvestPlus to search for nonindexed, grey literature to locate relevant programme evaluations and any additional trials. All searches were performed without any restrictions on publication date, language or publication status.

Selection Criteria

We included randomised controlled trials, quasiexperimental studies, controlled before-after studies and interrupted time series evaluating the effectiveness of preventive nutrition interventions among adolescents between 10 and 19 years of age from LMICs.

Data Collection and Analysis

Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data from included studies. Meta-analysis was conducted separately for each outcome and intervention. For dichotomous data, we reported risk ratios (RR) with 95% confidence intervals (CI). For continuous data, we reported the mean difference (MD) or standard mean difference (SMD) with 95% CI.

Main Results

This review summarises findings from a total of 10 studies from 15 papers including 10,802 participants. All the studies included in this review assessed the impact of micronutrient supplementation/fortification on health and nutritional status among adolescents in LMIC. We did not find any study assessing the impact of nutrition education and counselling or on macronutrient supplementation among adolescents. Micronutrient supplementation/fortification interventions included calcium/vitamin D supplementation/fortification, iron supplementation with or without folic acid, zinc supplementation and multiple micronutrient (MMN) fortification. The majority of the studies (eight out of 10 studies) included adolescent girls aged between 10 and 19 years of age. We did not find any large scale preventive nutrition intervention programmes targeting adolescents in LMICs. We are uncertain of the effect of iron supplementation with or without folic acid on anaemia (daily supplementation; RR: 1.04, 95% CI 0.88, 1.24; one study; 1,160 participants; low quality evidence. Weekly supplementation; RR: 1.07, 95% CI: 0.91, 1.26; one study; 1,247 participants; low quality evidence). We are uncertain of the effect of various micronutrient supplementation/fortification on body mass index (calcium/vitamin D supplementation; (MD: -0.01 kg/m2; 95% CI: -1.20, 1.17; two studies; 730 participants; I 2 94%; very low quality evidence, iron supplementation with or without folic acid; MD: 0.29 kg/m2; 95% CI: -0.25, 0.83; two studies; 652 participants; I 2 69%; very low quality evidence, zinc supplementation; MD: 0.35 kg/m2; 95% CI: -0.15, 0.85; one study; 382 participants; very low quality evidence) and MMN fortification; MD: 0.23 kg/m2, 95% CI: -0.11, 0.57; two studies; 943 participants; I 2 22%; very low quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Iron supplementation with or without folic acid may improve haemoglobin concentrations (MD: 0.42 g/dL, 95% CI: 0.13, 0.71; four studies; 1,020 participants; I 2 89%; low quality evidence). Calcium/vitamin D supplementation may improve serum 25(OH) D levels (standardised mean difference [SMD]: 2.85, 95% CI: 0.89, 4.82; two studies; 395 participants; I 2 99%; low quality evidence). We are uncertain of the effect of calcium only supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 233 participants; low quality outcome) and calcium + vitamin D supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 235 participants; low quality evidence) on total bone mineral density (BMD). We are uncertain of the effect of MMN fortification on haemoglobin concentrations (MD: -0.10 g/dL, 95% CI: -0.88, 0.68; two studies; 1102 participants; I 2 100%; very low quality evidence); calcium supplementation on total body bone mineral content (BMC); (MD: 30.20 g, 95% CI: -40.56, 100.96; one study; 233 participants; low quality evidence), calcium + vitamin D supplementation on total body BMC (MD: 21.60 g, 95% CI: -45.32, 88.52; one study; 235 participants; low quality evidence) and zinc supplementation on serum zinc levels (SMD: 6.94, 95% CI: -4.84, 18.71; two studies; 494 participants; very low quality evidence). One study reported the impact of iron supplementation with or without folic acid on cognition of adolescent girls suggesting improved cognition in most of the tests with daily or twice weekly supplementation compared to once weekly or no supplementation. None of the other secondary outcomes were reported including any other development outcomes and all-cause mortality. These findings warrant caution while interpreting due to very few studies and high heterogeneity.

Authors' Conclusions

There is limited evidence of micronutrient supplementation/fortification among adolescents on health and nutritional status in LMICs, with lack of evidence on nutrition education and counselling and macronutrient supplementation. The findings are generaliseable for adolescent girls since all studies (except one) targeted female adolescents.

Effects of Preventive Nutrition Interventions among Adolescents on Health and Nutritional Status in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10–19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: −0.01 kg/m²; 95% CI: −1.20, 1.17; two studies; 730 participants; I² 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m²; 95% CI: −0.17, 1.11; two studies; 652 participants; I² 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m²; 95% CI: −0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m², 95% CI: −0.11, 0.57; two studies; 943 participants; I² 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.

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.

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.

Anemia, a moderate public health concern among adolescents in South Ethiopia

BACKGROUND

Adolescence is characterized by rapid growth and development and iron requirements increase during this time. Adolescents with poor diet in early childhood and/or females with an early onset of menarche may be at greater risk for developing anemia due to the rapid depletion of iron stores in their bodies.

OBJECTIVE

The objective of this study was to assess the prevalence and severity of anemia among school adolescents in Wonago district, Gedeo Zone, South Ethiopia.

METHODS

A school based cross-sectional study was conducted among 443 randomly selected school adolescents across 15 schools (2 secondary schools and 13 primary schools) in the district. Hemoglobin concentration from a capillary blood sample was determined by portable hemoglobin meter (HemoCue). Descriptive statistics were computed for prevalence of anemia, anthropometric measurements, socio-economic and socio-demographic variables. A hierarchical multivariable logistic regression analysis was done to identify determinants of anemia among adolescents.

RESULTS

The prevalence of anemia among adolescents in the study area was 22%. Anemia was higher among those in early adolescence period (10-13 years) (AOR: 4.75, CI: 1.69-13.35) compared to late adolescence (17-19 years) and among those with height for age z-score less than -2 (AOR: 6.23, CI: 1.98-19.62). Similarly, anemia was higher among those in households with a family size greater than five members (AOR: 9.82, CI: 2.42-39.88), adolescents from rural areas (AOR: 4.37, CI: 1.54-12.46) and families who purchase food needed for daily consumption (AOR: 3.25, CI: 1.42-7.45). On the other hand, adolescents from middle wealth quintiles (AOR: 0.26 (CI: 0.07-0.98)) and female adolescents (AOR: 0.34 (CI: 0.15-0.79) were less likely to be anemic in this study.

