Protective effect of multimicronutrient supplementation against anemia among children, women, and adolescent girls in lower-income areas of Chiclayo, Peru

Drivers of stunting reduction in Peru: a country case study

BACKGROUND

Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016.

OBJECTIVES

We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016.

METHODS

Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru.

RESULTS

The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation.

CONCLUSIONS

Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.

Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women

BACKGROUND

Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long-term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent.

OBJECTIVES

To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation.

SEARCH METHODS

In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non-consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE.

MAIN RESULTS

We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source.Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low-quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate-quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low-quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low-quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low-quality evidence) and all-cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low-quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate-quality evidence).In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate-quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI -1.44 to 2.31; 10 studies, 2127 participants; low-quality evidence) but lower ferritin concentrations on average (MD -6.07 μg/L, 95% CI -10.66 to -1.48; 4 studies, 988 participants; low-quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low-quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate-quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all-cause morbidity.Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear.Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings.

AUTHORS' CONCLUSIONS

Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects.

Effectiveness of Distribution of Multimicronutrient Supplements in Children and in Women and Adolescent Girls of Childbearing Age in Chiclayo, Peru

Background

There is a need to better understand the coverage of scaled-up multimicronutrient supplementation programs.

Objective

The coverage of the distribution of multimicronutrient supplements in 26 urban communities among women and adolescent girls 12 through 44 years of age and children under 5 years of age was evaluated for purposes of scaling-up.

Methods

Formative research and descriptive statistics were used to analyze the distribution of supplements.

Results

Despite a delayed memorandum of understanding with the health sector and delayed delivery by the producer of the supplement, a high coverage rate of supplement distribution to the children (88% on average during the 3 months of supplementation) was still achieved as a result of the strong commitment of the community and the Integrated Food Security Program. The lower coverage rate among women and adolescent girls (47% on average) was the result of too short a period of enrollment in the program. There was no decrease of coverage during the 3 months of supplementation in both groups.

Conclusions

Effective, sustainable, large-scale micronutrient supplementation programs require broad partnerships with commitments of governmental and nongovernmental organizations, communities, and the private sector. Availability of the supplements and communication materials must be secured well ahead of the supplementation campaign and distribution of the supplement.

Effectiveness of the Communication Program on Compliance in a Weekly Multimicronutrient Supplementation Program in Chiclayo, Peru

Background

Compliance with daily micronutrient supplementation is usually poor and the question arises whether compliance with a weekly regimen would be better.

Objectives

The inputs (messages and channels), output (increase of knowledge), and outcome (behavior changes) of a communication campaign in a micronutrient supplementation program for women and adolescent girls 12 through 44 years of age and children under 5 years of age (primary audience) were analyzed.

Methods

The communication program addressed not only the primary, but also the secondary (facilitators) and tertiary audiences. Formative research and descriptive statistics were used to analyze the communication campaign.

Results

Nearly all women and adolescent girls (89%) and children (91%) took at least 75% of the supplements over the 3-month period. The incidence rates of reported negative side effects of supplementation in children and in women and adolescent girls were less than 10%. Knowledge of micronutrient nutrition among facilitators of all ages and education levels increased significantly (p < .001).

Conclusions

A thoroughly planned and implemented nutrition communication program can secure high compliance of the beneficiaries of micronutrient supplementation programs. The necessary supplies should be available at least 3 months before program implementation. With an adequate communication program, supplementation programs can be used to foster food-based approaches for the target audience.

Costs of the Multimicronutrient Supplementation Program in Chiclayo, Peru

Background

There is little information on the cost parameters of weekly multimicronutrient supplementation programs.

Objective

To assess the cost parameters and cost-effectiveness of a weekly multimicronutrient supplementation program in an urban population of Peru.

Methods

Data from the Integrated Food Security Program (Programa Integrado de Seguridad Alimentaria [PISA]), which distributed capsules and foodlets to women and adolescent girls and to children under five, were extrapolated to a population of 100,000 inhabitants.

Results

The annual cost per community member was US$1.51. The cost-effectiveness ratio was US$0.12 per 1% of prevented anemia per community member.

Conclusions

These costs are in the upper margin of iron supplementation alone. They will decrease notably when weekly multimicronutrient supplementation programs are integrated into health packages and participation by women increases. Focusing on micronutrient deficiencies would prevent these problems, and fooddistribution programs would be effectively targeted to food-deficient populations.

