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Zavala E, Rahman A, Kalbarczyk A, de Boer M, Khaled N, Chakraborty B, Rahman H, Ali H, Haque R, Ayesha K, Siddiqua TJ, Afsana K, Christian P, Thorne‐Lyman AL. Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh. MATERNAL & CHILD NUTRITION 2024; 20 Suppl 6:e13587. [PMID: 37991138 PMCID: PMC11439734 DOI: 10.1111/mcn.13587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023]
Abstract
Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.
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Affiliation(s)
- Eleonor Zavala
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Atiya Rahman
- Humanitarian HubJames P. Grant School of Public Health, BRAC UniversityDhakaBangladesh
| | - Anna Kalbarczyk
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Mary de Boer
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Nazrana Khaled
- Humanitarian HubJames P. Grant School of Public Health, BRAC UniversityDhakaBangladesh
| | - Barnali Chakraborty
- Humanitarian HubJames P. Grant School of Public Health, BRAC UniversityDhakaBangladesh
| | - Hafizur Rahman
- The JiVitA Maternal and Child Health and Nutrition Research ProjectRangpurBangladesh
| | - Hasmot Ali
- The JiVitA Maternal and Child Health and Nutrition Research ProjectRangpurBangladesh
| | - Rezwanul Haque
- The JiVitA Maternal and Child Health and Nutrition Research ProjectRangpurBangladesh
| | - Kaniz Ayesha
- The JiVitA Maternal and Child Health and Nutrition Research ProjectRangpurBangladesh
| | - Towfida J. Siddiqua
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
- The JiVitA Maternal and Child Health and Nutrition Research ProjectRangpurBangladesh
| | - Kaosar Afsana
- Humanitarian HubJames P. Grant School of Public Health, BRAC UniversityDhakaBangladesh
| | - Parul Christian
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Andrew L. Thorne‐Lyman
- Department of International HealthBloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMarylandUSA
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Thorne‐Lyman AL, Kalbarczyk A, Tumilowicz A, Christian P, Afsana K. Using formative research to enhance our understanding of implementation contexts: Preparing for a trial of maternal nutrition interventions. MATERNAL & CHILD NUTRITION 2024; 20 Suppl 6:e13639. [PMID: 39344039 PMCID: PMC11439738 DOI: 10.1111/mcn.13639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/25/2024] [Indexed: 10/01/2024]
Abstract
Formative research to understand the sociocultural and economic context into which interventions are introduced can help to maximize the uptake of interventions both in the context of effectiveness trials and ultimately for nutrition programs. Findings from the formative research study were used to inform different facets of the design of the effectiveness trial including providing evidence of the acceptability of the product, informing the decision to deliver the product to women's homes, and developing strategies to support adherence.
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Affiliation(s)
- Andrew L. Thorne‐Lyman
- Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Anna Kalbarczyk
- Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Alison Tumilowicz
- Maternal, Newborn, and Child Health, Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Parul Christian
- Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Kaosar Afsana
- Humanitarian Hub, James P. Grant School of Public HealthBRAC UniversityDhakaBangladesh
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McDonald CM, Wessells KR, Stewart CP, Dewey KG, de Pee S, Rana R, Hafeez-Ur-Rehman H, Mwangi MN, Hess SY. Perinatal intervention strategies providing food with micronutrients to pregnant and breastfeeding women in low- and middle-income countries: A scoping review. MATERNAL & CHILD NUTRITION 2024:e13681. [PMID: 38949186 DOI: 10.1111/mcn.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/03/2024] [Accepted: 05/28/2024] [Indexed: 07/02/2024]
Abstract
