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Soofi SB, Khan GN, Sajid M, Hussainyar MA, Shams S, Shaikh M, Ouma C, Azami S, Naeemi M, Hussain A, Umer M, Hussain I, Ahmed I, Ariff S. Specialized nutritious foods and behavior change communication interventions during the first 1000 d of life to prevent stunting: a quasi-experimental study in Afghanistan. Am J Clin Nutr 2024; 120:560-569. [PMID: 39004283 DOI: 10.1016/j.ajcnut.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Considerable evidence supports the effectiveness of nutritional supplementation with or without nutrition education in preventing stunting in developing countries, but evidence from Afghanistan is scarce. OBJECTIVES This project aimed to assess the effectiveness of specialized nutritious food (SNF), social and behavior change communication (SBCC) intervention to prevent stunting among children under 2 y during the first 1000 d of life in Badakhshan, Afghanistan. METHODS We used a community-based quasi-experimental pre-post study design with a control group. Pregnant and lactating women received a monthly ration of 7.5 kg of super cereal (250 g/d) during pregnancy and the first 6 mo of breastfeeding. Children aged 6-23 mo received 30 sachets of medium-quantity lipid-based nutrient supplement (50 g/sachet/d) monthly. We compared pre- and postintervention assessments of the intervention and control groups to isolate the effect of the intervention on key study outcomes at the endline by difference-in-differences (DID) estimates. RESULTS A total of 2928 and 3205 households were surveyed at baseline and endline. DID estimates adjusted for child, maternal, and household characteristics indicated a significant reduction in stunting (DID: -5% (95% confidence interval [CI]: -9.9, -0.2) and underweight (DID: -4.6% (95% CI: -8.6, -0.5) among children <2 y of age. However, DID estimates for wasting among children in the intervention and control groups were not significantly different (DID: -1.7 (95% CI: -5.1, 1.6). Furthermore, exposure to the SBCC messages was associated with improvements in the early initiation of breastfeeding (DID: 19.6% (95% CI: 15.6, 23.6), exclusive breastfeeding under 6 mo (DID: 11.0% (95% CI: 2.3, 19.7), minimum meal frequency (DID: 23% (95% CI: 17.7, 28.2), and minimum acceptable diet (DID: 13% (95% CI: 9.8, 16.3). CONCLUSIONS The provision of SNF in combination with SBCC during the first 1000 d of life was associated with reduction in stunting and underweight and improvements in infant and young child feeding practices among children under 2 y of age. This trial was registered at clinicaltrials.gov as NCT04581993.
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Affiliation(s)
- Sajid Bashir Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Gul Nawaz Khan
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Sajid
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | | | - Amjad Hussain
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Umer
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imtiaz Hussain
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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Terefe B, Chekole B. Prevalence of multiple micronutrient powders consumption and its determinants among 6- to 23-month-old children in East Africa: a mixed effect analysis using the recent population based cross sectional national health survey. BMC Nutr 2024; 10:79. [PMID: 38822432 PMCID: PMC11143561 DOI: 10.1186/s40795-024-00888-0] [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: 09/18/2023] [Accepted: 05/28/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND To address iron deficiency anemia, Multiple Micronutrient Powders (MMNPs) can be sprinkled onto any semisolid diet and given to young children. There is currently no data on actual MMNPs uptake by children; hence, the study's goal was to investigate MMNPs and determinants among children aged 6-23 months in East Africa. METHODS Data from the 2016-2022 East Africa demographic and health survey extracted from Kids Records (KR) files were used in this study. A total of 33,324 weighted 6- to 23-month-old child samples were included. For assessing model fitness and contrast, the intra-class correlation coefficient, median odds ratio, proportional change in variance, and deviance were used. A multilevel logistic regression model was applied to identify variables that may influence MMNPs intake. In the multivariable multilevel logistic regression analyses, variables were judged to be significantly linked with MMNPs intake if their p-values were < 0.05. RESULTS In East Africa, the prevalence of MMNPs intake among infants aged 6-23 months was 6.45% (95% CI, 6.19%, 6.22%). Several factors were found to be significantly associated with MMNPs consumption. These factors include older maternal age (AOR = 1.23, 95% CI, 1.09, 1.39) and (AOR = 1.46, 95% CI, 1.23, 1.73), poorer (AOR = 0.73, 95% CI, 0.64, 0.84), middle (AOR = 0.75, 95% CI, 0.66, 0.86), richer (AOR = 0.61, 95% CI, 0.52, 0.71), and richest (AOR = 0.49, 95% CI, 0.41, 0.59) as compared to poorest, having employment status (AOR = 0.65, 95% CI, 0.59, 0.71), mass media exposure (AOR = 1.61, 95% CI, 1.35, 1.78), longer birth interval (AOR = 1.19, 95% CI, 1.28, 1.36), place of delivery (AOR = 1.46, 95% CI, 1.28,1.66), and mothers from rural areas (AOR = 0.71, 95% CI, 0.62,0.80). CONCLUSIONS Overall, MMNPs intake was lower than the national and international recommendations. Only seven out of every hundred children received MMNPs. Improving maternal preventive health care and supporting marginalized women will have a positive impact.
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Affiliation(s)
- Bewuketu Terefe
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Post Office Box: 196, Gondar, Ethiopia.
| | - Bogale Chekole
- Department of Comprehensive Nursing, College of Medicine and Health Sciences, Wolkite University, Southern, Ethiopia
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Iddrisu I, Monteagudo-Mera A, Poveda C, Shahzad M, Walton GE, Andrews SC. A review of the effect of iron supplementation on the gut microbiota of children in developing countries and the impact of prebiotics. Nutr Res Rev 2024:1-9. [PMID: 38586996 DOI: 10.1017/s0954422424000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Iron is essential for many physiological functions of the body, and it is required for normal growth and development. Iron deficiency (ID) is the most common form of micronutrient malnutrition and is particularly prevalent in infants and young children in developing countries. Iron supplementation is considered the most effective strategy to combat the risk of ID and ID anaemia (IDA) in infants, although iron supplements cause a range of deleterious gut-related problems in malnourished children. The purpose of this review is to assess the available evidence on the effect of iron supplementation on the gut microbiota during childhood ID and to further assess whether prebiotics offer any benefits for iron supplementation. Prebiotics are well known to improve gut-microbial health in children, and recent reports indicate that prebiotics can mitigate the adverse gut-related effects of iron supplementation in children with ID and IDA. Thus, provision of prebiotics alongside iron supplements has the potential for an enhanced strategy for combatting ID and IDA among children in the developing world. However, further understanding is required before the benefit of such combined treatments of ID in nutritionally deprived children across populations can be fully confirmed. Such enhanced understanding is of high relevance in resource-poor countries where ID, poor sanitation and hygiene, alongside inadequate access to good drinking water and poor health systems, are serious public health concerns.
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Affiliation(s)
- Ishawu Iddrisu
- Rose Ward, Prospect Park Hospital, Berkshire Healthcare NHS Foundation Trust, Reading, RG30 4EJ, UK
- Department of Food and Nutritional Sciences, University of Reading, Whiteknights, Reading, RG6 6AP, UK
- School of Biological Sciences, University of Reading, Whiteknights, Reading, RG6 6EX, UK
| | - Andrea Monteagudo-Mera
- Department of Food and Nutritional Sciences, University of Reading, Whiteknights, Reading, RG6 6AP, UK
| | - Carlos Poveda
- Department of Food and Nutritional Sciences, University of Reading, Whiteknights, Reading, RG6 6AP, UK
| | - Muhammed Shahzad
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
- Faculty of Dentistry, Zarqa University, Zarqa, 13110, Jordan
| | - Gemma E Walton
- Department of Food and Nutritional Sciences, University of Reading, Whiteknights, Reading, RG6 6AP, UK
| | - Simon C Andrews
- School of Biological Sciences, University of Reading, Whiteknights, Reading, RG6 6EX, UK
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Harrison L, Padhani Z, Salam R, Oh C, Rahim K, Maqsood M, Ali A, Charbonneau K, Keats EC, Lassi ZS, Imdad A, Owais A, Das J, Bhutta ZA. Dietary Strategies for Complementary Feeding between 6 and 24 Months of Age: The Evidence. Nutrients 2023; 15:3041. [PMID: 37447369 PMCID: PMC10346638 DOI: 10.3390/nu15133041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Suboptimal complementary feeding practices remain highly prevent. This review aims to comprehensively synthesize new emerging evidence on a set of topics related to the selection and consumption of complementary foods. We synthesized evidence related to five key topics focused on nutritional interventions that target the complementary feeding period, based on four systematic reviews that include updated evidence to February 2022. While there have been many studies examining interventions during the complementary feeding period, there is an overall lack of relevant information through which to draw conclusions on the ideal feeding schedule by food type. Similarly, few studies have examined the effects of animal milk versus infant formula for non-breastfed infants (6-11 months), though those that did found a greater risk of anemia among infants who were provided cow's milk. This review highlights a number of interventions that are successful at improving micronutrient status and anthropometry during the complementary feeding period, including fortified blended foods, locally and commercially produced supplementary foods, and small-quantity lipid-based nutrient supplements. Complementary feeding education for caregivers can also be used to improve nutrition outcomes among infants in both food secure and insecure populations.