CONCLUSIONS

The prevalence of anemia in this population is of moderate public health concern, adolescents of both sexes are among groups at risk for the development of anemia. The need for further assessment of the etiology of anemia should be considered to design pragmatic intervention programs.

Beneficial Effects of ragi (Finger Millet) on Hematological Parameters, Body Mass Index, and Scholastic Performance among Anemic Adolescent High-School Girls (AHSG)

Adolescence is a period characterized by rapid physical, emotional, and mental growth and changes potentially resulting in health challenges. Anemia, which is a fairly common complication in this age group, is reported to negatively affect the cognitive ability of adolescents. Traditionally, ragi (Finger millet: Eleusine coracana), a cereal available in India, has been recommended as nutritional supplement to combat anemia because of its high protein and mineral content as well as anti-microbial property. This study sought to establish the effect of ragi in improving hematological parameters, body mass index, and scholastic performance among adolescent school girls. Sixty adolescent girls were randomly selected and divided into intervention (n = 30) and control groups (n = 30). The effect of dietary supplementation of ragi porridge on hematological parameters was evaluated on the intervention group at 45 and 90 days. Both groups were monitored for changes in body mass index and scholastic performance. A statistically significant increase in hemoglobin levels was observed in the intervention group after 90 days (from a mean of 11.3 g% to 12.54 g%; t ₍₂₉₎ = 7.514, p < .0001), with no significant changes in the control group. No statistically significant differences between the two groups were observed for mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, mean corpuscular volume, red cell distribution width, body mass index, and scholastic performance. The data show that daily dietary supplementation with ragi porridge has a positive effect on hemoglobin levels in adolescent high schools girls. A well planned nutrition education with dietary supplementation is thus recommended for better outcomes.

Determinants of prenatal anemia in Ethiopia

Background

Anemia is responsible for 20% of maternal mortality worldwide, and it is associated with premature birth, low birth weight, and infant mortality. In Ethiopia, about 22% of pregnant women are anemic. However, literatures are limited, therefore, this study aimed to investigate the prevalence and associated factors of anemia among pregnant women attending antenatal care (ANC) in Asossa Zone Public Health Institutions, northwest Ethiopia.

Methods

A facility based cross-sectional study was conducted from February to March 2016. Data were collected by interviewer administered, pretested and structured questionnaires. A multi-stage sampling technique was used to select 762 pregnant women. The hemoglobin level was determined by taking 5 ml of venous blood using Sahli's method. A multivariate binary logistic regression model was fitted to identify factors associated with anemia. Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was computed to show the strength of association and statistical significance was determined at a P-value of <0.05.

Results

The prevalence of anemia was 31.8% [95% CI: 28.9, 35.5]. In the adjusted analysis, maternal age of 30-34 years [AOR = 0.34, 95% CI: 0.14, 0.86], household size of ≥6 [AOR = 4.27, 95% CI: 1.58, 11.45], dietary diversity [AOR = 0.58, 95% CI: 0.38, 0.93], no meat consumption [AOR = 1.80, 95% CI: 1.11, 2.91], not drinking soft beverages [AOR =1.96, 95% CI: 1.19, 3.23], undernutrition [AOR = 7.38, 95% CI: 4.22, 12.91], not consuming fruits [AOR = 3.29, 95% CI: 1.59, 6.82], inter-pregnancy interval of ≥2 years [AOR = 0.59, 95% CI: 0.34, 0.99], and third trimester of pregnancy [AOR = 0.33, 95% CI: 0.20, 0.57] were significantly associated with anemia.

Conclusions

The prevalence of prenatal anemia is high in the Asossa Zone; suggesting a moderate public health concern. Socio-demographic and dietary intake characteristics were significantly associated with anemia. Therefore, improving dietary diversity and animal food consumption are the key to reduce the high burden of anemia. It is also important to strengthen interventions aiming to reduce closed birth interval and teenage pregnancy.

Systematic review on evidence-based adolescent nutrition interventions

Adolescence is a critical stage in the life cycle, and adequate nutrition is necessary for the proper growth and development of individuals and their offspring. Here, we comprehensively review all published systematic reviews (through October 2016) on adolescents (10-19 years) and women of reproductive age, including pregnant women, which targeted interventions related to nutrition. For interventions where there was no existing systematic review on adolescents, we reviewed primary studies/trials. We included interventions on micronutrient supplementation (iron, folic acid, iron-folic acid (IFA), calcium, vitamin D, vitamin A, zinc, iodine, and multiple micronutrients), food/protein energy supplementation, nutrition education for pregnant adolescents, obesity prevention and management, and management of gestational diabetes. We identified a total of 35 systematic reviews, of which only five were conducted on adolescents, and 107 primary studies on adolescents. Our review suggests that iron alone, IFA, zinc, and multiple micronutrient supplementation in adolescents can significantly improve serum hemoglobin concentration. While zinc supplementation in pregnant adolescents showed improvements in preterm birth and low birth weight, we found a paucity of trials on calcium, vitamin D, vitamin A, and iodine supplementation. We found limited evidence on food/protein energy supplementation in adolescents. Interventions to prevent and manage obesity showed a nonsignificant impact on reducing body mass index. This review underscores the importance of adolescent nutrition interventions. It is imperative that countries design nutritional interventions, particularly for adolescents.

