Multiple micronutrient supplementation during pregnancy and lactation in low-to-middle-income developing country settings: impact on pregnancy outcomes

Utilizing a multi-stage transition model for analysing child stunting in two urban slum settlements of Nairobi: A longitudinal analysis, 2011-2014

INTRODUCTION

Stunting is common among children in many low and middle income countries, particularly in rural and urban slum settings. Few studies have described child stunting transitions and the associated factors in urban slum settlements. We describe transitions between stunting states and associated factors among children living in Nairobi slum settlements.

METHODS

This study used data collected between 2010 and 2014 from the Nairobi Urban and Demographic Surveillance System (NUHDSS) and a vaccination study nested within the surveillance system. A subset of 692 children aged 0 to 3 years, with complete anthropometric data, and household socio-demographic data was used for the analysis. Height-for-age Z-scores (HAZ) was used to define stunting: normal (HAZ ≥ 1), marginally stunted (-2 ≤ HAZ < -1), moderately stunted (-3 ≤ HAZ < -2), and severely stunted (HAZ < -3). Transitions from one stunting level to another and in the reverse direction were computed. The associations between explanatory factors and the transitions between four child stunting states were modeled using a continuous-time multi-state model.

RESULTS

We observed that 48%, 39%, 41%, and 52% of children remained in the normal, marginally stunted, moderately stunted, and severely stunted states, respectively. About 29% transitioned from normal to marginally stunted state, 15% to the moderately stunted state, and 8% to the severely stunted state. Also, 8%, 12%, and 29% back transitioned from severely stunted, moderately stunted, and marginally stunted states, to the normal state, respectively. The shared common factors associated with all transitions to a more severe state include: male gender, ethnicity (only for mild and severe transition states), child's age, and household food insecurity. In Korogocho, children whose parents were married and those whose mothers had attained primary or post-primary education were associated with a transition from a mild state into a moderately stunted state. Children who were breastfed exclusively were less likely to transition from moderate to severe stunting state.

CONCLUSION

These findings reveal a high burden of stunting and transitions in urban slums. Context-specific interventions targeting the groups of children identified by the socio-demographic factors are needed. Improving food security and exclusive breastfeeding could potentially reduce stunting in the slums.

Nutritional Status of Breastfeeding Mothers and Impact of Diet and Dietary Supplementation: A Narrative Review

Adequate nutrition during breastfeeding is crucial for ensuring the good health of mothers and babies. Despite the high energy and nutrient demands of breastfeeding, lactating women are often vulnerable from a nutritional perspective. The nutritional focus during breastfeeding tends to be on the newborn, often neglecting the mother's diet. Therefore, in the present narrative review, nutrient intakes were compared with the dietary reference values (DRVs) proposed by the European Food Safety Authority (EFSA) as well as by the World Health Organization/Food and Agriculture Organization (WHO/FAO). In the diets of lactating mothers, dietary inadequacies were observed in the intake of some vitamins, such as folic acid, vitamin B12, vitamin A, and vitamin D, and in the intake of certain minerals like calcium, iron, and iodine; polyunsaturated omega-3 fatty acid deficiencies, primarily in eicosapentaenoic acid and docosahexaenoic acid, were also observed. On the other hand, the debate on the necessity of supplementation during lactation continues; the need for nutritional supplementation during lactation depends on many factors, such us mothers' eating habits. There seems to be a positive association between nutritional supplementation of the lactating mother and the concentration of certain nutrients in human milk. The present narrative review provides an update on the nutritional status (fatty acids and micronutrients) of breastfeeding mothers and the impact of diet and dietary supplementation on human milk composition.

Serum concentration of zinc, copper, iron, and its associated factors among pregnant women of small-scale farming in western Ethiopia