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Affiliation(s)
- Leila Harrison
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Zahra Padhani
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5005, Australia
| | - Rehana Salam
- The Daffodil Centre—A Joint Venture of Cancer Council and The University of Sydney, Sydney, NSW 2006, Australia
| | - Christina Oh
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Komal Rahim
- Internal Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Maria Maqsood
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Anna Ali
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5005, Australia
| | - Kimberly Charbonneau
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Emily C. Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Zohra S. Lassi
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5005, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Aamer Imdad
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Aatekah Owais
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Jai Das
- Division of Women & Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Division of Women & Child Health, Aga Khan University, Karachi 74800, Pakistan
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Wang O, Huang J, Huo J, Chen D, Xu Y, Sun J. Yingyangbao Intervention Was Associated with the Improvement of Body Growth and Nutrition Status of Infants and Young Children in Poor Rural Areas of China: The Annual Comparison from 2012 to 2020. Nutrients 2023; 15:nu15102350. [PMID: 37242232 DOI: 10.3390/nu15102350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Yingyangbao (YYB) is a soy-based micronutrient-fortified powder used in the Nutrition Improvement Project on Children in Poor Areas of China. After the baseline study in 2012, YYB intervention gradually spread to 21 provinces in China. From 2015 to 2020, a secular trend study was carried out to evaluate the body growth and nutritional status of 6-23-month-old infants and young children (IYC) under YYB intervention. The aim of this research was to investigate whether YYB intervention was associated with the improvement of body growth and development in large populations from broad areas with national and multi-year survey results. The anthropometric data collected in the baseline study and cross-sectional surveys were compared, and the correlation between YYB intake amount and body growth were analyzed. Compared with the results of the baseline study, the 6-23-month-old IYC under YYB intervention showed a significant increase in body weight, body length and Z scores since 2015, and the stunting rate decreased from 9.7% in 2012 to 5.3% in 2020. Significantly positive correlations were observed between the YYB intake amount and the body growth indicators. Therefore, YYB intervention was associated with the improvement of body growth and nutrition status of Chinese IYC. In the future, long-term and continuous efforts are still needed to further reveal the health benefits of YYB in depth.
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Affiliation(s)
- Ou Wang
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Jian Huang
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Junsheng Huo
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Di Chen
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Yifan Xu
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Jing Sun
- NHC Key Laboratory of Trace Element Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
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Khan A, Ul-Haq Z, Fatima S, Ahmed J, Alobaid HM, Fazid S, Muhammad N, Garzon C, Ihtesham Y, Habib I, Tanimoune M, Iqbal K, Arshad M, Safi SZ. Long-Term Impact of Multiple Micronutrient Supplementation on Micronutrient Status, Hemoglobin Level, and Growth in Children 24 to 59 Months of Age: A Non-Randomized Community-Based Trial from Pakistan. Nutrients 2023; 15:nu15071690. [PMID: 37049531 PMCID: PMC10096793 DOI: 10.3390/nu15071690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Cost-effective interventions are needed to address undernutrition, particularly micronutrient deficiencies, which are common in children under the age of five in low- and middle-income countries. A community-based, non-randomized clinical trial was undertaken in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019, to evaluate the effect of locally produced micronutrient powder (local name: Vita-Mixe) on plasma micronutrient status, hemoglobin level, and anthropometric outcomes. Children aged 24–48 months old were recruited and allocated to the intervention and control arm of the study. The enrolled children in the intervention arm received one micronutrient powder (MNP) sachet for consumption on alternate days for 12 months. To assess the impact of the intervention on plasma levels of zinc, vitamin D, vitamin A, and hemoglobin level, blood samples were taken at baseline and after one year following the intervention. The analysis was conducted using Enzyme-Linked Immunosorbent Assay (ELISA), atomic absorption spectrometry, and an automated hematology analyzer. For the impact on growth parameters, the anthropometric assessment was performed using WHO standard guidelines. A 24 h dietary recall interview was used to assess the nutrient intake adequacy. Results showed that in the intervention arm, children had on average a 7.52 ng/mL (95% CI 5.11–9.92, p-value < 0.001) increase in the plasma level of vitamin A, 4.80 ng/mL (95% CI 1.63–7.95, p-value < 0.002) increase in vitamin D levels and 33.85 µg/dL (95% CI 24.40–43.30, p-value < 0.001) increase in the plasma zinc level, as well as a 2.0g/dL (95% CI 1.64–2.40, p-value < 0.001) increase in hemoglobin level. Statistically significant improvement was observed in the weight-for-height z-score (WHZ) (from −1.0 ± 0.88 to −0.40 ± 1.01, p < 0.001) and weight-for-age z-score (WAZ) (from −1.40 ± 0.50 to −1.05 ± 0.49, p < 0.001) in the intervention group compared to the control group. No statistically significant change was observed in the height-for-age z-score (HAZ) in the intervention group (p = 0.93). In conclusion, micronutrient powder supplementation is a cost-effective intervention to improve the micronutrient status, hemoglobin level, and growth parameters in under-five children, which can be scaled up in the existing health system to address the alarming rates of undernutrition in Pakistan and other developing countries.
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Locks LM, Newell KB, Imohe A, Moloney GM, Shaker-Berbari L, Paudyal N, Jefferds MED. The effect of interventions distributing home fortification products on infant and young child feeding (IYCF) practices: A systematic narrative review. MATERNAL & CHILD NUTRITION 2023:e13488. [PMID: 36842164 DOI: 10.1111/mcn.13488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/14/2022] [Accepted: 01/26/2023] [Indexed: 02/27/2023]
Abstract
Interventions distributing micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements (SQ-LNS), or home fortification products (HFPs), have the potential to improve infant and young child feeding (IYCF) practices and children's nutrition. We systematically searched for studies on the effect of interventions distributing HFP on IYCF practices. We identified 12 (8 MNP, 4 SQ-LNS) studies: seven programmes with IYCF behaviour change communications (BCC) and MNP (IYCF-MNP) and one provided MNP without IYCF BCC (MNP only). Three SQ-LNS studies came from randomised trials without an IYCF component (SQ-LNS only) and one from a programme with both IYCF BCC and SfQ-LNS (IYCF-SQ-LNS). Five IYCF-MNP programmes reported positive associations with some IYCF practices-four with minimum dietary diversity, two with minimum meal frequency, four with minimum acceptable diet, and three with the initiation of complementary foods at 6 months. Two reported no association between MNP and IYCF indicators, and one reported a decline in IYCF practices during the intervention, although it also reported significant changes to the IYCF programme during the evaluation period. Two studies from interventions that distributed SQ-LNS (one from a related set of randomised controlled trials and the sole IYCF-SQ-LNS programme) reported a positive association with IYCF practices; one trial reported no change in breast milk intake with the provision of SQ-LNS and one found no association with IYCF practices. SQ-LNS and MNP can address nutrient gaps for young children in low-resource settings; our findings indicate that programmes that combine HFP with IYCF interventions may also contribute to improved IYCF practices in some settings.
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Affiliation(s)
- Lindsey M Locks
- Department of Health Sciences, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts, USA.,Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Katharine B Newell
- Department of Health Sciences, College of Health and Rehabilitation Sciences: Sargent College, Boston University, Boston, Massachusetts, USA
| | - Annette Imohe
- United Nation Children's Fund (UNICEF) Headquarters, New York City, New York, USA
| | - Grainne M Moloney
- United Nation Children's Fund (UNICEF) Headquarters, New York City, New York, USA
| | - Linda Shaker-Berbari
- United Nation Children's Fund (UNICEF) Headquarters, New York City, New York, USA
| | - Naveen Paudyal
- United Nation Children's Fund (UNICEF) Nepal Country Office, Kathmandu, Nepal
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Kundu S, Alam SS, Mia MAT, Hossan T, Hider P, Khalil MI, Musa KI, Islam MA. Prevalence of Anemia among Children and Adolescents of Bangladesh: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1786. [PMID: 36767153 PMCID: PMC9914578 DOI: 10.3390/ijerph20031786] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/02/2022] [Accepted: 09/08/2022] [Indexed: 06/18/2023]
Abstract
The prevalence of anemia is high among children and adolescents in low- and middle-income countries because of undernutrition resulting from their poor socioeconomic status and lack of knowledge on proper nutrition. We conducted a systematic review and meta-analysis to determine the prevalence of anemia among children and adolescents aged between 6 months and 19 years in Bangladesh. Databases such as PubMed, Scopus, and Google Scholar were searched to identify the studies that reported the prevalence of anemia among children and adolescents. A total of 24 studies, including the data of 14,062 cases, were included in the systematic review and meta-analysis of the time period between 1997 and 2019. The random-effects model was used to calculate the summary estimates. The protocol was registered with PROSPERO (CRD42021246960). The pooled prevalence of anemia, iron deficiency anemia (IDA), and non-severe and severe anemia were 46.8% [95% CI: 36.0-57.6], 13.6% [95% CI: 8.0-19.2], 56.4% [95% CI: 39.6-73.1] and 0.7% [95% CI: 0.1-1.4], respectively. Prevalence of anemia exhibited the highest among the children aged ≤2 years. Briefly, 91.67% of the studies were of high quality. No significant publication bias was found; however, two outlier studies were detected. The prevalence of anemia among children and adolescents was estimated as high in Bangladesh.