Intermittent iron supplementation for improving nutrition and development in children under 12 years of age

BACKGROUND

Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that half of the cases are due to iron deficiency. Consequences of iron deficiency anaemia during childhood include growth retardation, reduced school achievement, impaired motor and cognitive development, and increased morbidity and mortality. The provision of daily iron supplements is a widely used strategy for improving iron status in children but its effectiveness has been limited due to its side effects, which can include nausea, constipation or staining of the teeth. As a consequence, intermittent iron supplementation (one, two or three times a week on non-consecutive days) has been proposed as an effective and safer alternative to daily supplementation.

OBJECTIVES

To assess the effects of intermittent iron supplementation, alone or in combination with other vitamins and minerals, on nutritional and developmental outcomes in children from birth to 12 years of age compared with a placebo, no intervention or daily supplementation.

SEARCH METHODS

We searched the following databases on 24 May 2011: CENTRAL (2011, Issue 2), MEDLINE (1948 to May week 2, 2011), EMBASE (1980 to 2011 Week 20), CINAHL (1937 to current), POPLINE (all available years) and WHO International Clinical Trials Registry Platform (ICTRP). On 29 June 2011 we searched all available years in the following databases: SCIELO, LILACS, IBECS and IMBIOMED. We also contacted relevant organisations (on 3 July 2011) to identify ongoing and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of 12 years at the time of intervention with no specific health problems. The intervention assessed was intermittent iron supplementation compared with a placebo, no intervention or daily supplementation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

MAIN RESULTS

We included 33 trials, involving 13,114 children (˜49% females) from 20 countries in Latin America, Africa and Asia. The methodological quality of the trials was mixed.Nineteen trials evaluated intermittent iron supplementation versus no intervention or a placebo and 21 studies evaluated intermittent versus daily iron supplementation. Some of these trials contributed data to both comparisons. Iron alone was provided in most of the trials.Fifteen studies included children younger than 60 months; 11 trials included children 60 months and older, and seven studies included children in both age categories. One trial included exclusively females. Seven trials included only anaemic children; three studies assessed only non-anaemic children, and in the rest the baseline prevalence of anaemia ranged from 15% to 90%.In comparison with receiving no intervention or a placebo, children receiving iron supplements intermittently have a lower risk of anaemia (average risk ratio (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.72, ten studies) and iron deficiency (RR 0.24, 95% CI 0.06 to 0.91, three studies) and have higher haemoglobin (mean difference (MD) 5.20 g/L, 95% CI 2.51 to 7.88, 19 studies) and ferritin concentrations (MD 14.17 µg/L, 95% CI 3.53 to 24.81, five studies).Intermittent supplementation was as effective as daily supplementation in improving haemoglobin (MD -0.60 g/L, 95% CI -1.54 to 0.35, 19 studies) and ferritin concentrations (MD -4.19 µg/L, 95% CI -9.42 to 1.05, 10 studies), but increased the risk of anaemia in comparison with daily iron supplementation (RR 1.23, 95% CI 1.04 to1.47, six studies). Data on adherence were scarce and it tended to be higher among those children receiving intermittent supplementation, although this result was not statistically significant.We did not identify any differential effect of the type of intermittent supplementation regimen (one, two or three times a week), the total weekly dose of elemental iron, the nutrient composition, whether recipients were male or female or the length of the intervention.

AUTHORS' CONCLUSIONS

Intermittent iron supplementation is efficacious to improve haemoglobin concentrations and reduce the risk of having anaemia or iron deficiency in children younger than 12 years of age when compared with a placebo or no intervention, but it is less effective than daily supplementation to prevent or control anaemia. Intermittent supplementation may be a viable public health intervention in settings where daily supplementation has failed or has not been implemented. Information on mortality, morbidity, developmental outcomes and side effects, however, is still lacking.

Intermittent iron supplementation for reducing anaemia and its associated impairments in menstruating women

BACKGROUND

Daily iron supplementation has been traditionally a standard practice for preventing and treating anaemia but its long term use has been limited as it has been associated with adverse side effects such as nausea, constipation and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at population level, especially in areas where this condition is highly prevalent.

OBJECTIVES

To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments in menstruating women, compared with no intervention, a placebo or daily supplementation.

SEARCH METHODS

We searched the following databases in May 2011: CENTRAL (The Cochrane Library 2011, Issue 2), MEDLINE (1948 to May Week 3, 2011), EMBASE (1980 to 2011 Week 20), CINAHL (1937 to current), POPLINE (all available years), Science Citation Index (1970 to 27 May 2011), BIOSIS Previews (1969 to current), and CPCI-S (1990 to 27 May 2011). On 7 July 2011 we searched all available years in the following databases: SCIELO, LILACS, IBECS and IMBIOMED, the Networked Digital Library of Theses and Dissertations, metaRegister and the WHO International Clinical Trials Registry Platform (ICTRP). We also contacted relevant organisations (on 11 October 2011) to identify ongoing and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were menstruating women, that is women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non-consecutive days) compared with no intervention, a placebo, or the use of same supplements on a daily basis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy and assessed the risk of bias of the included studies.