Micro-nutrients are required in small amounts to maintain growth and cell functioning to complete the life cycle through reproductions. However, pregnant women in developing countries like Ethiopia are vulnerable to multiple micro-nutrient deficiencies. Therefore, this study aimed at assessing the serum level of metals and associated factors like dietary diversity, and health-related problems in pregnant women among small-scale farming in Kellem Wellega, western Ethiopia. A cross-sectional laboratory-based study was conducted from June to August 2021 on 417 pregnant women attending antenatal care at rural healthcare facilities. Data was collected by using per-tested structured questionnaires via face-to-face interviews. The data analysis was conducted using SPSS version 24.0, and multivariate logistic regression analysis was performed to determine the association between predictor and outcome variables. A statistically significant was considered at p value < 0.05 for all the analyses. Our study findings showed that 62.1, 80.9, and 71.9% of the participants were deficient in iron, zinc, and copper micro-nutrient levels, respectively. Pregnant women who could not have formal education were 3.24 (AOR = 3.24, 95% CI 1.33-7.91) and 3.98 (AOR = 3.98, 95% CI 1.2-13.15) times more likely to show zinc and copper deficiency than those who attended secondary school and above, respectively. Furthermore, pregnant women involved only in farming activities were 0.57 (AOR = 0.57, 95% CI 0.36-0.91) and 4.33 (AOR = 5.72, 95% CI 2.34-13.97) times more likely to be exposed to iron and zinc deficiency than those who were engaged in other activities. This study revealed that pregnant women with low income were 6.36 times more likely to be exposed to zinc micro-nutrient deficiencies than those with high-income participants (AOR = 6.36, 95% CI 1.47-27.61). Additionally, those participants who ate a varied diet between 1 and 4 items per day were 2.26 (AOR = 2.26, 95% CI 1.43-3.59) and 2.77 (AOR = 2.77, 95% CI 1.6-4.61) times more likely to suffer zinc and copper micro-nutrient insufficiency than those who consumed 5-10 items per day. Finally, pregnant women who developed diarrhea in the past three months were 1.82 (AOR = 2.77, 95% CI 1.14-2.92) and 2.52 (AOR = 2.52, 95% CI 1.3-4.91) times more likely to be exposed to iron and copper deficiency than those who never show the symptoms, respectively. This study identified low concentrations of zinc, iron, and copper in the blood serum of pregnant women of small-scale farmers.

Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review

Background

Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation.

Objectives

To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy.

Search Methods

We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies.

Selection Criteria

We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis.

Data Collection and Analysis

Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach.

Main Results

A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1.

Authors' Conclusions

The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.

Multidimensional Approach to Assess Nutrition and Lifestyle in Breastfeeding Women during the First Month of Lactation

The first month of lactation is a vulnerable nutritional period for the mother. Our aims were (1) to evaluate the nutritional status of breastfeeding women in the first month of lactation, and (2) to explore different aspects of nutrition and lifestyle through a multidimensional approach. A total of 30 healthy breastfeeding women were enrolled in this study. Dietary pattern was assessed through a 72-hour dietary recall questionnaire (days 7 and 28 postpartum) and data were compared with Dietary Recommendation Values (DRV), and through the Adherence to Healthy Food Pyramid (HFP) questionnaire (day 28). Anthropometric parameters were evaluated by bioimpedance. Using factor analysis, nutritional dimensions were extracted, and linear regression models were used to analyze the association between anthropometric parameters and dimensions. Compared to the DRV, women showed insufficient energy, water, vitamin D, and potassium intake and excessive proteins, vitamins B1, B2, B3, B6, B12, and iron intake. We observed a moderate adherence to the HFP, with women being high in the fruits, vegetables, and oil categories, and low adherence to the physical activity, dairy products, and hydration categories. The nutritional dimension, including the HFP categories of physical activity, hydration, and animal protein intake together, was negatively associated with body weight (β = -3.7 ± 1.7; p-value = 0.047). In conclusion, during the first month postpartum, breastfeeding women exhibited several nutritional imbalances and poor physical activity negatively influencing anthropometric parameters. We propose a multidimensional approach to assess the nutritional status of breastfeeding women as a tool to detect specific deficiencies, allowing for personalized counseling.

Tipping the scale: the role of a national nutritional supplementation programme for pregnant mothers in reducing low birth weight and neonatal mortality in India