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Affiliation(s)
- Shoumik Kundu
- Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Sayeda Sadia Alam
- Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Md Al-Tareq Mia
- Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Tareq Hossan
- Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
- Department of Bone Marrow Transplant, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Phil Hider
- Department of Population Health, University of Otago, Christchurch 8140, New Zealand
| | - Md. Ibrahim Khalil
- Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Kamarul Imran Musa
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
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Effects of Different Doses, Forms, and Frequencies of Zinc Supplementation on Biomarkers of Iron and Zinc Status among Young Children in Dhaka, Bangladesh. Nutrients 2022; 14:nu14245334. [PMID: 36558493 PMCID: PMC9781687 DOI: 10.3390/nu14245334] [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: 11/02/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Young children in resource-constrained settings are susceptible to zinc deficiency and its deleterious health effects. The objective of this secondary analysis was to evaluate the effects of the following six interventions on biomarkers of iron and zinc status among a subgroup of young children in Dhaka, Bangladesh, who participated in the Zinc in Powders Trial (ZiPT): (1) standard micronutrient powders (MNPs) containing 4.1 mg zinc and 10 mg iron, daily; (2) high-zinc (10 mg) and low-iron (6 mg) (HiZn LoFe) MNP, daily; (3) HiZn (10 mg) and LoFe (6 mg)/HiZn (10 mg) and no-iron MNPs on alternating days; (4) dispersible zinc tablet (10 mg), daily; (5) dispersible zinc tablet (10 mg), daily for 2 weeks at enrollment and at 12 weeks; (6) placebo powder, daily. At the end of the 24 week intervention period, children in the daily dispersible zinc tablet group exhibited a mean serum zinc concentration (SZC) of 92.5 μg/dL, which was significantly higher than all other groups except the HiZn LoFe MNP alternating group (81.3 μg/dL). MNPs containing 10 mg and 6 mg of iron had a similar impact on biomarkers of iron status, with no evidence of an adverse interaction with zinc.
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Sun C, Ye R, Akhtar M, Dill SE, Yuan P, Zhou H, Rozelle S. Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach. BMC Public Health 2022; 22:2250. [DOI: 10.1186/s12889-022-14731-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/25/2022] [Indexed: 12/04/2022] Open
Abstract
Abstract
Background
The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework.
Methods
Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework.
Results
Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (β = 0.440, P < 0.001), intention (β = 0.374, P < 0.001), knowledge and skills (β = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (β=-0.142, P < 0.001), and caregiver generation (β = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen’s f2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers.
Conclusion
There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence.
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Consumption of Micronutrient Powder, Syrup or Fortified Food Significantly Improves Zinc and Iron Status in Young Mexican Children: A Cluster Randomized Trial. Nutrients 2022; 14:nu14112231. [PMID: 35684031 PMCID: PMC9183015 DOI: 10.3390/nu14112231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/28/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to compare the effect of three micronutrient products on biomarkers of iron and zinc status of Mexican children 6−12 months of age. As part of research to improve the impact of a national program, 54 communities were randomly assigned to receive: (1) fortified food (FF), provided by the program at the time, or (2) micronutrient powders (MNP) or (3) syrup. Each product contained 10 mg each of zinc and iron, plus other micronutrients. Children consumed the product 6 days/week for four months. Primary outcomes were changes in serum zinc, ferritin, soluble transferrin receptor, hemoglobin concentrations, and their deficiencies. Zinc concentration increased significantly from baseline to follow-up in all groups, with the largest change in the syrup group (geometric mean difference: +4.4 µmol/L; 95%CI: 3.2, 5.5), followed by MNP (+2.9 µmol/L; 95%CI: 2.1, 3.6) and FF (+0.9 µmol/L; 95%CI: 0.3, 1.6). There was a significant increase in hemoglobin concentration (+5.5 g/L; 2.5, 8.4) and a significant reduction in anemia prevalence (44.2% to 26.8%, p < 0.01) only in the MNP group. Compliance differed significantly among groups (MNP vs. FF, p = 0.04; MNP vs. syrup, p = 0.04), but may not fully explain the greater improvement in zinc and iron status in the syrup and MNP groups. The food matrix may influence nutrient utilization from supplements.
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12
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Islam MM, Black RE, Krebs NF, Westcott J, Long J, Islam KM, Peerson JM, Sthity RA, Khandaker AM, Hasan M, El Arifeen S, Ahmed T, King JC, McDonald CM. Different Doses, Forms, and Frequencies of Zinc Supplementation for the Prevention of Diarrhea and Promotion of Linear Growth among Young Bangladeshi Children: A Six-Arm, Randomized, Community-Based Efficacy Trial. J Nutr 2022; 152:1306-1315. [PMID: 35015856 DOI: 10.1093/jn/nxab439] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/29/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Children in resource-limited settings remain vulnerable to zinc deficiency and its consequences. OBJECTIVES To evaluate the effects of different doses, durations, and frequencies of zinc supplementation on the incidence of diarrhea and change in linear growth among young children. METHODS We conducted a randomized, partially double-blind, controlled, 6-arm, community-based efficacy trial in Dhaka, Bangladesh. Children aged 9-11 mo were randomly assigned to receive 1 of the following interventions for 24 wk: 1) standard micronutrient powder (MNP) containing 4.1 mg zinc and 10 mg iron, daily; 2) high-zinc (10 mg), low-iron (6 mg) (HiZn LoFe) MNP, daily; 3) HiZn (10 mg) LoFe (6 mg)/HiZn (10 mg), no-iron MNPs on alternating days; 4) dispersible zinc tablet (10 mg), daily; 5) dispersible zinc tablet (10 mg), daily for 2 wk at enrollment and 12 wk; 6) placebo powder, daily. Primary outcomes were incidence of diarrhea and change in length-for-age z-score (LAZ) over the 24-wk intervention period. Home visits were conducted twice weekly to assess diarrhea and other morbidity. Incidence and prevalence outcomes were compared among groups with Poisson regression; continuous outcomes were compared using ANCOVA. RESULTS A total of 2886 children were enrolled between February 2018 and July 2019. The mean incidence and prevalence of diarrhea among all participants was 1.21 episodes per 100 d and 3.76 d per 100 d, respectively. There were no differences in the incidence or prevalence of diarrhea across intervention groups. The decline in LAZ was slightly smaller among children in the daily HiZn LoFe MNP group compared with the placebo powder group (P < 0.05). CONCLUSIONS The dose of zinc in MNPs as well as the duration and frequency of supplementation evaluated in this trial were not effective in reducing diarrhea; however, the daily HiZn LoFe MNP formulation offered modest improvements in linear growth among young children. This trial was registered at clinicaltrials.gov as NCT03406793.
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Affiliation(s)
- M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Robert E Black
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nancy F Krebs
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jamie Westcott
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julie Long
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kazi Munisul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | | | - Rahvia Alam Sthity
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Afsana Mim Khandaker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Shams El Arifeen
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Janet C King
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Children's Hospital Oakland Research Institute, Oakland, CA, USA.,Department of Nutritional Sciences and Toxicology, University of California, Berkeley, CA, USA
| | - Christine M McDonald
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Children's Hospital Oakland Research Institute, Oakland, CA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, School of Medicine, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA
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13
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Hinnouho GM, Hampel D, Shahab-Ferdows S, Barffour MA, McAnena L, Arnold CD, Ryan Wessells K, Kounnavong S, Allen LH, McNulty H, Hess SY. Daily supplementation of a multiple micronutrient powder improves folate but not thiamine, riboflavin, or vitamin B 12 status among young Laotian children: a randomized controlled trial. Eur J Nutr 2022; 61:3423-3435. [PMID: 35534778 PMCID: PMC9464137 DOI: 10.1007/s00394-022-02890-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the effects of intervention with a daily multiple micronutrient powder (MNP) on thiamine, riboflavin, folate, and B12 status among young Laotian children. METHODS Children (n = 1704) aged 6-23 mo, participating in a double-blind placebo-controlled randomized trial were individually randomized to receive daily either MNP (containing 0.5 mg of thiamine, 0.5 mg riboflavin, 150 μg folic acid, and 0.9 μg vitamin B12 along with 11 other micronutrients) or placebo and followed for ~ 36 weeks. In a randomly selected sub-sample of 260 children, erythrocyte thiamine diphosphate (eThDP), plasma folate and B12 concentrations, and erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin biomarker) were assessed at baseline and endline. RESULTS There was no treatment effect on endline eThDP concentrations (110.6 ± 8.9 nmol/L in MNP vs. 109.4 ± 8.9 nmol/L in placebo group; p = 0.924), EGRac (1.46 ± 0.3 vs. 1.49 ± 0.3; p = 0.184) and B12 concentrations (523.3 ± 24.6 pmol/L vs. 515.9 ± 24.8 pmol/L; p = 0.678). Likewise, the prevalence of thiamine, riboflavin, and B12 deficiencies did not differ significantly between the two groups. However, endline folate concentration was significantly higher in the MNP compared to the placebo group (28.2 ± 0.8 nmol/L vs 19.9 ± 0.8 nmol/L, respectively; p < 0.001), and correspondingly, the prevalence of folate deficiency was significantly lower in the MNP group (1.6% vs 17.4%; p = 0.015). CONCLUSIONS Compared to a placebo, daily MNP for 9 months increased only folate but not thiamine, riboflavin, or B12 status in young Laotian children. TRIAL REGISTRATION The trial was registered at www. CLINICALTRIALS gov (NCT02428647) on April 29 2015.
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Affiliation(s)
- Guy-Marino Hinnouho
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA, USA. .,Helen Keller International, Washington, DC, USA.
| | - Daniela Hampel
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA ,USDA, ARS Western Human Nutrition Research Center, Davis, CA USA
| | | | - Maxwell A. Barffour
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA ,University of Missouri School of Medicine, Columbia, MO USA ,Public Health Program, College of Health and Human Services, Missouri State University, Springfield, MO USA
| | - Liadhan McAnena
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland UK
| | - Charles D. Arnold
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA
| | - K. Ryan Wessells
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People’s Democratic Republic
| | - Lindsay H. Allen
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA ,USDA, ARS Western Human Nutrition Research Center, Davis, CA USA
| | - Helene McNulty
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland UK
| | - Sonja Y. Hess
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, CA USA
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14
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The Effects of Deworming and Multiple Micronutrients on Anaemia in Preschool Children in Bangladesh: Analysis of Five Cross-Sectional Surveys. Nutrients 2021; 14:nu14010150. [PMID: 35011023 PMCID: PMC8746749 DOI: 10.3390/nu14010150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/20/2022] Open
Abstract
Anaemia is a major public health problem among children < 5 years of age in Bangladesh due to recurrent intestinal parasite infections. The aim of this study was to understand the association between combining deworming and MNP home fortification (MNP + Deworming) and the prevalence of anaemia among children < 5 years of age in Bangladesh. We used pooled data from five cross-sectional surveys and performed multivariable logistic regression and calculated crude and adjusted odds ratios (AORs) to quantify the association of anaemia with the exposure variables. A total of 9948 households were considered for this paper. In the unadjusted logistic regression, no significant association was detected between the effective MNP coverage and anaemia prevalence, but the associations were significant (p < 0.001) between the deworming and anaemia prevalence and between the MNP + Deworming condition and anaemia prevalence. In the adjusted model, children who were exposed to both deworming and effective MNP coverage were 30% (AOR 0.70; 95% CI 0.52, 0.94; p = 0.018) less likely to be anaemic compared with children who were unexposed to combined MNP + Deworming. The combined effects of deworming and MNP supplementation on the reduction in anaemia prevalence highlighted the importance of using integrated and multidisciplinary intervention strategies.