The Impact of Nutritional Interventions beyond the First 2 Years of Life on Linear Growth: A Systematic Review and Meta-Analysis

A large body of evidence suggests that the first 1000 d from conception is a critical window in which interventions to address malnutrition will be most effective, but little is known about the impact on linear growth of nutritional interventions in children ≥2 y of age. The aim of this analysis was to evaluate the effectiveness of several nutrition-based interventions, specifically iron, zinc, calcium, iodine, vitamin A, multiple (≥2) micronutrients, protein, and food, at improving growth in children ≥2 y of age. A systematic search of MEDLINE and EMBASE retrieved 7794 articles. A total of 69 studies met prespecified inclusion criteria. Baseline height-for-age z score, age, nutrient dose, and study duration were examined as potential sources of heterogeneity. Zinc (mean effect size: 0.15; 95% CI: 0.06, 0.24), vitamin A (0.05; 95% CI: 0.01, 0.09), multiple micronutrients (0.26; 95% CI: 0.13, 0.39), and protein (0.68; 95% CI: 0.30, 1.05) had significant positive effects on linear growth, with baseline height-for-age z score as a significant inverse predictor of the effect size. Iron, calcium, iodine, and food-based interventions had no significant effect on growth. Age at baseline, study duration, and dose were not related to effect size for any nutrient examined. These findings suggest that zinc, vitamin A, multiple micronutrients, and protein interventions delivered after 24 mo of age can have a positive effect on linear growth, especially in populations that have experienced growth failure.

Improvement the nutritional status of pre-school children following intervention with a supplement containing iron, zinc, copper, vitamin A, vitamin C and prebiotic

Abstract This study investigated the effects of a vitamin and mineral fortified powder product supplemented with inulin, on the iron and vitamin A status of 110 pre-schools childrens in Viçosa, MG, Brazil. The 2 to 5-year-old children were submitted to anthropometric (weight and height), biochemical (erythrocytes, hemoglobin, mean corpuscular volume – MCV, mean corpuscular hemoglobin - MCH, serum iron, ferritin and serum retinol) and dietary (direct food weighing, 24 h recall, and food intake record) evaluations, at the beginning and at the end of a 45-day intervention. The supplement (30 g) was provided daily as part of the afternoon snack, diluted in 100 mL of water, 5 times/week and it supplied 30% of the recommended daily doses of iron, zinc, copper and vitamins A and C. Dietary and biochemical data was compared by the Wilcoxon test, and anthropometric data by the paired t-test. Values of z-scores for weight and height, erythrocytes, hemoglobin, MCV, MCH and ferritin were significantly higher after intervention; no change was observed in serum retinol. The prebiotic-containing supplement significantly increased the intake of energy, macro and micronutrients, and was effective in improving the iron and anthropometric status.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF).

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, mRCT, and reference lists up to 30 September 2016. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using either a fixed-effect or random-effects model) and assessed heterogeneity.We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Thirty-three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoeaThere is currently not enough evidence from well-conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized (very low certainty evidence).In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD -11.46 hours, 95% CI -19.72 to -3.19; 2581 children, 9 trials, low certainty evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD -26.39 hours, 95% CI -36.54 to -16.23; 419 children, 5 trials, high certainty evidence).Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, 2 trials, moderate certainty evidence), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, moderate certainty evidence).None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence). Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, 5 trials, moderate certainty evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well-nourished children, and in settings where children are at low risk of zinc deficiency.

Multiple-Micronutrient Fortified Non-Dairy Beverage Interventions Reduce the Risk of Anemia and Iron Deficiency in School-Aged Children in Low-Middle Income Countries: A Systematic Review and Meta-Analysis (i-iv)

Multiple-micronutrient (MMN) fortification of beverages may be an effective option to deliver micronutrients to vulnerable populations. The aim of the present systematic review and meta-analysis is to evaluate the nutritional impacts of MMN fortified beverages in the context of low-middle income countries. A systematic search of published literature yielded 1022 citations, of which 10 randomized controlled trials (nine in school-aged children and one in pregnant women) met inclusion criteria. Results of school-aged children were included in the meta-analysis. Compared to iso-caloric controls, children who received MMN fortified beverages for 8 weeks to 6 months showed significant improvements in hemoglobin (+2.76 g/L, 95% CI [1.19, 4.33], p = 0.004; 8 studies) and serum ferritin (+15.42 pmol/L, [5.73, 25.12], p = 0.007; 8 studies); and reduced risk of anemia (RR 0.58 [0.29, 0.88], p = 0.005; 6 studies), iron deficiency (RR 0.34 [0.21, 0.55], p = 0.002; 7 studies), and iron deficiency anemia (RR 0.17 [0.06, 0.53], p = 0.02; 3 studies). MMN fortified beverage interventions could have major programmatic implications for reducing the burden of anemia and iron deficiency in school-aged children in low-middle income countries. Additional research is needed to investigate effects on other biochemical outcomes and population subgroups.

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.

Impact of micronutrient fortification of yoghurt on micronutrient status markers and growth - a randomized double blind controlled trial among school children in Bangladesh

Background

Interventions providing foods fortified with multiple micronutrients can be a cost-effective and sustainable strategy to improve micronutrient status and physical growth of school children. We evaluated the effect of micronutrient-fortified yoghurt on the biochemical status of important micronutrients (iron, zinc, iodine, vitamin A) as well as growth indicators among school children in Bogra district of Bangladesh.

Methods

In a double-masked randomized controlled trial (RCT) conducted in 4 primary schools, 1010 children from classes 1–4 (age 6–9 years) were randomly allocated to receive either micronutrient fortified yoghurt (FY, n = 501) or non-fortified yoghurt (NFY, n = 509). For one year, children were fed with 60 g yoghurt everyday providing 30% RDA for iron, zinc, iodine and vitamin A. Anthropometric measurements and blood/urine samples were collected at base-, mid- and end-line. All children (FY, n = 278, NFY, n = 293) consenting for the end-line blood sample were included in the present analyses.

Results

Both groups were comparable at baseline for socio-economic status variables, micronutrient status markers and anthropometry measures. Compliance was similar in both the groups. At baseline 53.4% of the population was anemic; 2.1% was iron deficient (ferritin <15.0 μg/L and TfR > 8.3 mg/L). Children in the FY group showed improvement in Hb (mean difference: 1.5; 95% CI: 0.4-2.5; p = 0.006) as compared to NFY group. Retinol binding protein (mean diff: 0.05; 95% CI: 0.002-0.09; p = 0.04) and iodine levels (mean difference: 39.87; 95% CI: 20.39-59.35; p < 0.001) decreased between base and end-line but the decrease was significantly less in the FY group. Compared to NFY, the FY group had better height gain velocity (mean diff: 0.32; 95% CI: 0.05-0.60; p = 0.02) and height-for-age z-scores (mean diff: 0.18; 95% CI: 0.02-0.33; p = 0.03). There was no difference in weight gain velocity, weight-for-age z-scores or Body Mass Index z-scores.