With over 1·3 million Anganwadi centres (AWC) (meaning ‘courtyard shelter’), the Indian government runs a nationwide intervention providing nutrition supplement to pregnant mothers to improve the health of their children. Using two successive rounds of the nationally representative cross-sectional National Family Health Survey data (collected during 2005–2006 and 2015–2016) of India, we assessed whether nutrition supplements given to pregnant mothers through AWC were associated with select child health indicators – extremely low birth weight (ELBW), very low birth weight (VLBW), low birth weight (LBW) and neonatal mortality (death during day 0–27) stratified by death during day 0–1, day 2–6 and day 7–27. A total of 148 019 children and 205 593 children were eligible for analysing birth weight and neonatal mortality, respectively. OR with 95% CI, estimated from multivariate logistic regression models, suggest that receipt of nutrition supplements was associated with decreased risk of VLBW (OR: 0·73, 95% CI 0·63, 0·83, P < 0·001), LBW (OR: 0·92, 95% CI 0·88, 0·96, P < 0·001), but not ELBW (OR: 0·80, 95% CI 0·56, 1·15, P = 0·226). Women who always received nutrition supplements during their pregnancy saw lower risk of death of their neonates (OR: 0·67, 95% CI 0·61, 0·73, P < 0·001), including death on day 0–1 (OR: 0·66, 95% CI 0·58, 0·74, P < 0·001), day 2–6 (OR: 0·69, 95% CI 0·58, 0·82, P < 0·001) and day 7–27 (OR: 0·68, 95% CI 0·53, 0·87, P = 0·002). Therefore, nutritional supplementation to pregnant mothers appears to be helpful in deterring various stages of neonatal mortality, VLBW and LBW, though it might not be effective in mitigating ELBW. Findings were discussed considering possible limitations of the study.

Maternal nutritional supplement delivery in developing countries: a scoping review

Background

Maternal under-nutrition in low-income countries has been inextricably linked to negative child outcomes. Developing countries lack policies for monitoring and evaluating maternal nutritional programs, which has led to a gap in data collection regarding the effectiveness of prenatal supplement delivery methods. The objective of this scoping review is to examine and determine the delivery methods of maternal nutritional supplements in developing countries.

Methods

Scoping review of maternal supplement programs delivery methods in low-income countries including Bangladesh, Ethiopia, India, Kenya, and Nepal are examined. A systematic search was performed in six databases; CINAHL (Cumulative Index to Nursing & Allied Health), MEDLINE, Web of Science, PubMed, Scopus, and FSTA (Food Science and Technology Abstracts).

Results

A systematic search performed in six databases yielded a total of 510 un-duplicated results; (CINAHL: 42, Medline: 112, Web of Science: 77, PubMed: 46, Scopus: 179, FSTA: 38, and additional records: 16). Results after duplicates were removed (n = 308), these results were screened, and relevant studies based on the research question identified and selected (n = 12). The 12 full-text articles were assessed for eligibility and 8 of these studies were excluded for not meeting the scoping review criteria. Data was extracted and charted from the four remaining studies. The findings were collated and summarized.Three modes of delivery were identified: 1. Volunteer maternal nutrition educator delivered supplements to the pregnant woman's home; 2. The pregnant woman received a maternal supplements from school, health/local center, or village market; and 3. The pregnant woman received a ration card for subsidized food.

Conclusions

Barriers in delivering maternal supplements included lack of trained professional volunteers, limited support and guidance provided to volunteers, and a high cost of equipment, supplies, and buildings. Pregnant women in developing countries faced many obstacles in accessing maternal supplement programs including poverty, rural isolation, limited transportation, low social status, traditional, cultural, and religious practices. Strategies required to improve program delivery involved an earlier invitation to prenatal supplements, increase in partnerships, a focus on adolescent girls' health, paid maternal leave, increase in training and incentives for volunteers, and self-help groups focused on prenatal education and counseling services.

Assessment of Nutritional Status and Dietary Intake of Pregnant Women in Rural Area of Vhembe District, Limpopo Province

Poor consumption of balanced diet could result in poor weight gain during pregnancy increasing the risk of premature delivery, low birth weight, and birth defects. To assess the nutritional status and dietary intake of pregnant women in rural areas of Vhembe district. A cross-sectional descriptive study was carried out among 240pregnant women who were selected conveniently from 16 clinics in Vhembe District. An interviewer-administered questionnaire was used for data collection. Anthropometric measurements were measured following standard techniques. Data on dietary intake were collected using Food Frequency Questionnaire (FFQ). Permission and clearance were obtained and participant's rights were respected. Majority (78%) had secondary educational level while 19.5% had tertiary educational level. The mean energy and carbohydrate intake was 2248 Kcal and 372.1 g, respectively. Prevalence of underweight, overweight and obese using BMI was 16.3%, 24.2%, and 8.7% respectively. Dietary intake of the study participants showed that the intake of energy, fats, carbohydrates and vitamin C met the Recommended Dietary Allowance (RDA) values. The mean intake of protein was 30.2 ± 18.2 g. However, micronutrients like zinc, iron, magnesium, calcium including Vitamin A, B1 and B2 did not meet the RDA values in the current study. Despite government's programs to ensure adequate consumption of micronutrients and proper weight gain during pregnancy, malnutrition and insufficient consumption of micronutrients remains a major public health problem in South Africa. Improving nutritional status during pregnancy should follow an integrated approach tackling both malnutrition and micronutrient deficiencies at the same time considering the behavioral approach which will improve child survival and maternal health.