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15
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Liyanage G, Anupama KGIS, Sudarshini MLP. Acceptability of home fortification with multiple micro-nutrients among Sri Lankan children. PLoS One 2021; 16:e0261516. [PMID: 34936678 PMCID: PMC8694412 DOI: 10.1371/journal.pone.0261516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Abstract
Micronutrient deficiencies are mostly hidden; clinically less visible compared to macronutrient deficiencies. Food fortification with multiple micronutrients (MMN) is provided for children between 6-23 months, daily for two months at three-time points. We assessed the acceptance and adherence of this nutritional intervention in an urban community setting in Sri Lanka. This cross-sectional study enrolled caregivers of children aged 7 to 23 months with a cluster sampling method. Caregivers ' acceptance of taste and smell, health gains, ease of use, and need perception (Cronbach's reliability: 0.801) were assessed. Also, anemia knowledge (Cronbach's reliability: 0.642), MMN knowledge, and reported adherence (number of sachets consumed per month) were evaluated through a self-administered questionnaire. Adequate adherence was defined as the use of ≥80% sachets. The univariate and multivariate statistical analysis examined the association of acceptability, adherence, and anemia knowledge with independent variables (socio-demographic, household characteristics, and knowledge). The survey included 153 respondents. The Median (range) age of children was 12 months (7-23). The mean (SD) acceptability score was 66.82% (9.78%). Acceptance of sensory qualities (smell/taste) had a lower score than perceived health benefit. Most consumed MMN adequately (72.5%). The mean (SD) anemia knowledge score was 62.20% (25.79%). In multivariate analysis, child's age (OR: -0.360, 95% CI:-0.510,-0.211) and father's education (OR: 2.148, 95% CI: 0.439, 3.857) were independently associated with acceptability. Child's age (OR: -0.108, 95% CI:0.818, 0.985), anemia knowledge (OR:0.016, 95% CI: 1.003, 1.031) and acceptability (OR:0.236, 95% CI:1.140, 1.406) were significant determinants of adherence. Anemia knowledge was significantly associated with the mother's education and household income when adjusted. In conclusion, unpleasant smell/taste and daily schedule were reported as barriers to MMN use. Yet, perception and trust regarding health benefits were encouraging. Reported adherence was somewhat high. Improving acceptability and anemia knowledge could enhance adherence further in this population.
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Affiliation(s)
- G. Liyanage
- Department of Paediatrics, Faculty of Medical Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
| | - K. G. I. S. Anupama
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
| | - M. L. P. Sudarshini
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
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16
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da Silva Lopes K, Yamaji N, Rahman MO, Suto M, Takemoto Y, Garcia-Casal MN, Ota E. Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews. Cochrane Database Syst Rev 2021; 9:CD013092. [PMID: 34564844 PMCID: PMC8464655 DOI: 10.1002/14651858.cd013092.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling). OBJECTIVES To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle. METHODS In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting). MAIN RESULTS We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus). AUTHORS' CONCLUSIONS Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.
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Affiliation(s)
| | - Noyuri Yamaji
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Md Obaidur Rahman
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Maiko Suto
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Yo Takemoto
- Department of Obstetrics and Gynaecology, School of Medicine, Juntendo University, Tokyo, Japan
| | | | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University , Tokyo, Japan
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17
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The critical roles of iron during the journey from fetus to adolescent: Developmental aspects of iron homeostasis. Blood Rev 2021; 50:100866. [PMID: 34284901 DOI: 10.1016/j.blre.2021.100866] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022]
Abstract
Iron is indispensable for human life. However, it is also potentially toxic, since it catalyzes the formation of harmful oxidative radicals in unbound form and may facilitate pathogen growth. Therefore, iron homeostasis needs to be tightly regulated. Rapid growth and development require large amounts of iron, while (especially young) children are vulnerable to infections with iron-dependent pathogens due to an immature immune system. Moreover, unbalanced iron status early in life may have effects on the nervous system, immune system and gut microbiota that persist into adulthood. In this narrative review, we assess the critical roles of iron for growth and development and elaborate how the body adapts to physiologically high iron demands during the journey from fetus to adolescent. As a first step towards the development of clinical guidelines for the management of iron disorders in children, we summarize the unmet needs regarding the developmental aspects of iron homeostasis.
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Black MM, Fernandez-Rao S, Nair KM, Balakrishna N, Tilton N, Radhakrishna KV, Ravinder P, Harding KB, Reinhart G, Yimgang DP, Hurley KM. A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency. J Nutr 2021; 151:2029-2042. [PMID: 33880548 PMCID: PMC8245888 DOI: 10.1093/jn/nxab066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. OBJECTIVES This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. METHODS We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. RESULTS At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. CONCLUSIONS Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.
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Affiliation(s)
- Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
- RTI International, Research Triangle Park, NC, USA
| | - Sylvia Fernandez-Rao
- Department of Behavioral Science, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Krishnapillai Madhavan Nair
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nagalla Balakrishna
- Department of Biostatistics, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nicholas Tilton
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Punjal Ravinder
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | | | - Gregory Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
| | - Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristen M Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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19
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Young MF, Mehta RV, Gosdin L, Kekre P, Verma P, Larson LM, Girard AW, Ramakrishnan U, Chaudhuri I, Srikantiah S, Martorell R. Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial. J Nutr 2021; 151:1983-1992. [PMID: 33880566 PMCID: PMC8245869 DOI: 10.1093/jn/nxab065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/11/2020] [Accepted: 02/22/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking. OBJECTIVES We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization. METHODS We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact. RESULTS At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp). CONCLUSIONS Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Rukshan V Mehta
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Lucas Gosdin
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Priya Kekre
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Leila M Larson
- Arnold School of Public Health, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | - Amy Webb Girard
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | | | | | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Doctoral Program in Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
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20
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Nikooyeh B, Neyestani TR. Effectiveness of various methods of home fortification in under-5 children: where they work, where they do not. A systematic review and meta-analysis. Nutr Rev 2021; 79:445-461. [PMID: 33011799 DOI: 10.1093/nutrit/nuaa087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT The common approaches of home fortification (HF) for prevention and/or treatment of micronutrient deficiencies are micronutrient powders (MNPs), foodlets, and lipid-based nutrient supplements (LNSs). There are mixed results for the impact of HF on growth and nutritional status of young children. OBJECTIVE This systematic review was prepared in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate current evidence from randomized controlled trials including children younger than 5 years to assess the effect of strategies of HF on growth and micronutrient status. METHODS The MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar databases were searched to July 2018. A total of 1301 studies were found in a preliminary search. After screening of titles and abstracts, 30 studies were selected. RESULTS Treatment with MNPs, foodlets, and LNSs effectively increased hemoglobin concentrations by at least 2.52 g/L, 4.59 g/L, and 4.4 g/dL, respectively, as compared with a control. There was a significant decrease in risk of anemia development after foodlet intervention compared with a control or iron drops (odds ratio, 0.27; 95%CI, 0.10-0.74; P = 0.01). However, these interventions did not result in any significant improvement in z-scores for changes of height for age, weight for age, and weight for height. The results indicated that MNP (7.16; 95%CI, 0.31-14.01; P = 0.04) and foodlet treatment (4.92; 95%CI, 0.28-9.57; P = 0.04) could increase serum zinc levels. However, none of the home fortification methods improved vitamin A status in the target group. CONCLUSION Home fortification can be used as an effective method to improve hemoglobin, iron, and zinc status, although in this study it had no effect on vitamin A or anthropometric indicators of the target population. More investigations are warranted for newer approaches of HF to improve a broader range of micronutrients as well as child growth indices and for evaluation of the coverage, compliance, and consistency of such interventions at the population level. PROSPERO REGISTRATION NO CRD42018109279.
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Affiliation(s)
- Bahareh Nikooyeh
- Laboratory of Nutrition Research, National Nutrition and Food Technology Research Institute and Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tirang R Neyestani
- Laboratory of Nutrition Research, National Nutrition and Food Technology Research Institute and Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Sarma H. Implementation science in nutrition: a summary and synthesis. Public Health Nutr 2021; 24:s1-s6. [PMID: 33634773 PMCID: PMC8042575 DOI: 10.1017/s1368980021000884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled 'Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh'. DESIGN Commentary, summary and synthesis. SETTINGS Low- and middle-income country. RESULTS The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation's effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify 'effective' interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme. CONCLUSIONS Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.