Conclusion

In the absence of iron deficiency at baseline the impact on iron status would not be expected to be observed and hence cannot be evaluated. Improved Hb concentrations in the absence of a change in iron status suggest improved utilization of iron possibly due to vitamin A and zinc availability. Fortification improved height gain without affecting weight gain.

Trial registration

ClinicalTrial.gov: NCT00980733

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods

MAIN RESULTS

Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere. Acute diarrhoea. There is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2175 children, six trials, low quality evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence). Persistent diarrhoea. In children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of moderate malnutrition is high, zinc may be of benefit in children aged six months or more.The current evidence does not support the use of zinc supplementation in children below six months of age.

Evaluation of the impact of a food program on the micronutrient nutritional status of Argentinean lactating mothers

This study was conducted to evaluate the impact of a food aid program (Plan Más Vida, PMV) on the micronutrient nutritional condition of lactating mothers 1 year after its implementation. The food program provided supplementary diets (wheat- and maize-fortified flour, rice or sugar, and fortified soup) to low-income families from the province of Buenos Aires, Argentina. A prospective, non-experimental study was carried out to evaluate the micronutrient nutritional status of lactating mothers (n = 178 at baseline and n = 151 after 1 year). Biochemical tests (hemoglobin, ferritin, zinc, vitamin A, and folic acid), anthropometric assessments (weight and height) and dietary surveys (24-h recall) were performed. We found no significant changes in anthropometric values 1 year after the intervention. The risk for vitamin A (retinol 20-30 μg/dl) and folate deficiency significantly decreased 1 year after PMV implementation (56.3 vs. 29.9 and 50.3 vs. 3.4 %, respectively; p < 0.001). Anemia was seen in 25.8 % of lactating mothers at baseline, without statistically significant differences 1 year after (p = 0.439). The nutritional data obtained after assessing the early impact of PMV actions may be useful to provincial health authorities to perform periodic evaluations in the future.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods

MAIN RESULTS

Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere.Acute diarrhoeaThere is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2091 children, five trials, low quality evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence).Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of moderate malnutrition is high, zinc may be of benefit in children aged six months or more.The current evidence does not support the use of zinc supplementation in children below six months of age.

Effect of long-term intermittent supplementation with multiple micronutrients compared with iron-and-folic acid supplementation on Hb and micronutrient status of non-anaemic adolescent schoolgirls in rural Bangladesh

The present study examined whether long-term supplementation with once- and twice-weekly multiple micronutrients (MMN-1 and MMN-2) can improve Hb and micronutrient status more than twice-weekly Fe–folic acid (IFA-2) supplementation in non-anaemic adolescent girls in Bangladesh. An equal number of 324 rural schoolgirls aged 11–17 years were given MMN-1 or MMN-2 or IFA-2 supplements for 52 weeks in a randomised, double-blind trial. Blood samples were collected at baseline, and at 26 and 52 weeks of supplementation. The girls receiving IFA-2 supplements were more likely to be anaemic than the girls receiving MMN-2 supplements for 26 weeks (OR 5·1, 95 % CI 1·3, 19·5; P = 0·018). All three supplements reduced Fe deficiency effectively. Both the MMN-1 and MMN-2 groups showed significantly greater improvements in vitamins A, B2 and C status than the girls in the IFA-2 group, as might be expected. Receiving a MMN-1 supplement was found to be less effective than MMN-2 supplement in improving Fe, vitamins A, B2 and folic acid status. Receiving micronutrient supplements beyond 26 weeks showed little additional benefit in improving micronutrient status. In conclusion, given twice-weekly for 26 weeks, MMN supplements can improve micronutrient status effectively with no significant increase in Hb concentration compared with IFA supplements in non-anaemic Bangladeshi adolescent girls. However, it significantly reduces the risk of anaemia. Before any recommendations can be made, further research, including into cost-effectiveness, is needed to see whether MMN supplementation has any additional longer-term health benefits over that of IFA supplementation in this population.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library, PUBMED, MEDLINE, LILACS; and trial registry databases, all up to June 2011. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children below 18 years of age. We included trials comparing orally administered iron, iron with antimalarial treatment, or iron with folic acid versus placebo or no treatment. Iron fortification was excluded. Antihelminthics could be administered to either group. Additional micronutrients had to be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were clinical (symptomatic) malaria, severe malaria, and death. Two authors independently selected the studies and extracted the data. We assessed heterogeneity and conducted subgroup analyses by the presence of anaemia at baseline, age, and malaria endemicity. We assessed risk of bias using domain-based evaluation. We performed a fixed-effect meta-analysis for all outcomes and random-effects meta-analysis for hematological outcomes. We adjusted analyses for cluster randomized trials.

MAIN RESULTS

Seventy-one trials (45,353 children) were included. For clinical malaria, no significant difference between iron alone and placebo was detected, (risk ratio (RR) 0.99, 95% confidence intervals (CI) 0.90 to 1.09, 13 trials). The results were similar in the subgroups of non-anaemic children and children below 2 years of age. There was no significant difference in deaths in hyper- and holoendemic areas, risk difference +1.93 per 1000 children (95% CI -1.78 to 5.64, 13 trials, 17,898 children). Iron administered for treatment of anaemia resulted in a larger increase in haemoglobin than iron given for prevention, and the benefit was similar in hyper- or holoendemic and lower endemicity settings. Iron and folic acid supplementation resulted in mixed results for severe malaria. Overall, the risk for clinical malaria was higher with iron or with iron plus folic acid in trials where services did not provide for malaria surveillance and treatment. Iron with antimalarial treatment significantly reduced malaria. Iron supplementation during an acute attack of malaria did not increase the risk for parasitological failure, (RR 0.96, 95% CI 0.74 to 1.24, three trials) or deaths.