MAIN RESULTS

We included 21 trials involving 10,258 women. Although the quality across trials was variable, the results consistently show that in comparison with no intervention or a placebo, intermittent iron supplementation (alone or with any other vitamins and minerals) reduces the risk of having anaemia (RR 0.73; 95% CI 0.56 to 0.95, 10 trials) and improves the concentration of haemoglobin (MD 4.58 g/L; 95% CI 2.56 to 6.59, 13 trials) and ferritin (MD 8.32 μg/L; 95% CI 4.97 to 11.66, six trials). However, in comparison with daily supplementation, women receiving supplements intermittently presented anaemia more frequently (RR 1.26; 95% CI 1.04 to 1.51, six trials), despite achieving similar haemoglobin concentrations on average (MD -0.15 g/L; 95% CI -2.20 to 1.91, eight trials).Information on disease outcomes, adherence, side effects, economic productivity and work performance is scarce and the evidence about the effects of intermittent supplementation on them is unclear.Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria is frequent, although very few trials were conducted in these settings.

AUTHORS' CONCLUSIONS

Intermittent iron supplementation in menstruating women is a feasible intervention in settings where daily supplementation is likely to be unsuccessful or not possible. In comparison with daily supplementation, the provision of iron supplements intermittently is less effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression and adherence to the intervention.

A systematic review of the evidence on integration of targeted health interventions into health systems

A longstanding debate on health systems organization relates to benefits of integrating health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing the relative merits of each approach. However, all too frequently these arguments have not been based on hard evidence. The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach, but the relative merits of integration in various contexts and for different interventions have not been systematically analysed and documented. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions, (ii) how the integration or non-integration of health programmes into critical health systems functions in different contexts has influenced programme success, (iii) how contextual factors have affected the extent to which these programmes were integrated into critical health systems functions. Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably.

Lessons learned from the scaling-up of a weekly multimicronutrient supplementation program in the integrated food security program (PISA)

BACKGROUND

Weekly multimicronutrient supplementation was initiated as an appropriate intervention to protect poor urban populations from anemia.

OBJECTIVE

To identify the lessons learned from the Integrated Food Security Program (Programa Integrado de Seguridad Alimentaria [PISA]) weekly multimicronutrient supplementation program implemented in poor urban populations of Chiclayo, Peru.

METHODS

Data were collected from a 12-week program in which multimicronutrient supplements were provided weekly to women and adolescent girls 12 through 44 years of age and children under 5 years of age. A baseline survey was first conducted. Within the weekly multimicronutrient supplementation program, information was collected on supplement distribution, compliance, biological effectiveness, and cost.

RESULTS

Supplementation, fortification, and dietary strategies can be integrated synergistically within a micronutrient intervention program.

CONCLUSIONS

To ensure high cost-effectiveness of a weekly multimicronutrient supplementation program, the following conditions need to be met: the program should be implemented twice a year for 4 months; the program should be simultaneously implemented at the household (micro), community (meso), and national (macro) levels; there should be governmental participation from health and other sectors; and there should be community and private sector participation. Weekly multimicronutrient supplementation programs are cost effective options in urban areas with populations at low risk of energy deficiency and high risk of micronutrient deficiencies.

We know much about what to do but little about how to do it: experiences with a weekly multimicronutrient supplementation campaign

BACKGROUND

Global population growth is concentrated in urban areas, but there is little understanding of how to implement the necessary interventions to control food and nutrition insecurity. In the urban area of Peru, food insecurity is characterized mainly by micronutrient deficiencies and not by energy deficiency.

OBJECTIVE

To increase the effectiveness and cost-effectiveness of weekly multimicronutrient supplementation programs in poor urban communities.

METHODS

A series of operational studies were conducted of preventive weekly multimicronutrient supplementation to reduce micronutrient-deficiency anemia in a population consisting of 8,081 children under 5 years of age and 20,082 women and adolescent girls of reproductive age (12 through 44 years).

RESULTS

This is one of a series of papers that describe in as much detail as possible the experiences of a multimicronutrient intervention program for poor urban mothers and their young children and summarizes the lessons learned for consideration of future programming.

CONCLUSIONS

This paper shows that such programs can achieve a high compliance with good training of program staff involvement of the community, education and motivation of beneficiaries, adequate supplies, and careful monitoring.