In resource-constrained settings, pregnant and breastfeeding women and girls (PBW/G) are particularly vulnerable to undernutrition. Micronutrient-fortified balanced energy protein (BEP) supplementation may be provided to boost maternal nutritional status and improve birth and infant outcomes. We conducted a scoping review of the published literature to determine the impact of BEP and other related nutrition interventions that provided fortified food or cash along with a minimum of 3 micronutrients on maternal, birth, and infant/child outcomes in low- and middle-income countries. We conducted a PubMed search using pre-defined keywords and controlled vocabulary search terms. All titles and abstracts were reviewed for eligibility by two independent reviewers, and data were extracted according to outcome type. We identified 149 eligible research articles that reported on a total of 21 trials and/or programme evaluations which assessed the health impact of one or more products (fortified lipid-based nutrient supplement [LNS, n = 12], fortified blended flours [n = 5], milk-based beverages [n = 2], and local food/snacks [n = 3]) that provided 118-750 kcal/day and varying levels of protein and micronutrients. Only one of these programme evaluations assessed the impact of the provision of cash and fortified food. Effects on maternal outcomes such as gestational weight gain and duration of gestation were promising but inconsistent. Birth outcomes were reported in 15 studies, and the effects on birthweight and birth length were generally positive. Seven studies demonstrated sustained benefits on infant and child growth out of the 15 studies that reported at least one of these outcomes, although data were sparse. Additional research is needed to investigate issues of dose, cost-effectiveness, and incorporation into multi-component interventions.
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Affiliation(s)
- Christine M McDonald
- Departments of Pediatrics, and Epidemiology & Biostatistics, University of California, San Francisco, California, USA
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, California, USA
| | - K Ryan Wessells
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, California, USA
| | - Christine P Stewart
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, California, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, California, USA
| | - Saskia de Pee
- Nutrition Division, World Food Programme HQ, Rome, Italy
| | - Ritu Rana
- Nutrition Division, World Food Programme HQ, Rome, Italy
| | | | | | - Sonja Y Hess
- Institute for Global Nutrition and Department of Nutrition, University of California, Davis, California, USA
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Eglovitch M, Abate FW, Shifraw T, Shiferie F, Amanuel H, Tadesse AW, Worku A, Isanaka S, Berhane Y, Lee ACC. Balanced Energy Protein Supplementation in Pregnancy: Adherence and Acceptability among Pregnant Women in Rural Ethiopia. Curr Dev Nutr 2024; 8:103796. [PMID: 39055242 PMCID: PMC11269774 DOI: 10.1016/j.cdnut.2024.103796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/03/2024] [Accepted: 06/08/2024] [Indexed: 07/27/2024] Open
Abstract
Background Balanced energy protein (BEP) supplementation in pregnant women in low-and middle-income countries may reduce the risk of stillbirth and low birth weight. Objectives The objective of this study was to assess the adherence to and acceptability of a corn-soy blend (CSB) BEP product among pregnant women in rural Ethiopia. Methods This formative study was conducted from October to November 2018 among pregnant women in the rural Amhara region of Ethiopia prior to initiation of a clinical effectiveness study (ISRCTN: 15116516). We assessed adherence and acceptability of a micronutrient-fortified CSB BEP supplement among 40 pregnant women during a 4-wk utilization period. Acceptability was assessed using a 7-point Likert-style scale about the hedonic characteristics of the BEP product at 2 wk and 4 wk. Adherence was assessed by weekly monitoring and empty sachet counts for BEP consumption over 4 wk. Results Adherence to the BEP was, on average, 89% over the month-long pilot. The BEP product was rated favorably (mean Likert score >6 of 7) for the following domains: color, taste, odor, and likeability at mid and endpoints. Women found the product convenient to eat [mean (standard deviation [SD] = 5.9 (1.0))] and filling (mean (SD) = 6.1 (1.5) out of 7). Scores on acceptability and perception of the product remained stable throughout the duration of use. A majority of women (63%) reported consuming the BEP as a snack to supplement meals and splitting the serving over 2 or more sessions (68%). A quarter of respondents reported sharing the supplement with family members. Conclusions Adherence and acceptability of the CSB BEP product were high among this population in rural Amhara, Ethiopia. This formative data was important to select the final product and shape the counseling and delivery of BEP in the parent study.