AUTHORS' CONCLUSIONS

Iron alone or with antimalaria treatment does not increase the risk of clinical malaria or death when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

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.

Review of fortified food and beverage products for pregnant and lactating women and their impact on nutritional status

Fortified beverages and supplementary foods, when given during pregnancy, have been shown to have positive effects on preventing maternal anaemia and iron deficiency. Studies show that use of micronutrient fortified supplementary foods, especially those containing milk and/or essential fatty acids during pregnancy, increase mean birthweight by around 60-73 g. A few studies have also shown that fortified supplementary foods have impacts on increasing birth length and reducing preterm delivery. Fortification levels have ranged generally from 50% to 100% of the recommended nutrient intake (RNI). Iron, zinc, copper, iodine, selenium, vitamins A, D, E, C, B1, B2, B6, and B12, folic acid, niacin and pantothenic acid are important nutrients that have been included in fortified beverages and supplemental foods for pregnant and lactating women. While calcium has been shown to reduce the risk of pre-eclampsia and maternal mortality, calcium, phosphorus, potassium, magnesium and manganese can have negative impacts on organoleptic properties, so many products tested have not included these nutrients or have done so in a limited way. Fortified food supplements containing milk and essential fatty acids offer benefits to improving maternal status and pregnancy outcome. Fortified beverages containing only multiple micronutrients have been shown to reduce micronutrient deficiencies such as anaemia and iron deficiency.

A multi-micronutrient beverage enhances the vitamin A and zinc status of Nigerian primary schoolchildren

Schoolchildren in Nigeria are rarely targeted by micronutrient interventions. We completed a 6-mo, double-blind, placebo-controlled trial to determine the effects of a multi-micronutrient beverage on biochemical and anthropometric indicators of nutritional status among schoolchildren participating in a pilot school feeding program in Nasarawa State, Nigeria. Children received 1 of 2 interventions 5 d/wk during school hours: 1) 250 mL/d of a multi-micronutrient beverage that included vitamin A, iron, and zinc (micronutrient); or 2) an isoenergetic control beverage (control). At baseline, 566 children 5-13 y old were randomized to groups (micronutrient: n = 288; control: n = 278). Height, weight, hemoglobin, and serum concentrations of C-reactive protein, ferritin, retinol, and zinc were measured at baseline and at the end of the study. A total of 270 children in the micronutrient group and 264 children in the control group completed the study. Self-reports of vomiting increased in both groups at 6 mo; however, the prevalence tended to be greater in the micronutrient group (21%) compared to the control group (14%) (P = 0.06). Biochemical changes were greater in the micronutrient group compared to control for serum retinol (0.10 ± 0.02 μmol/L vs. 0.02 ± 0.02 μmol/L; P = 0.016) and zinc (1.0 ± 0.2 μmol/L vs. 0.6 ± 0.2 μmol/L; P = 0.031). The intervention did not significantly affect hemoglobin or serum ferritin concentrations. The cost effectiveness of the intervention needs to be further evaluated, as does the efficacy of the beverage on anemia and indicators of iron status.

Can multi-micronutrient food fortification improve the micronutrient status, growth, health, and cognition of schoolchildren? A systematic review

Micronutrient deficiencies compromise the health and development of many school-age children worldwide. Previous research suggests that micronutrient interventions might benefit the health and development of school-age children and that multiple micronutrients might be more effective than single micronutrients. Fortification of food is a practical way to provide extra micronutrients to children. Earlier reviews of (multiple) micronutrient interventions in school-age children did not distinguish between supplementation or fortification studies. The present review includes studies that tested the impact of multiple micronutrients provided via fortification on the micronutrient status, growth, health, and cognitive development of schoolchildren. Twelve eligible studies were identified. Eleven of them tested the effects of multiple micronutrients provided via fortified food compared to unfortified food. One study compared fortification with multiple micronutrients to fortification with iodine alone. Multi-micronutrient food fortification consistently improved micronutrient status and reduced anemia prevalence. Some studies reported positive effects on morbidity, growth, and cognitive outcomes, but the overall effects on these outcomes were equivocal.

Efficacy of a microencapsulated iron pyrophosphate-fortified fruit juice: a randomised, double-blind, placebo-controlled study in Spanish iron-deficient women

Fe-deficiency anaemia is a worldwide health problem. We studied the influence of consuming an Fe-fortified fruit juice on Fe status in menstruating women. A randomised, double-blind, placebo-controlled study of 16 weeks of duration was performed. Subjects were randomised into two groups: the P group (n 58) or the F group (n 64), and consumed, as a supplement to their usual diet, 500 ml/d of a placebo fruit juice or an Fe-fortified fruit juice, respectively. The Fe-fortified fruit juice, containing microencapsulated iron pyrophosphate, provided 18 mg Fe/d (100 % of the RDA). At baseline and monthly, dietary intake, body weight and Fe parameters were determined: total erythrocytes, haematocrit, mean corpuscular volume (MCV), red blood cell distribution width (RDW), Hb, serum Fe, serum ferritin, serum transferrin, transferrin saturation, soluble transferrin receptor (sTfR) and zinc protoporphyrin (ZnPP). The fruit juice consumption involved increased intake of carbohydrates and vitamin C, and increased BMI within normal limits. Ferritin was higher in the F group after week 4 (P < 0·05) and became 80 % higher than in the P group after week 16 (P < 0·001), and transferrin decreased in the F group compared with the P group after week 4 (P < 0·001). RDW was higher at weeks 4 and 8 in the F group compared with the P group (P < 0·05). Transferrin saturation increased after week 8, and haematocrit, MCV and Hb increased after week 12, in the F group compared with the P group. Serum Fe did not change. sTfR and ZnPP decreased in the F group at week 16 (P < 0·05). Iron pyrophosphate-fortified fruit juice improves Fe status and may be used to prevent Fe-deficiency anaemia.

The nutritional status of school-aged children: why should we care?