Barriers and Facilitators to Fruit and Vegetable Consumption Among Rural Indian Women of Reproductive Age

BACKGROUND

Micronutrient deficiencies have been a serious public health problem among women of reproductive age in low- and middle-income countries including India, adversely affecting maternal and child health and human capital outcomes. Fruit and vegetables are important sources of micronutrients, and consumption of these foods is less than recommendations.

OBJECTIVE

The objective of this study was to identify perceived barriers and facilitators to fruit and vegetable consumption among women of reproductive age living in rural communities in the State of Maharashtra, India.

METHODS

Women aged 18 to 40 years were recruited from 8 villages surrounding the city of Wardha, Maharashtra, India. We used qualitative methods and held 9 focus group discussions and 12 one-to-one interviews. The data collection was stopped when no new information emerged. We used inductive thematic coding to analyze the data.

RESULTS

Women knew that fruit and vegetables were beneficial to health and expressed that they wanted to increase the intake of these foods for themselves and their children. Seven main themes were identified as being barriers or facilitators to fruit and vegetable consumption: (1) personal factors, (2) household dynamics, (3) social and cultural norms, (4) workload, (5) time pressures, (6) environmental factors, and (7) cost.

CONCLUSIONS

Rural Indian women consumed fruit and vegetables infrequently and said they would like to consume more. Several potentially modifiable factors affecting the intake of fruit and vegetables were identified. Value chain analyses of fruit and vegetables in these communities will be important to identify opportunities to intervene and increase consumption.

Dietary micronutrient intakes among women of reproductive age in Mumbai slums

Objectives

To (1) describe micronutrient intakes among women of reproductive age living in Mumbai slums; (2) assess the adequacy of these intakes compared with reference values; (3) identify important dietary sources of micronutrients.

Subjects/methods

Participants were 6426 non-pregnant women aged 16–39 years, registered in a randomised controlled trial of a food-based intervention set in the Bandra, Khar and Andheri areas of Mumbai, India. Cross-sectional quantified food frequency questionnaire (FFQ) data were collected. Vitamin (n = 9) and mineral (n = 6) intakes were calculated and analysed in relation to dietary reference values (DRVs). Important dietary sources were identified for each micronutrient.

Results

Median intakes of all micronutrients, except vitamin E, were below the FAO/WHO reference nutrient intake (RNI). Intakes of calcium, iron, vitamin A and folate were furthest from the RNI. For seven of the micronutrients, over half of the women had intakes below the lower reference nutrient intake (LRNI); this figure was over 75% for calcium and riboflavin. The majority of women (93%) had intakes below the EAR for 5 or more micronutrients, and 64% for 10 or more. Adolescents had lower intakes than women aged >19 years. Less than 1% of adult women and no adolescents met the EAR for all micronutrients. Animal source foods and micronutrient-rich fruit and vegetables were consumed infrequently.

Conclusions

These women had low intakes of multiple micronutrients, increasing their risk of insufficiency. There is a need to determine the factors causing poor intakes, to direct interventions that improve diet quality and nutritional sufficiency.