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Affiliation(s)
- Michelle Eglovitch
- Brigham and Women’s Hospital, Boston, MA, United States
- Virginia Commonwealth University, Richmond, VA, United States
| | | | - Tigest Shifraw
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Fisseha Shiferie
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | | | - Amare Worku Tadesse
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alemayehu Worku
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Sheila Isanaka
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Anne CC Lee
- Brigham and Women’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Erchick DJ, Lama TP, Khatry SK, Katz J, Mullany LC, Zavala E, LeClerq SC, Christian P, Tielsch JM. Supplementation with fortified balanced energy-protein during pregnancy and lactation and its effects on birth outcomes and infant growth in southern Nepal: protocol of a 2×2 factorial randomised trial. BMJ Paediatr Open 2023; 7:e002229. [PMID: 37923345 PMCID: PMC10626787 DOI: 10.1136/bmjpo-2023-002229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/26/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION Many women in low and middle-income countries enter pregnancy with low nutritional reserves with increased risk of fetal growth restriction and poor birth outcomes, including small-for-gestational-age (SGA) and preterm birth. Balanced energy-protein (BEP) supplements have shown reductions in risk of stillbirth and SGA, yet variations in intervention format and composition and limited evidence on the impact of BEP during lactation on growth outcomes warrant further study. This paper describes the protocol of the Maternal Infant Nutrition Trial (MINT) Study, which aims to evaluate the impact of a fortified BEP supplement during pregnancy and lactation on birth outcomes and infant growth in rural Nepal. METHODS AND ANALYSIS MINT is a 2×2 factorial, household randomised, unblinded, efficacy trial conducted in a subarea of Sarlahi District, Nepal. The study area covers six rural municipalities with about 27 000 households and a population of approximately 100 000. Married women (15-30 years) who become pregnant are eligible for participation in the trial and are randomly assigned at enrolment to supplementation with fortified BEP or not and at birth to fortified BEP supplementation or not until 6 months post partum. The primary pregnancy outcome is incidence of SGA, using the INTERGROWTH-21st standard, among live born infants with birth weight measured within 72 hours of delivery. The primary infant growth outcome is mean length-for-age z-score at 6 months using the WHO international growth reference. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA (IRB00009714), the Committee on Human Research IRB at The George Washington University, Washington, DC, USA (081739), and the Ethical Review Board of the Nepal Health Research Council, Kathmandu, Nepal (174/2018). TRIAL REGISTRATION NUMBER NCT03668977.
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Affiliation(s)
- Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tsering P Lama
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project Sarlahi (NNIPS), Kathmandu, Nepal
| | - Subarna K Khatry
- Nepal Nutrition Intervention Project Sarlahi (NNIPS), Kathmandu, Nepal
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eleonor Zavala
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project Sarlahi (NNIPS), Kathmandu, Nepal
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
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Ciulei MA, Smith ER, Perumal N, Jakazi CS, Sudfeld CR, Gernand AD. Nutritious Supplemental Foods for Pregnant Women from Food Insecure Settings: Types, Nutritional Composition, and Relationships to Health Outcomes. Curr Dev Nutr 2023; 7:100094. [PMID: 37250388 PMCID: PMC10209485 DOI: 10.1016/j.cdnut.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
There is growing evidence that the provision of nutritious supplemental foods to undernourished pregnant women can improve maternal and infant outcomes. However, comparing and synthesizing the evidence base is complicated by differences in interventions and products and the use of ambiguous terminology. We aimed to define 2 common types of nutritious supplemental foods used in pregnancy, balanced energy-protein (BEP) supplements and lipid-based nutrient supplements (LNS), and to review the evidence supporting each via a narrative review of systematic reviews and meta-analyses (SRMAs). Information about the nutritional composition of the food supplements and their effects on maternal and infant outcomes was abstracted. Five SRMAs (n = 20 trials) evaluated the effect of BEP compared with no BEP/control (comparison group commonly received iron and folic acid [IFA]). BEP foods/products ranged in calories (118-1017 kcals), protein (3-50 g), fat (6-57 g), and micronutrient content. Overall, maternal BEP improved birth weight and reduced the risk of stillbirth and small for gestational age when compared with no BEP/control in pregnancy. Three SRMAs (n = 5 trials) evaluated the effect of LNS compared with IFA or multiple micronutrients (MMNs). The LNS interventions comprised small- and large-quantity LNS that ranged in calories (118-746 kcals), protein (3-21 g), fat (10-53 g), and micronutrient content. LNS compared with IFA increased pregnancy duration, birth weight, and birth length and reduced the risk of small for gestational age and infant stunting; however, no beneficial effect of LNS was identified when compared with MMN. Despite heterogeneity in the nutritional composition of BEP supplements, the evidence suggests that in nutritionally at-risk populations, these products may improve birth outcomes in pregnant women. The evidence is limited but promising when LNS is compared with IFA in improving maternal and infant outcomes. Overall, BEP, compared with MMN or LNS, are key areas that have not been studied and deserve attention.