BACKGROUND

The nutritional status of school-aged children impacts their health, cognition, and subsequently their educational achievement. The school is an opportune setting to provide health and nutrition services to disadvantaged children. Yet, school-aged children are not commonly included in health and nutrition surveys. An up-to-date overview of their nutritional status across the world is not available.

OBJECTIVE

To provide a summary of the recent data on the nutritional status of school-aged children in developing countries and countries in transition and identify issues of public health concern.

METHODS

A review of literature published from 2002 to 2009 on the nutritional status of children aged 6 to 12 years from Latin America, Africa, Asia, and the Eastern Mediterranean region was performed. Eligible studies determined the prevalence of micronutrient deficiencies or child under- and overnutrition using biochemical markers and internationally accepted growth references.

RESULTS

A total of 369 studies from 76 different countries were included. The available data indicate that the nutritional status of school-aged children in the reviewed regions is considerably inadequate. Underweight and thinness were most prominent in populations from South-East Asia and Africa, whereas in Latin America the prevalence of underweight or thinness was generally below 10%. More than half of the studies on anemia reported moderate (> 20%) or severe (> 40%) prevalence of anemia. Prevalences of 20% to 30% were commonly reported for deficiencies of iron, iodine, zinc, and vitamin A. The prevalence of overweight was highest in Latin American countries (20% to 35%). In Africa, Asia, and the Eastern Mediterranean, the prevalence of overweight was generally below 15%.

CONCLUSIONS

The available data indicate that malnutrition is a public health issue in school-aged children in developing countries and countries in transition. However, the available data, especially data on micronutrient status, are limited. These findings emphasize the need for nutrition interventions in school-aged children and more high-quality research to assess nutritional status in this age group.

Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron + folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Effect of vitamin A, vitamin A plus iron and multiple micronutrient-fortified seasoning powder on infectious morbidity of preschool children

OBJECTIVE

Improvement of hemoglobin and serum retinol and facilitation of the mobilization of iron storage were achieved with a multiple-micronutrient-fortified diet in preschoolers for 6 mo in a suburb of Chongqing, China. We investigated whether fortification with multiple micronutrients in a diet for preschool children results in changes in children's infectious morbidity compared with diets fortified solely with vitamin A and with vitamin A plus iron.

METHODS

From December 2005 to June 2006, 226 2- to 6-y-old preschool children were recruited from three nurseries randomly assigned to three different fortified-diet groups for 6 mo. Group I was fortified with vitamin A; groups II and III were fortified with vitamin A plus iron and vitamin A plus iron, thiamine, riboflavin, folic acid, niacinamide, zinc, and calcium, respectively. The secondary functional outcomes, morbidity of diarrhea and respiratory infection, were collected during supplementation.

RESULTS

The groups were comparable concerning compliance and loss to follow-up. There was evidence of a lower incidence rate of respiratory-related illnesses, diarrhea-related illness, fewer symptoms of runny nose, cough, and fever, and shorter duration of respiratory-related illnesses and cough for children in group III compared with children in groups I and II. However, there was no significantly or clinically important difference between children in groups I and II.

CONCLUSION

The beneficial effects on infectious morbidity over 6 mo, in addition to some biochemical improvements, highlight the potential of this micronutrient-fortified seasoning powder supplied in a diet for preschool children.

Effects of weaning biscuits on the nutritional profile and the cognitive development in preschool children

AIM

To study the effect of weaning biscuits supplementation of the nutritional parameters and cognitive performance of the selected children.

METHODS

Three primary schools situated in Salem District, Tamilnadu, India were selected. A total number of 150 school children, 61 from primary school I, 46 from primary school II and 43 from primary school III comprised the study sample. About 80 primary school children with Grade II malnutrition were selected for the experimental study. Home diet without any supplementation was followed by Group I (n=20, control group), potato flour biscuit was supplemented to Group II (n=20), wheat biscuits was given to Group III (n=20) and ragi biscuits were given to Group IV (n=20) for the period of 3 months. Parameters like anthropometric measurements, hemoglobin content clinical picture and cognitive performance were analyzed before and after supplementation.

RESULTS

Results about Group I (control group) showed no significant difference in height, weight and clinical picture and cognitive performance after three months on their home diet. In Group II, III and IV significant increase in all the above parameters was noticed. More increase was found in Group II children supplemented with potato flour biscuits for a period of 3 months. About cognitive performance better results was obtained in Group II followed by Group III (supplemented with wheat biscuits) and Group IV (supplemented with ragi biscuits). Least was obtained by control group children who are in their home diet.

CONCLUSION

All these observations evident that if such weaning biscuits made with potato flour, wheat and Ragi can form a daily ingredient in their diets, it will bring out better all round development of the children.

Provision of a school snack is associated with vitamin B-12 status, linear growth, and morbidity in children from Bogota, Colombia

In 2004, Bogotá's Secretary of Education (SED) initiated a snack program in public primary schools. A midmorning food ration was provided free of charge to children to supplement 30 and 50% of their daily requirements of energy and iron, respectively. The purpose of this study, an observational investigation of 3202 children ages 5-12 y, was to examine whether the snack program improved children's nutritional and health status. We measured micronutrient levels (plasma ferritin and vitamin B-12, and erythrocyte folate), anthropometry, and reported morbidity during the first semester of the 2006 school year. After adjusting for socioeconomic status and other school interventions, children at schools receiving the snack (n = 1803) had greater increases in plasma vitamin B-12 (42 pmol/L; P < 0.0001) from baseline to 3 mo of follow-up than children at schools not receiving the snack (n = 1399). They also experienced a smaller decrease in height-for-age Z-scores than children who did not receive the snack (P = 0.001). Provision of the SED snack was associated with significantly fewer reported days with morbidity symptoms (e.g. cough with fever, diarrhea with vomiting), 44% fewer doctor visits (P = 0.02), and 23% fewer days of school absenteeism (P = 0.03). The snack was not related to ferritin or folate levels. In conclusion, provision of a school-administered snack was related to improved vitamin B-12 status and linear growth and decreased reported morbidity. Although provision of the snack was not related to BMI changes over a 4-mo period, snack components such as candy and sugar-sweetened beverages should be replaced with healthier options, as the rates of child overweight in Colombia are not negligible.