Who is the Woman in Women's Nutrition? A Narrative Review of Evidence and Actions to Support Women's Nutrition throughout Life

Nutrition interventions that target mothers alone inadequately address women's needs across their lives: during adolescence, preconception, and in later years of life. They also fail to capture nulliparous women. The extent to which nutrition interventions effectively reach women throughout the life course is not well documented. In this comprehensive narrative review, we summarized the impact and delivery platforms of nutrition-specific and nutrition-sensitive interventions targeting adolescent girls, women of reproductive age (nonpregnant, nonlactating), pregnant and lactating women, women with young children <5 y, and older women, with a focus on nutrition interventions delivered in low- and middle-income countries. We found that although there were many effective interventions that targeted women's nutrition, they largely targeted women who were pregnant and lactating or with young children. There were major gaps in the targeting of interventions to older women. For the delivery platforms, community-based settings, compared with facility-based settings, more equitably reached women across the life course, including adolescents, women of reproductive age, and older women. Nutrition-sensitive approaches were more often delivered in community-based settings; however, the evidence of their impact on women's nutritional outcomes was less clear. We also found major research and programming gaps relative to targeting overweight, obesity, and noncommunicable disease. We conclude that focused efforts on women during pregnancy and in the first couple of years postpartum fail to address the interrelation and compounding nature of nutritional disadvantages that are perpetuated across many women's lives. In order for policies and interventions to more effectively address inequities faced by women, and not only women as mothers, it is essential that they reflect on how, when, and where to engage with women across the life course.

Minerals in Pregnancy and Lactation: A Review Article

Micronutrients (include vitamins and minerals) are essential for normal function, growth and development. Minerals have important effects on the health of the mother and foetus. But biological mechanisms of minerals are not completely understood. Micronutrient deficiency during pregnancy can lead to anaemia, hypertension, obstetric complications and even maternal death and in foetus lead to a fail in growth and development. Mineral deficiency during pregnancy, particularly exist in developing countries. During pregnancy due to the increased demands caused by physiological changes, deficiency is exaggerated and as a result its complications occur. Thus, ensuring to receive enough macronutrients and micronutrients before and during pregnancy, is important. Nevertheless, there are controversies regarding administrating supplements. There are not enough studies about some of the minerals and the challenges remain. Regarding the importance of minerals in pregnancy and lactation, in this review we will analyze the role of them in pregnancy and lactation.

Longer exposure to a new refugee food ration is associated with reduced prevalence of small for gestational age: results from 2 cross-sectional surveys on the Thailand-Myanmar border

Background: Despite the high risk of compromised nutrition, evidence of the effect of refugee rations on fetal growth is limited. A new ration containing micronutrient-fortified flour without increased caloric content of the general food basket was introduced to the Maela refugee camp in Thailand, July 2004.Objective: The effect of the length of gestational exposure of the new ration on fetal growth was compared with birth outcomes [small for gestational age (SGA), preterm birth (PTB)].Design: In an observational study in 987 newborns from 1048 prospectively followed antenatal clinic (ANC) attendees enrolled in 2 cross-sectional surveys, exposure was categorized in 2004 according to gestation at the time of commencing the new ration and in 2006 as comprehensive (preconception and pregnancy). In both surveys, the pregnancy-specific ration and vitamin supplements were routine.Results: In 2004, the proportions of SGA decreased with longer exposure to the new ration: no exposure during pregnancy (27.7%; n = 13 of 47) and exposure in the third (27.6%; n = 37 of 134), second (18.6%; n = 35 of 188), and first (19.4%; n = 6 of 31) trimesters, respectively (adjusted P-trend = 0.046). In 2006, the new ration was available to all women and there was no significant additional impact of the pregnancy-specific ration and vitamin supplements. Between 2004 and 2006, SGA decreased from 28.9% (13 of 45) to 17.3% (69 of 398) (adjusted P = 0.050), a reduction of 40.1% (95% CI: 34.7%, 45.9%); there was also a decrease in the percentage of underweight women on admission to the ANC (38.2%; 95% CI: 31.4%, 45.5%). PTB rates were low and not significantly different with exposure to the new ration.Conclusions: In 2004, the earlier in gestation in which the new ration was available the greater the effect on fetal growth as shown by a reduced prevalence of SGA. In 2006, additional benefits to fetal growth from the pregnancy-specific ration and vitamin supplements beyond those of the preconception ration were not observed. Good nutrition in pregnancy remains an important challenge for refugee populations. This trial was registered at http://drks-neu.uniklinik-freiburg.de/drks_web/ as DRKS00007736.

Differences in the anthropometry of Asian children and its role in metabolic health in later life: A narrative review

BACKGROUND

The increasing incidence of childhood obesity in Asia could be a reflection of early life programming in which environmental/nutritional challenges during pregnancy and first two years of life (the so-called first 1000 days) influence later health.