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Affiliation(s)
- Haribondhu Sarma
- Research School of Population Health, Colleague of Health and Medicine, The Australian National University, Canberra, ACT2601, Australia
- Nutrition and Clinical Services Division, icddr,b, Dhaka1212, Bangladesh
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22
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Mithra P, Khatib MN, Sinha AP, Kumar N, Holla R, Unnikrishnan B, Vijayamma R, Nair NS, Gaidhane A, Quazi Zahiruddin S. Interventions for Addressing Anemia Among Children and Adolescents: An Overview of Systematic Reviews. Front Pediatr 2021; 8:549549. [PMID: 33665173 PMCID: PMC7921152 DOI: 10.3389/fped.2020.549549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/18/2020] [Indexed: 01/08/2023] Open
Abstract
Context: Anemia is a public health problem that can lead to growth, cognitive, and motor impairments. Objective: To collate evidence on interventions for addressing childhood and adolescent anemia. Methods: In this overview of systematic reviews, we included Cochrane as well as non-Cochrane systematic reviews (SRs) irrespective of language and publication status. Two sets of review authors independently screened articles for eligibility and extracted data from relevant SRs. We present data in a tabular format and summarize results based on outcome reported, age of participants, and type of interventions. We also adopt a "measurement for change" approach to assess the utility of measurement for development of interventions in childhood and adolescent anemia. Results: Our search yielded 2,601 records of which 31 SRs were found eligible for inclusion. Results were favorable for fortification and supplementation with clear reduction in the risk of anemia and increase in hemoglobin levels across all age groups. Other interventions reported by the SRs were inconclusive and suggest further research. Conclusions: Current evidence suggests that fortification or supplementation with iron and micronutrients leads to better reduction in the risk of anemia and improvements in hemoglobin levels among children and adolescents. Results of this overview can help decision makers in informing selection of interventions to address childhood and adolescent anemia. Review Registration: PROSPERO CRD42016053687.
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Affiliation(s)
- Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Mahalaqua Nazli Khatib
- Division of Evidence Synthesis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
| | - Anju Pradhan Sinha
- Division of Reproductive, Maternal and Child Health, Indian Council of Medical Research, New Delhi, India
| | - Nithin Kumar
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Ramesh Holla
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Bhaskaran Unnikrishnan
- Department of Community Medicine, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Ratheebhai Vijayamma
- Manipal Institute of Communication, Manipal Academy of Higher Education, Manipal, India
| | - N. Sreekumaran Nair
- Medical Biometrics & Informatics (Biostatistics), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Abhay Gaidhane
- Department of Community Medicine, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
| | - Syed Quazi Zahiruddin
- Department of Community Medicine, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, India
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Barffour MA, Hinnouho GM, Wessells KR, Kounnavong S, Ratsavong K, Sitthideth D, Bounheuang B, Sengnam K, Chanhthavong B, Arnold CD, Brown KH, Larson CP, Hess SY. Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial. J Glob Health 2021; 10:010424. [PMID: 32612816 PMCID: PMC7321011 DOI: 10.7189/jogh.10.010424] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment. Methods Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models. Results Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72). Conclusions There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo. Trial registration ClinicalTrials.gov: NCT02428647.
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Affiliation(s)
- Maxwell A Barffour
- Institute for Global Nutrition, University of California, Davis, California, USA.,College of Health and Human Services, Public Health Program, Missouri State University, Springfield, Missouri, USA
| | - Guy-Marino Hinnouho
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Kethmany Ratsavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bangone Bounheuang
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Khanpaseuth Sengnam
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bigphone Chanhthavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Kenneth H Brown
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Charles P Larson
- School of Population and Global Health, McGill University, Montreal, Canada
| | - Sonja Y Hess
- Institute for Global Nutrition, University of California, Davis, California, USA
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24
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Seyoum Y, Baye K, Humblot C. Iron homeostasis in host and gut bacteria - a complex interrelationship. Gut Microbes 2021; 13:1-19. [PMID: 33541211 PMCID: PMC7872071 DOI: 10.1080/19490976.2021.1874855] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/16/2020] [Accepted: 01/03/2021] [Indexed: 02/08/2023] Open
Abstract
Iron deficiency is the most frequent nutritional deficiency in the world with an estimated 1.4 billion people affected. The usual way to fight iron deficiency is iron fortification, but this approach is not always effective and can have undesirable side effects including an increase in the growth and virulence of gut bacterial pathogens responsible for diarrhea and gut inflammation. Iron is mainly absorbed in the duodenum and is tightly regulated in mammals. Unabsorbed iron enters the colonic lumen where many microorganisms, referred to as gut microbiota, reside. Iron is essential for these bacteria, and its availability consequently affects this microbial ecosystem. The aim of this review is to provide further insights into the complex relationship between iron and gut microbiota. Given that overcoming anemia caused by iron deficiency is still a challenge today, gut microbiota could help identify more efficient ways to tackle this public health problem.
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Affiliation(s)
- Yohannes Seyoum
- Center for Food Science and Nutrition, College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Christèle Humblot
- QualiSud, Université de Montpellier, Avignon Université, CIRAD, Institut Agro, IRD, Université de la Réunion, Montpellier, France
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25
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Brewer JD, Shinnick J, Román K, Santos MP, Paz-Soldan VA, Buttenheim AM. Behavioral Insights Into Micronutrient Powder Use for Childhood Anemia in Arequipa, Peru. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:721-731. [PMID: 33361238 PMCID: PMC7784068 DOI: 10.9745/ghsp-d-20-00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
Abstract
Health care provider-caregiver interactions and caregivers’ shifting emotional states between intention formation and use affected their adherence to a government-provided micronutrient powder intervention to prevent childhood anemia. In counseling directed to caregivers, we suggest providers offer clear messaging on MNP impact and planning for challenges during MNP use. Childhood anemia remains a significant driver of morbidity in low- and middle-income countries, including Peru. To identify behavioral challenges to using micronutrient powder (MNP) that is given to supplement children’s diets and prevent anemia, we applied a behavioral design approach to interviews and focus groups with 129 caregivers in Arequipa, Peru. We examined 3 key points in the decision-making process: accessing MNP through the health system; forming intentions to use MNP; and MNP use at the time of child feeding. Using the NUDGE (Narrow, Understand, Discover, Generate, Evaluate) approach, we identified the following behavioral barriers and facilitators: (1) caregivers’ experiences with health care providers shaped their motivation to access MNP; (2) caregivers felt accessing MNP at clinics was inconvenient and created hassle factors; (3) caregivers’ mental models about anemia prevention shaped MNP intentions and use; (4) caregivers’ salient negative experiences could have caused them to stop giving MNP; (5) caregivers forgot to give MNP if they did not have cues to remind them but could be prompted with salient cues; and (6) caregivers were affected by emotional, cognitive, and attentional factors during feeding that were difficult to anticipate. Our results, based on a behavioral design approach, suggest opportunities to adapt current messaging, counseling, and education around MNP use. Adaptations include providing culturally relevant messages, leveraging caregivers’ emotional and cognitive states, and encouraging small but impactful changes to feeding routines to address barriers to MNP use.
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Affiliation(s)
- Jessica D Brewer
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Julianna Shinnick
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Karina Román
- Department of Health Management, Universidad Peruana Cayetano Heredia Facultad de Salud Pública y Administración Carlos Vidal Layseca, Lima, Peru.,Asociación Benéfica PRISMA, Lima, Peru
| | - Maria P Santos
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Valerie A Paz-Soldan
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.,Asociación Benéfica PRISMA, Lima, Peru.,Zoonotic Disease Research Lab, Universidad Peruana Cayetano Heredia Facultad de Salud Pública y Administración Carlos Vidal Layseca, Arequipa, Peru
| | - Alison M Buttenheim
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
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26
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Albelbeisi A, Shariff ZM, Mun CY, Rahman HA, Abed Y. Multiple micronutrient supplementation improves growth and reduces the risk of anemia among infants in Gaza Strip, Palestine: a prospective randomized community trial. Nutr J 2020; 19:133. [PMID: 33278899 PMCID: PMC7719238 DOI: 10.1186/s12937-020-00652-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 11/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infants and young children 6-24 months of age are the most nutritionally vulnerable groups, as their needs for vitamins and minerals are high relative to the amount of food they consume. This study determines the effect of Micronutrient Powder Supplementation (MNP) on growth and hemoglobin of infants in Gaza Strip, Palestine. METHOD This was a two-arm parallel-group randomized controlled trial conducted in two health care clinics of the United Nations Relief and Work Agency (UNRWA) at the Middle Area governorate of Gaza Strip, Palestine. A total of 200 healthy infants aged 6-month-old were recruited and randomized to receive 3 sachets/week of MNP for 12 months alongside with the National Micronutrient Supplement (NMS) (n = 100) or NMS alone (n = 100). Weight, length, blood hemoglobin, and dietary intakes were measured at 6, 9, 12, 15, 18, and 21 (3 months after the end of intervention) months of age. Analysis was by intention to treat. RESULTS The experimental group had a higher concentration of hemoglobin at 12 and 15 months than did the control group, and a significant difference (p < 0.05) was observed at 15 months only. Significantly greater weight, length, weight-for-age, length-for-age, and weight-for-length z-scores were observed in the experimental group than that in the control group at 12 and 15 months (p < 0.05). The prevalence of anemia (18% vs. 52%) and stunting (1% vs. 11%) were higher in the control than the experimental group, respectively. After controlling for sex, similar findings were reported. CONCLUSIONS Addition of MNP to the existing NMS program improved the nutritional status of young children. The potential benefits of MNP supplementation on physical growth and hemoglobin should be considered in the existing NMS program. TRIAL REGISTRATION ISRCTN57594793 ; Date of registration: 20-03-2018 (Retrospectively registered).