Leaf concentrate as an alternative to iron and folic acid supplements for anaemic adolescent girls: a randomised controlled trial in India

Objective

Despite public health campaigns based on Fe and folic acid supplements, Fe-deficiency anaemia remains highly prevalent among women in India. We investigated leaf concentrate as an alternative to Fe and folic acid supplements for treating anaemia in adolescent girls.

Design

Randomised controlled two-arm trial over 3 months: one group received daily Fe and folic acid (IFA; 60 mg Fe, 500 μg folic acid); the other daily leaf concentrate (LC; 5 mg Fe, 13 μg folic acid). Hb concentration, mean cell volume, serum Fe, serum ferritin and total Fe-binding capacity were measured pre- and post-intervention.

Setting

Jaipur, India.

Subjects

One hundred and two adolescent girls aged 14–18 years.

Results

Of the 102 girls randomized to the two arms of the trial, four (3·9 %) were severely anaemic (Hb < 7 g/dl), twenty-eight (27·5 %) were moderately anaemic (Hb ≥ 7 g/dl, <10 g/dl) and seventy (68·6 %) were mildly anaemic (Hb ≥ 10 g/dl, <12 g/dl). In the IFA group, eleven girls (20·4 %) withdrew due to side-effects, compared with one girl (2·1 %) in the LC group (P = 0·005). Total losses to follow-up were 14/54 in the IFA group and 2/48 in the LC group. At the end of the trial, none of the eighty-six remaining girls were severely anaemic, nine (10·5 %) were moderately anaemic and twenty-six (30·2 %) were mildly anaemic; fifty-one (59·3 %) had normal Hb levels (≥12 g/dl). After adjustment for baseline values, LC was as effective as IFA in improving serum Fe parameters and treating anaemia.

Conclusions

Leaf concentrate is an effective, and more palatable, alternative to Fe and folic acid supplements for treating anaemia in adolescent girls.

Haematological effects of multimicronutrient supplementation in non-pregnant Gambian women

BACKGROUND/OBJECTIVES

The use of multimicronutrient (MMN) supplementation to reduce the burden of anaemia in non-pregnant women of reproductive age has been little studied, particularly in Africa. The objective of the study was to evaluate haematological outcomes in non-pregnant, rural Gambian women of reproductive age, receiving daily MMN supplements for 1 year.

SUBJECTS/METHODS

The study in 293 women aged from 17 to 45 years old was nested within a double-blind, randomized placebo-controlled trial of periconceptional MMN supplementation [ISRCTN 13687662], using the United Nations International Multiple Micronutrient Preparation (UNIMMAP), received daily for 1 year or until conception. Red cell parameters and free erythrocyte protoporphyrin concentration were measured at baseline and after 12 months in those women who did not conceive.

RESULTS

Anaemic women (haemoglobin concentration <12 g per 100 ml) were more likely to be older and in economic deficit at baseline. Mean change in haemoglobin concentration was +0.6+/-1.4 g per 100 ml in the intervention arm and -0.2+/-1.2 g per 100 ml in the placebo arm (P<0.001). After supplementation with MMN, the relative risk of anaemia (<12 g per 100 ml) was 0.59 (0.46, 0.76) compared with placebo. Anaemic subjects at baseline showed an increase in mean haemoglobin from 10.6 g per 100 ml to 11.8 g/l (P<0.001) after MMN supplementation.

CONCLUSIONS

MMN supplementation should be considered as a strategy for improving the micronutrient and haematological status of non-pregnant women of reproductive age.

Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library (2009, issue 1); MEDLINE; EMBASE; LILACS and metaRegister of Controlled Trials, all up to March 2009. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster-randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children < 18 years. We included trials comparing orally administered iron with or without folic acid vs. placebo or no treatment. Iron fortification was excluded. Antimalarials and/or antiparasitics could be administered to either group. Additional micronutrients could only be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were malaria-related events and deaths. Secondary outcomes included haemoglobin, anaemia, other infections, growth, hospitalizations, and clinic visits. We assessed risk of bias using domain-based evaluation. Two authors independently selected studies and extracted data. We contacted authors for missing data. We assessed heterogeneity. We performed fixed-effect meta-analysis and presented random-effects results when heterogeneity was present. We present pooled risk ratios (RR) with 95% confidence intervals (CIs). We used adjusted analyses for cluster-randomized trials.

MAIN RESULTS

Sixty-eight trials (42,981 children) fulfilled the inclusion criteria. Iron supplementation did not increase the risk of clinical malaria (RR 1.00, 95% CI 0.88 to 1.13; 22,724 children, 14 trials, random-effects model). The risk was similar among children who were non-anaemic at baseline (RR 0.96, 95% CI 0.85 to 1.09). An increased risk of malaria with iron was observed in trials that did not provide malaria surveillance and treatment. The risk of malaria parasitaemia was higher with iron (RR 1.13, 95% CI 1.01 to 1.26), but there was no difference in adequately concealed trials. Iron + antimalarial was protective for malaria (four trials). Iron did not increase the risk of parasitological failure when given during malaria (three trials). There was no increased risk of death across all trials comparing iron versus placebo (RR 1.11, 95% CI 0.91 to 1.36; 21,272 children, 12 trials). Iron supplementation increased haemoglobin, with significant heterogeneity, and malaria endemicity did not affect this effect. Growth and other infections were mostly not affected by iron supplementation.

AUTHORS' CONCLUSIONS

Iron does not increase the risk of clinical malaria or death, when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Are Vitamin A and Iron Deficiencies Re-Emerging in Urban Latin America? A Survey of Schoolchildren in Bogota, Colombia

Background

In Latin America, the burden of vitamin A and iron deficiencies has been documented primarily in preschool-age children. There are few recent reports on the vitamin A and iron status of school-age children.

Objective

We aimed to determine the prevalence and predictors of vitamin A and iron deficiencies in Colombian schoolchildren.

Methods

We examined plasma retinol and ferritin concentrations in relation to socioeconomic and anthropometric factors in a representative sample of 2,811 low- and middle-income children 5 to 12 years of age in Bogotá, Colombia.