OBJECTIVE OF NARRATIVE REVIEW

To assess differences/similarities of anthropometric measures in early life and their influences on metabolic health risk in later life among children in Asia.

METHODS

Literature search for publication in English using selected key words from Medline (PubMed), Scopus, Science Direct and Google Scholar published from 1994 to October 2014. Some comparisons with Caucasian setting were made when relevant.

RESULTS

From 152 publications selected for this narrative review, differences in foetal growth and birth weight were deducted between Asian and Caucasian children. Infants in India and Hong Kong had increased fat mass at birth and early infancy as compared to those from other parts of the world. Pre- and during pregnancy conditions influenced birth weight; feeding practices and gender influenced post-natal growth and body composition development. High and low birth weights followed by rapid postnatal growth were linked to increased risks of obesity, insulin resistance and high blood pressure in later life.

CONCLUSION

Foetal and postnatal growth trajectories are different between countries within and outside Asia. Extremes in birth weight followed by rapid postnatal growth were linked to increased risks of metabolic health of children in this region. As there is limited evidence in Asia, it is important to conduct thorough investigations by using longitudinal studies on early life programming.

Nutritional and developmental status among 6- to 8-month-old children in southwestern Uganda: a cross-sectional study

BACKGROUND

Undernutrition continues to pose challenges to Uganda's children, but there is limited knowledge on its association with physical and intellectual development.

OBJECTIVE

In this cross-sectional study, we assessed the nutritional status and milestone development of 6- to 8-month-old children and associated factors in two districts of southwestern Uganda.

DESIGN

Five hundred and twelve households with mother-infant (6-8 months) pairs were randomly sampled. Data about background variables (e.g. household characteristics, poverty likelihood, and child dietary diversity scores (CDDS)) were collected using questionnaires. Bayley Scales of Infant and Toddler Development (BSID III) and Ages and Stages questionnaires (ASQ) were used to collect data on child development. Anthropometric measures were used to determine z-scores for weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), head circumference (HCZ), and mid-upper arm circumference. Chi-square tests, correlation coefficients, and linear regression analyses were used to relate background variables, nutritional status indicators, and infant development.

RESULTS

The prevalence of underweight, stunting, and wasting was 12.1, 24.6, and 4.7%, respectively. Household head education, gender, sanitation, household size, maternal age and education, birth order, poverty likelihood, and CDDS were associated (p<0.05) with WAZ, LAZ, and WLZ. Regression analysis showed that gender, sanitation, CDDS, and likelihood to be below the poverty line were predictors (p<0.05) of undernutrition. BSID III indicated development delay of 1.3% in cognitive and language, and 1.6% in motor development. The ASQ indicated delayed development of 24, 9.1, 25.2, 12.2, and 15.1% in communication, fine motor, gross motor, problem solving, and personal social ability, respectively. All nutritional status indicators except HCZ were positively and significantly associated with development domains. WAZ was the main predictor for all development domains.

CONCLUSION

Undernutrition among infants living in impoverished rural Uganda was associated with household sanitation, poverty, and low dietary diversity. Development domains were positively and significantly associated with nutritional status. Nutritional interventions might add value to improvement of child growth and development.

Modeling historical tuberculosis epidemics among Canadian First Nations: effects of malnutrition and genetic variation

Late 19th century epidemics of tuberculosis (TB) in Western Canadian First Nations resulted in peak TB mortality rates more than six times the highest rates recorded in Europe. Using a mathematical modeling approach and historical TB mortality time series, we investigate potential causes of high TB mortality and rapid epidemic decline in First Nations from 1885 to 1940. We explore two potential causes of dramatic epidemic dynamics observed in this setting: first, we explore effects of famine prior to 1900 on both TB and population dynamics. Malnutrition is recognized as an individual-level risk factor for TB progression and mortality; its population-level effects on TB epidemics have not been explored previously. Second, we explore effects of heterogeneity in susceptibility to TB in two ways: modeling heterogeneity in susceptibility to infection, and heterogeneity in risk of developing disease once infected. Our results indicate that models lacking famine-related changes in TB parameters or heterogeneity result in an implausibly poor fit to both the TB mortality time series and census data; the inclusion of these features allows for the characteristic decline and rise in population observed in First Nations during this time period and confers improved fits to TB mortality data.