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Affiliation(s)
- Ali Albelbeisi
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan, Malaysia.
| | - Zalilah Mohd Shariff
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan, Malaysia
| | - Chan Yoke Mun
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan, Malaysia
| | - Hejar Abdul Rahman
- Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan, Malaysia
| | - Yehia Abed
- Faculty of Public Health, Al Quds University of Gaza- Palestine, Jerusalem, Palestinian Territory
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Moorthy D, Merrill R, Namaste S, Iannotti L. The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews. Adv Nutr 2020; 11:1631-1645. [PMID: 32845972 PMCID: PMC7666908 DOI: 10.1093/advances/nmaa070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/12/2020] [Accepted: 05/21/2020] [Indexed: 11/14/2022] Open
Abstract
Anemia is a multifactorial condition arising from inadequate nutrition, infection, chronic disease, and genetic-related etiologies. Our aim was to assess the impact of nutrition-sensitive and nutrition-specific interventions on hemoglobin (Hb) concentrations and anemia to inform the prioritization and scale-up of interventions to address the multiple causes of anemia. We performed a meta-review synthesis of information by searching multiple databases for reviews published between 1990 and 2017 and used standard methods for conducting a meta-review of reviews, including double independent screening, extraction, and quality assessment. Quantitative pooling and narrative syntheses were used to summarize information. Hb concentration and anemia outcomes were pooled in specific population groups (children aged <5 y, school-age children, and pregnant women). Methodological quality of the systematic reviews was assessed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. Of the 15,444 records screened, we identified 118 systematic reviews that met inclusion criteria. Reviews focused on nutrition-specific interventions (96%). Daily and intermittent iron supplementation, micronutrient powders, malaria treatment, use of insecticide-treated nets (ITNs), and delayed cord clamping were associated with increased Hb concentration in children aged <5 y. Among children older than 5 y, daily and intermittent iron supplementation and deworming, and in pregnant women, daily iron-folic acid supplementation, use of ITNs, and delayed cord clamping, were associated with increased Hb concentration. Similar results were obtained for the reduced risk of anemia outcome. This meta-review suggests the importance of nutrition-specific interventions for anemia and highlights the lack of evidence to understand the influence of nutrition-sensitive and multifaceted interventions on the condition.
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Affiliation(s)
- Denish Moorthy
- USAID Advancing Nutrition (USAID AN), Arlington, VA, USA
| | - Rebecca Merrill
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sorrel Namaste
- The Demographic and Health Survey Program, ICF, Rockville, MD, USA
| | - Lora Iannotti
- Brown School, Institute for Public Health, Washington University in St Louis, MO, USA
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Samuel A, Brouwer ID, Pamungkas NP, Terra T, Lelisa A, Kebede A, Osendarp SJM. Determinants of adherence to micronutrient powder use among young children in Ethiopia. MATERNAL AND CHILD NUTRITION 2020; 17:e13111. [PMID: 33169528 PMCID: PMC7988858 DOI: 10.1111/mcn.13111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 10/15/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale‐up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6–11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66–0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54–0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52–0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled‐up, by taking into account factors that positively and negatively determine adherence.
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Affiliation(s)
- Aregash Samuel
- Food Science and Nutrition Research Directorate, Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Inge D Brouwer
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Nindya P Pamungkas
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Tosca Terra
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | - Azeb Lelisa
- Nutrition International, Ethiopia, C/O Ethiopia-Canada Cooperation Office (CIDA-ECCO), Addis Ababa, Ethiopia
| | - Amha Kebede
- Food Science and Nutrition Research Directorate, Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | - Saskia J M Osendarp
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2020; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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30
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Sarfo J, Keding GB, Boedecker J, Pawelzik E, Termote C. The Impact of Local Agrobiodiversity and Food Interventions on Cost, Nutritional Adequacy, and Affordability of Women and Children's Diet in Northern Kenya: A Modeling Exercise. Front Nutr 2020; 7:129. [PMID: 32903921 PMCID: PMC7443573 DOI: 10.3389/fnut.2020.00129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/06/2020] [Indexed: 01/18/2023] Open
Abstract
Wild plant species are often excellent sources of micronutrients and have the potential to promote healthy living, yet they are under-exploited. Distribution of micronutrient powders as diet supplements can play an effective role in reducing micronutrient deficiencies among infants and young children. However, assessing their effects in ensuring a nutritious diet at low cost have been limited. This study assessed the impact of including wild plant species and micronutrient powders in modeled optimized lowest-cost diets for women and children in rural Kenya. Market surveys, focus group discussions in six villages and a 24-h dietary intake recall were used to collect data that were subsequently entered in the cost of diet linear programming tool to model lowest-cost nutritious diets for women and children in Turkana County, Kenya. Three wild vegetables, three wild fruits, and micronutrient powder were added to the models to assess their impact on the cost and the nutrient adequacy of the diets. A locally adapted cost optimized nutritious diet without any intervention costs between 50 and 119 Kenyan shillings (KES) daily ($0.5 to $1.2) for children between 6 and 23 months and 173 to 305 KES ($1.8 to $2.9) for women. Addition of the three wild vegetables resulted in cost reductions between 30 and 71% as well as making up for iron and zinc gaps. The micronutrient powder had an insignificant effect on diet cost and filling nutrient gaps. Edible wild plant species, specifically wild vegetables, can reduce diet costs in considerable proportions while filling nutrient gaps year-round. However, affordability of a nutritious diet remains a major challenge in Turkana County, irrespective of the wealth group.
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Affiliation(s)
- Jacob Sarfo
- Division Quality of Plant Products, University of Goettingen, Goettingen, Germany
| | - Gudrun B Keding
- Division Quality of Plant Products, University of Goettingen, Goettingen, Germany
| | - Julia Boedecker
- Bioversity International, Healthy Diets From Sustainable Food Systems, Nairobi, Kenya
| | - Elke Pawelzik
- Division Quality of Plant Products, University of Goettingen, Goettingen, Germany
| | - Céline Termote
- Bioversity International, Healthy Diets From Sustainable Food Systems, Nairobi, Kenya
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31
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Hinnouho GM, Wessells KR, Barffour MA, Sayasone S, Arnold CD, Kounnavong S, Hess SY. Impact of Different Strategies for Delivering Supplemental Zinc on Selected Fecal Markers of Environmental Enteric Dysfunction among Young Laotian Children: A Randomized Controlled Trial. Am J Trop Med Hyg 2020; 103:1416-1426. [PMID: 32618258 PMCID: PMC7543857 DOI: 10.4269/ajtmh.20-0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The objective of this study was to assess the impact of different strategies for delivering supplemental zinc on fecal myeloperoxidase (MPO), neopterin (NEO), and calprotectin (CAL) among young Laotian children. In a double-blind controlled trial, children aged 6-23 months were randomized to receive either daily preventive zinc (PZ) tablets (7 mg/day), daily micronutrient powder (MNP; containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days), or daily placebo powder and followed for ∼36 weeks. Stool samples were collected at baseline and endline. Fecal MPO, NEO, and CAL concentrations were determined in a randomly selected subsample of 720 children using commercially available ELISA kits. At baseline, the mean age was 14.1 ± 4.9 months and prevalence of stunting was 39%. The endline prevalence of stunting was 43%; there was no overall treatment effect on physical growth in the parent trial. At endline, the mean (95% CI) MPO in the PZ group was 1,590 [1,396; 1,811] ng/mL and did not differ from that in the MNP (1,633 [1,434; 1,859] ng/mL), TZ (1,749 [1,535; 1,992] ng/mL), and control (1,612 [1,415; 1,836] ng/mL) groups (P = 0.749). Similarly, there was no overall treatment effect on NEO and CAL concentrations (P = 0.226 and 0.229, respectively). In this population, the provision of PZ or TZ supplements or MNP had no impact on growth or environmental enteric dysfunction (EED) as assessed by fecal MPO, NEO, and CAL. Additional research is needed to better understand the etiology and proposed mechanisms of EED pathogenesis.
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Affiliation(s)
- Guy-Marino Hinnouho
- Helen Keller International, Washington, District of Columbia.,Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - K Ryan Wessells
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Maxwell A Barffour
- Public Health Program, College of Health and Human Services, Missouri State University, Springfield, Missouri.,Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Somphou Sayasone
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Charles D Arnold
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Sonja Y Hess
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
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32
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Zaidi S, Das JK, Khan GN, Najmi R, Shah MM, Soofi SB. Food supplements to reduce stunting in Pakistan: a process evaluation of community dynamics shaping uptake. BMC Public Health 2020; 20:1046. [PMID: 32616009 PMCID: PMC7331235 DOI: 10.1186/s12889-020-09103-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 06/12/2020] [Indexed: 12/22/2022] Open
Abstract
Background There is an increasing interest in use of food supplements to prevent childhood stunting, however the evidence on the process indicators is scarce. We in this study explore the barriers to the effective implementation of food supplementation programs and the possible mitigation strategies which can guide the design of future programs. Methods We undertook a process evaluation of a stunting prevention food supplementation pilot program in rural Pakistan that distributed Wheat Soy Blend (WSB) to pregnant & lactating women, and Lipid-based Nutrient Supplement (LNS) and micronutrient powder (MNP) to < 5 years children. We used a mixed methods approach through a quantitative survey of 800 households and conducted 18 focused group discussion (FGDs) (with male and female caregivers), 4 FGDs (with Community Health Workers (CHWs)) and 22 key informant interviews (with district stakeholders) to evaluate the community side factors affecting uptake through five parameters: value, acceptability, receipt of supplement, usage and correct dosage. Results The findings show that proportionately few beneficiaries consumed the full dose of supplements, despite reasonable knowledge amongst caregivers. Sharing of supplements with other household member was common, and the full monthly stock was usually not received. Qualitative findings suggest that caregivers did not associate food supplements with stunting prevention. WSB was well accepted as an extra ration, LNS was popular due its chocolaty taste and texture, whereas MNP sprinkles were perceived to be of little value. The cultural food practices led to common sharing, whereas interaction with CHWs was minimal for nutrition counselling. Qualitative findings also indicate CHWs related programmatic constraints of low motivation, multi-tasking, inadequate counselling skills and weak supervision. Conclusion We conclude that the community acceptability of food supplements does not translate into optimal consumption. Hence a greater emphasis is needed on context specific demand creation and focusing on the supply side constraints with improved logistical planning, enhanced motivation and supervision of community workers with involvement of multiple stakeholders. While, similar studies are needed in varying contexts to help frame universal guidelines. Trial registration ClinicalTrials.gov Identifier: NCT02422953. Registered on April 22, 2015.