Results

The prevalence rates of deficiencies of vitamin A (plasma retinol < 0.70 μmol/L) and iron (plasma ferritin < 15 μg/L) were 14% and 3%, respectively. In multivariate analysis, plasma retinol concentrations were positively associated with child's age and household's socioeconomic stratum, whereas ferritin concentrations were positively related to child's age, number of home assets, and having a nonsingle mother. Ferritin concentrations were much lower among girls than boys in the 11- and 12-year-old age group, whereas there were only small positive differences between girls and boys in younger children (p for interaction < .0001) . Both vitamin A and iron deficiencies were independently associated with lower z-scores for body-mass-index-for-age, after adjustment for sociodemographic factors and C-reactive protein concentrations. Neither vitamin A nor iron status was related to height-for-age.

Conclusions

The prevalence rates of vitamin A and iron deficiencies among schoolchildren from Bogotá, Colombia, are not negligible. Both vitamin A and iron status are positively associated with socioeconomic status and anthropometric indices. The effect of improving vitamin A and iron status on physical growth and other functional outcomes needs to be further examined in this age group.

Provision of multiple rather than two or fewer micronutrients more effectively improves growth and other outcomes in micronutrient-deficient children and adults

Deficiencies of multiple micronutrients (MMN) usually coexist in developing countries, but supplements have usually provided only 1 or 2 micronutrients (MN). To inform policy, in this article we compared the relative benefits of supplying MMN vs. a placebo or 1 or 2 MN on the following: children's growth, health, and development; pregnancy outcome; nutritional status; and HIV/AIDS mortality and morbidity in adults. Sufficient data were available to perform random-effects meta-analyses of randomized controlled trials (RCT) for the effects of MMN on child growth and nutritional status. Results for other outcomes are presented as effect sizes (ES) when available. In children, MMN interventions resulted in small but significantly greater improvements in length or height (ES = 0.13; 95% CI: 0.055, 0.21) and weight (ES = 0.14; 95% CI: 0.029, 0.25), hemoglobin (ES = 0.39; 95% CI: 0.25, 0.53), serum zinc (ES = 0.23; 95% CI: 0.18, 0.43), serum retinol (ES = 0.33; 95% CI: 0.050, 0.61), and motor development. A Cochrane review reported that compared with no supplementation or a placebo, MMN supplementation during pregnancy reduced the relative risk of low birth weight (0.83), small-for-gestational age (0.92), and anemia (0.61); however, MMN were not more effective than iron + folic acid alone. There is some evidence that MMN supplementation improves CD4 counts and HIV-related morbidity and mortality in adults. The efficacy of MMN varies across trials, but overall there is evidence that outcomes are better than when providing < or =2 MN. The policy implications of these studies are discussed.

Oral zinc for treating diarrhoea in children

BACKGROUND

Diarrhoea causes around two million child deaths annually. Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH STRATEGY

In November 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation (>/= 5 mg/day for any duration) with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and methodological quality, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.

MAIN RESULTS

Eighteen trials enrolling 6165 participants met our inclusion criteria. In acute diarrhoea, zinc resulted in a shorter diarrhoea duration (MD -12.27 h, 95% CI -23.02 to -1.52 h; 2741 children, 9 trials), and less diarrhoea at day three (RR 0.69, 95% CI 0.59 to 0.81; 1073 children, 2 trials), day five (RR 0.55, 95% CI 0.32 to 0.95; 346 children, 2 trials), and day seven (RR 0.71, 95% CI 0.52 to 0.98; 4087 children, 7 trials). The four trials (1458 children) that reported on diarrhoea severity used different units and time points, and the effect of zinc was less clear. Subgroup analyses by age (trials with only children aged less than six months) showed no benefit with zinc. Subgroup analyses by nutritional status, geographical region, background zinc deficiency, zinc type, and study setting did not affect the results' significance. Zinc also reduced the duration of persistent diarrhoea (MD -15.84 h, 95% CI -25.43 to -6.24 h; 529 children, 5 trials). Few trials reported on severity, and results were inconsistent. No trial reported serious adverse events, but vomiting was more common in zinc-treated children with acute diarrhoea (RR 1.71, 95% 1.27 to 2.30; 4727 children, 8 trials).

AUTHORS' CONCLUSIONS

In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.

A micronutrient-fortified seasoning powder reduces morbidity and improves short-term cognitive function, but has no effect on anthropometric measures in primary school children in northeast Thailand: a randomized controlled trial

BACKGROUND

Reductions in iodine and zinc deficiencies and improvements in hemoglobin were achieved from a micronutrient-fortified seasoning powder consumed in school lunches by children in northeast Thailand.

OBJECTIVE

The objective was to determine whether fortification with 4 micronutrients in a school lunch results in changes in children's growth, morbidity, and cognitive function compared with no fortification.

DESIGN

In a randomized controlled trial of 569 children aged 5.5-13.4 y from 10 schools, we compared the efficacy of a seasoning powder fortified with or without 5 mg Fe, 5 mg Zn, 50 mug I, and 270 mug vitamin A per serving consumed with a school lunch 5 d/wk. Here we report on results of the secondary functional outcomes.

RESULTS

The groups were comparable concerning compliance and loss to follow-up. The intervention had no statistically significant effect on anthropometric measures over 31 wk, but reduced the incidence of respiratory-related illnesses [rate ratio (RR): 0.83; 95% CI: 0.73, 0.94], symptoms of runny nose (RR: 0.80; 95% CI: 0.70, 0.92), cough (RR: 0.80; 95% CI: 0.66, 0.96), and diarrhea (RR: 0.38; 95% CI: 0.16, 0.90). For the visual recall test, those in the fortified group recalled 0.5 more items (95% CI: 0.1, 0.9) than did the controls. There were no statistically significant differences between groups in the results of the digits forward and backward tests or in school grades at the conclusion of the 2 semesters.

CONCLUSION

The beneficial effects on morbidity and visual recall over a short period, in addition to some biochemical improvements, highlight the potential of this micronutrient-fortified seasoning powder supplied in a school lunch. This trial was registered at clinical trials.gov as ACTRN12605000341628.