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Affiliation(s)
- Mihaela A. Ciulei
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
| | - Emily R. Smith
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Exercise and Nutrition Sciences, George Washington University Milken Institute School of Public Health, Washington, DC, United States
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Nandita Perumal
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
| | - Chioniso S. Jakazi
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, United States
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States
- Department of Nutrition, Harvard School of Public Health, Boston, MA, United States
| | - Alison D. Gernand
- Department of Nutritional Sciences, the Pennsylvania State University, University Park, PA, United States
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Lama TP, Khatry SK, Isanaka S, Moore K, Jones L, Bedford J, Katz J, de Pee S, LeClerq SC, Tielsch JM. Acceptability of 11 fortified balanced energy-protein supplements for pregnant women in Nepal. MATERNAL & CHILD NUTRITION 2022; 18:e13336. [PMID: 35263004 PMCID: PMC9218317 DOI: 10.1111/mcn.13336] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 06/01/2023]
Abstract
Evidence suggests that multiple micronutrient and balanced energy protein (BEP) supplementation during pregnancy can decrease the risk of stillbirth and small-for-gestational-age births and increase birth weight. We conducted a mixed-methods formative research study to identify the most acceptable among a range of 11 candidates fortified BEP supplements for use in pregnancy and lactation in a rural district in Nepal. Forty pregnant women aged 15-40 years participated in a test meal tasting of 11 different sweet and savoury candidate BEP supplements. Each participant rated the products on organoleptic properties using a 7-point hedonic scale (1 = Dislike it very much to 7 = Like it very much), ranked her 'top 3' most liked supplements, and subsequently discussed each product with peers in focus group discussions (FGDs). Five supplements (sweet lipid-based nutrient supplement (LNS), savoury LNS, sweet vanilla biscuits, vanilla instant drinks and seasoned pillows) achieved the maximum overall median hedonic score of 7, with sweet LNS and seasoned pillows ranking as the top 2. This was consistent with the assessments in FGDs. Women in the FGDs expressed dislike of the smell and taste of the cocoa drink, savoury masala bar, sweet mango bar and savoury curry biscuit, which was consistent with the hedonic scale scores. This study provides valuable insights into our understanding of women's acceptance of different BEP supplements during pregnancy in rural Nepal and has helped identify the two most accepted BEP supplements to be used in a two-month home trial to assess utilisation and compliance in this setting.
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Affiliation(s)
- Tsering P. Lama
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Subarna K. Khatry
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS)KathmanduNepal
| | - Sheila Isanaka
- Departments of Nutrition and Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | | | | | | | - Joanne Katz
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Saskia de Pee
- Department of Global Health, Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Steven C. LeClerq
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS)KathmanduNepal
| | - James M. Tielsch
- Department of Global Health, Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
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