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Affiliation(s)
- Shehla Zaidi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. .,Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Jai K Das
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Gul Nawaz Khan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rabia Najmi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mashal Murad Shah
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sajid B Soofi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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33
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Iron status and inherited haemoglobin disorders modify the effects of micronutrient powders on linear growth and morbidity among young Lao children in a double-blind randomised trial. Br J Nutr 2020; 122:895-909. [PMID: 31303184 PMCID: PMC7672373 DOI: 10.1017/s0007114519001715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Some studies found that providing micronutrient powder (MNP) causes adverse health outcomes, but modifying factors are unknown. We aimed to investigate whether Fe status and inherited Hb disorders (IHbD) modify the impact of MNP on growth and diarrhoea among young Lao children. In a double-blind controlled trial, 1704 children of age 6–23 months were randomised to daily MNP (with 6 mg Fe plus fourteen micronutrients) or placebo for about 36 weeks. IHbD, and baseline and final Hb, Fe status and anthropometrics were assessed. Caregivers provided weekly morbidity reports. At enrolment, 55·6 % were anaemic; only 39·3 % had no sign of clinically significant IHbD. MNP had no overall impact on growth and longitudinal diarrhoea prevalence. Baseline Hb modified the effect of MNP on length-for-age (LAZ) (P for interaction = 0·082). Among children who were initially non-anaemic, the final mean LAZ in the MNP group was slightly lower (–1·93 (95 % CI –1·88, –1·97)) v. placebo (–1·88 (95 % CI –1·83, –1·92)), and the opposite occurred among initially anaemic children (final mean LAZ –1·90 (95 % CI –1·86, –1·94) in MNP v. –1·92 (95 % CI –1·88, –1·96) in placebo). IHbD modified the effect on diarrhoea prevalence (P = 0·095). Among children with IHbD, the MNP group had higher diarrhoea prevalence (1·37 (95 % CI 1·17, 1·59) v. 1·21 (95 % CI 1·04, 1·41)), while it was lower among children without IHbD who received MNP (1·15 (95 % CI 0·95, 1·39) v. 1·37 (95 % CI 1·13, 1·64)). In conclusion, there was a small adverse effect of MNP on growth among non-anaemic children and on diarrhoea prevalence among children with IHbD.
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Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME. Predictors of micronutrient powder (MNP) knowledge, coverage, and consumption during the scale-up of an integrated infant and young child feeding (IYCF-MNP) programme in Nepal. MATERNAL AND CHILD NUTRITION 2020; 15:e12712. [PMID: 31622040 PMCID: PMC6856851 DOI: 10.1111/mcn.12712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/26/2022]
Abstract
Large-scale programmes using micronutrient powders (MNPs) may not achieve maximum impact due to limited/inappropriate MNP coverage, consumption, and use. We identify predictors of MNP coverage, maternal knowledge of appropriate use, and child MNP consumption in Nepal. A cross-sectional survey was conducted in 2,578 mother-child pairs representative of children 6-23 months in two districts that were part of the post-pilot, scale-up of an integrated infant and young child feeding-MNP (IYCF-MNP) programme. Children aged 6-23 months were expected to receive 60 MNP sachets every 6 months from a female community health volunteer (FCHV) or health centre. Outcomes of interest were MNP coverage (ever received), maternal knowledge of appropriate use (correct response to seven questions), repeat coverage (receipt ≥ twice; among children 12-23 months who had received MNP at least once, n = 1342), and high intake (child consumed ≥75% of last distribution, excluding those with recent receipt/insufficient time to use 75% at recommended one-sachet-per-day dose, n = 1422). Multivariable log-binomial regression models were used to identify predictors of the four outcomes. Coverage, knowledge of appropriate use, and repeat coverage were 61.3%, 33.5%, and 45.9%, respectively. Among MNP receivers, 97.9% consumed MNP at least once and 38.9% of eligible children consumed ≥75% of last distribution. FCHV IYCF-MNP counselling was positively associated with knowledge, coverage, repeat coverage, and high intake; health worker counselling with knowledge and coverage indicators; and radio messages with coverage indicators only. FCHV counselling had the strongest association with knowledge, coverage, and high intake. Community-based counselling may play a vital role in improving coverage and intake in MNP programmes.
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Affiliation(s)
- Lindsey M Locks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Nutrition Section, United Nations Children's Fund (UNICEF) Headquarters, New York, New York, USA
| | - Pradiumna Dahal
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Rajkumar Pokharel
- Nutrition Section, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | | | - Naveen Paudyal
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Ralph D Whitehead
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stanley Chitekwe
- Nutrition Section, United Nations Children's Fund (UNICEF), Kathmandu, Nepal
| | - Zuguo Mei
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
| | - Bikash Lamichhane
- Child Health Division, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | - Aashima Garg
- Nutrition Section, United Nations Children's Fund (UNICEF) Headquarters, New York, New York, USA
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and Obesity, United States Centers of Disease Control and Prevention, Atlanta, Georgia, USA
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35
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Ford ND, Ruth LJ, Ngalombi S, Lubowa A, Halati S, Ahimbisibwe M, Baingana R, Whitehead RD, Mapango C, Jefferds ME. An Integrated Infant and Young Child Feeding and Micronutrient Powder Intervention Does Not Affect Anemia, Iron Status, or Vitamin A Status among Children Aged 12-23 Months in Eastern Uganda. J Nutr 2020; 150:938-944. [PMID: 31923315 PMCID: PMC8127862 DOI: 10.1093/jn/nxz314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/24/2019] [Accepted: 11/26/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Micronutrient powders (MNP) can reduce iron deficiency and anemia in children. OBJECTIVE We evaluated the impact of an integrated infant and young child feeding (IYCF)-MNP intervention on anemia and micronutrient status among children aged 12-23 mo in Eastern Uganda. The intervention focused on MNP distribution, IYCF education, and caregiver behavior change. METHODS Population-based cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts were collected in June/July 2015 at baseline (n = 1260) and 12 mo after implementation at endline in 2016 (n = 1490). From pooled capillary blood, we assessed hemoglobin, malaria, ferritin, retinol binding protein (RBP), C-reactive protein, and ɑ1-acid glycoprotein. Ferritin and RBP were regression-adjusted to correct for inflammation. Caregivers reported sociodemographic characteristics and MNP knowledge and practices. Linear regression estimated the difference-in-difference (DiD) effect of MNP on hemoglobin, ferritin, and RBP, and logistic regression estimated DiD effect of MNP on anemia (hemoglobin <11.0 g/dL), iron deficiency (ferritin <12.0 µg/L), iron deficiency anemia (hemoglobin <11.0 g/dL and ferritin <12.0 µg/L), and vitamin A deficiency (VAD; RBP equivalent to <0.70 µmol/L retinol: <0.79 µmol/L at baseline and RBP <0.67 µmol/L at endline). RESULTS In Amuria, 96% of children had ever consumed MNP versus <1% of children in Soroti. Fifty-four percent of caregivers reported organoleptic changes when MNP were added to foods cooked with soda ash. Adjusting for age, sex, malaria, recent morbidity, and household-level factors, the intervention was associated with -0.83 g/dL lower hemoglobin (95% CI, -1.36, -0.30 g/dL; P = 0.003) but not with anemia, ferritin, iron deficiency, iron deficiency anemia, RBP, or VAD. CONCLUSIONS Despite high program fidelity, the intervention was associated with reduced hemoglobin concentrations but not with change in anemia or micronutrient status among children aged 12-23 mo in Eastern Uganda. Contextual factors, such as cooking with soda ash, might explain the lack of effectiveness.
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Affiliation(s)
- Nicole D. Ford
- McKing Consulting Corp, Fairfax, Virginia,Nutrition Branch, Division of Nutrition, Physical
Activity, and Obesity, United States Centers of Disease Control and Prevention,
Atlanta, Georgia
| | - Laird J Ruth
- McKing Consulting Corp, Fairfax, Virginia,Nutrition Branch, Division of Nutrition, Physical
Activity, and Obesity, United States Centers of Disease Control and Prevention,
Atlanta, Georgia
| | | | | | - Siti Halati
- United Nations World Food Programme, Kampala, Uganda
| | | | | | - Ralph D. Whitehead
- Nutrition Branch, Division of Nutrition, Physical
Activity, and Obesity, United States Centers of Disease Control and Prevention,
Atlanta, Georgia
| | - Carine Mapango
- Nutrition Branch, Division of Nutrition, Physical
Activity, and Obesity, United States Centers of Disease Control and Prevention,
Atlanta, Georgia
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical
Activity, and Obesity, United States Centers of Disease Control and Prevention,
Atlanta, Georgia
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36
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Suchdev PS, Jefferds MED, Ota E, da Silva Lopes K, De‐Regil LM. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev 2020; 2:CD008959. [PMID: 32107773 PMCID: PMC7046492 DOI: 10.1002/14651858.cd008959.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi-solid food for children six months of age or older. The use of MNPs for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out-of-date. OBJECTIVES To assess the effects and safety of home (point-of-use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi-solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point-of-use fortification. SEARCH METHODS We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with individual randomisation or cluster-randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron-containing supplements, which is standard practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 29 studies (33,147 children) conducted in low- and middle-income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty-six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron-only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate-certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high-certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low-certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate-certainty evidence) at follow-up compared with children receiving the control intervention. We did not find an effect on weight-for-age (MD 0.02, 95% CI -0.03 to 0.07; 10 studies; 9287 children; moderate-certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all-cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low-certainty evidence) and haemoglobin concentrations (MD -2.81 g/L, 95% CI -10.84 to 5.22; 2 studies; 278 children; very low-certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low-certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. AUTHORS' CONCLUSIONS Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.
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Affiliation(s)
- Parminder S Suchdev
- Emory UniversityDepartment of Pediatrics1760 Haygood DrAtlantaGAUSA30322
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Maria Elena D Jefferds
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | - Katharina da Silva Lopes
- St. Luke's International UniversityGraduate School of Public Health3‐6‐2 TsukijiChuo‐KuTokyoMSJapan104‐0045
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Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting. Public Health Nutr 2020; 24:s7-s22. [PMID: 32102713 PMCID: PMC8045137 DOI: 10.1017/s1368980019004415] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting. Design: We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science. Results: Based on this review, we developed a comprehensive framework which we have conceptualised as an implementation science process that describes the transition from the use of scientific evidence through to scaling-up with the aim of making an intervention sustainable. The framework consisted of three domains: Domain i – efficacy to effectiveness trials, Domain ii – scaling-up and Domain iii – sustainability. These three domains encompass five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The framework was successfully applied to a nutrition implementation program in Bangladesh. Conclusions: Our conceptual framework built from an implantation science perspective offers a comprehensive approach supported by a foundational and holistic understanding of its key components. This framework provides guidance for implementation researchers, policy-makers and programme managers to identify and review an effective intervention, to scale it up and to sustain it over time.
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Tam E, Keats EC, Rind F, Das JK, Bhutta ZA. 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. Nutrients 2020; 12:E289. [PMID: 31973225 PMCID: PMC7071447 DOI: 10.3390/nu12020289] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/10/2020] [Accepted: 01/19/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Emily Tam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
| | - Emily C. Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
| | - Fahad Rind
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan;
| | - Jai K. Das
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan;
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan;
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Das JK, Salam RA, Mahmood SB, Moin A, Kumar R, Mukhtar K, Lassi ZS, Bhutta ZA. Food fortification with multiple micronutrients: impact on health outcomes in general population. Cochrane Database Syst Rev 2019; 12:CD011400. [PMID: 31849042 PMCID: PMC6917586 DOI: 10.1002/14651858.cd011400.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Jai K Das
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Rehana A Salam
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteAdelaideAustralia
| | - Salman Bin Mahmood
- Aga Khan University HospitalDepartment of PaediatricsKarachiSindhPakistan
| | - Anoosh Moin
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Rohail Kumar
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Kashif Mukhtar
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
| | - Zohra S Lassi
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan
- University of AdelaideRobinson Research InstituteAdelaideAustraliaAustralia
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2019; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 08/29/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) are critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness is currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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Effect of Micronutrient Powder (MNP) with a Low-Dose of Iron on Hemoglobin and Iron Biomarkers, and Its Effect on Morbidities in Rural Bangladeshi Children Drinking Groundwater with a High-Level of Iron: A Randomized Controlled Trial. Nutrients 2019; 11:nu11112756. [PMID: 31766250 PMCID: PMC6893643 DOI: 10.3390/nu11112756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 01/12/2023] Open
Abstract
Micronutrient Powder (MNP) is beneficial to control anemia, but some iron-related side-effects are common. A high level of iron in the groundwater used for drinking may exacerbate the side-effects among MNP users. We conducted a randomized controlled trial examining the effect of a low-dose iron MNP compared with the standard MNP in children aged 2–5 years residing in a high-groundwater-iron area in rural Bangladesh. We randomized 327 children, who were drinking from the “high-iron” wells (≥2 mg/L), to receive either standard (12.5 mg iron) or low-dose iron (5.0 mg iron) MNP, one sachet per day for two months. Iron parameters were measured both at baseline and end-point. The children were monitored weekly for morbidities. A generalized linear model was used to determine the treatment effect of the low-dose iron MNP. Poisson regressions were used to determine the incidence rate ratios of the morbidities. The trial was registered at ISRCTN60058115. Changes in the prevalence of anemia (defined as a hemoglobin level < 11.0 g/dL) were 5.4% (baseline) to 1.0% (end-point) in the standard MNP; and 5.8% (baseline) to 2.5% (end-point) in the low-dose iron MNP groups. The low-dose iron MNP was non-inferior to the standard MNP on hemoglobin outcome (β = −0.14, 95% CI: −0.30, 0.013; p = 0.07). It resulted in a lower incidence of diarrhea (IRR = 0.29, p = 0.01, 95% CI: 0.11–0.77), nausea (IRR = 0.24, p = 0.002, 95% CI: 0.09–0.59) and fever (IRR = 0.26, p < 0.001, 95% CI: 0.15–0.43) compared to the standard MNP. Low-dose iron MNP was non-inferior to the standard MNP in preventing anemia yet demonstrated an added advantage of lowering the key side-effects.
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Lanou HB, Osendarp SJ, Argaw A, De Polnay K, Ouédraogo C, Kouanda S, Kolsteren P. Micronutrient powder supplements combined with nutrition education marginally improve growth amongst children aged 6-23 months in rural Burkina Faso: A cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2019; 15:e12820. [PMID: 30941887 PMCID: PMC6859995 DOI: 10.1111/mcn.12820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 01/18/2023]
Abstract
Micronutrients powder (MNP) can prevent anaemia amongst children 6-23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron-containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6-23 months and the effect of sustained use of MNP on morbidity in a malaria-endemic area. Child feeding practises and nutritional status were assessed through cross-sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (-0.7% [-6.8, 5.3] points; p = .805), stunting (+4.6% [-2.9, 12.0] points; p = .201), or mean length-for-age z-score and weight-for-length z-score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.
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Affiliation(s)
- Hermann B. Lanou
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | | | - Alemayehu Argaw
- Nutrition InternationalOttawaOntarioCanada
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
- Department of Population and Family HealthJimma UniversityJimmaEthiopia
| | - Kirrily De Polnay
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | | | - Seni Kouanda
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
| | - Patrick Kolsteren
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
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Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME. Changes in growth, anaemia, and iron deficiency among children aged 6-23 months in two districts in Nepal that were part of the post-pilot scale-up of an integrated infant and young child feeding and micronutrient powder intervention. MATERNAL & CHILD NUTRITION 2019; 15:e12693. [PMID: 30226293 PMCID: PMC6585661 DOI: 10.1111/mcn.12693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/16/2018] [Accepted: 08/31/2018] [Indexed: 11/27/2022]
Abstract
There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross-sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6-23 months in two districts in Nepal that were part of a post-pilot scale-up of a IYCF-MNP programme. Multivariable log-binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length-for-age z-score <-2), wasting (weight-for-length z-score <-2), underweight (weight-for-age z-score <-2), anaemia (altitude-adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude-adjusted haemoglobin <100 g/L), iron deficiency (inflammation-adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12-23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable-adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal-FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF-MNP programmes to improve children's nutritional status.
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Affiliation(s)
- Lindsey M. Locks
- Department of NutritionHarvard TH Chan School of Public HealthBostonMassachusetts
- Nutrition SectionUnited Nations Children's Fund (UNICEF) HeadquartersNew YorkNew York
| | - Pradiumna Dahal
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | | | | | - Naveen Paudyal
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | - Ralph D. Whitehead
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
| | - Stanley Chitekwe
- Nutrition SectionUnited Nations Children's Fund (UNICEF)KathmanduNepal
| | - Zuguo Mei
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
| | | | - Aashima Garg
- Nutrition SectionUnited Nations Children's Fund (UNICEF) HeadquartersNew YorkNew York
| | - Maria Elena Jefferds
- Nutrition Branch, Division of Nutrition, Physical Activity, and ObesityUnited States Centers of Disease Control and PreventionAtlantaGeorgia
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Borg B, Mihrshahi S, Griffin M, Sok D, Chhoun C, Laillou A, Wieringa FT. Acceptability of locally-produced Ready-to-Use Supplementary Food (RUSF) for children under two years in Cambodia: A cluster randomised trial. MATERNAL AND CHILD NUTRITION 2019; 15:e12780. [PMID: 30690869 DOI: 10.1111/mcn.12780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 12/14/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready-to-use foods were developed. This trial aimed to assess the acceptability of the novel ready-to-use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn-soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9-23 months from communities in peri-urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were greatest for borbor fortified with MNP versus RUSF snack (unadjusted OR = 6.79, CI = 2.80-16.47, p < 0.001). However, the median energy children received when consuming the RUSF with borbor (57 kcals) or as a snack (48 kcals) was greater than with CSB++ (15 kcals) or borbor fortified with MNP (18 kcals; p < 0.001). Therefore, although children ate less RUSF, it provided approximately three times more kilocalories. Caregivers reported that their children had the highest preference for borbor fortified with MNP. Caregivers themselves ranked the novel RUSF snack highest. Thus, the innovative RUSF was considered sufficiently acceptable to proceed to an effectiveness trial.
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Affiliation(s)
- Bindi Borg
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Seema Mihrshahi
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Mark Griffin
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
| | - Daream Sok
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.,Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, Ministry of Agriculture, Forestry and Fisheries, Phnom Penh, Cambodia
| | - Chamnan Chhoun
- Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, Ministry of Agriculture, Forestry and Fisheries, Phnom Penh, Cambodia
| | - Arnaud Laillou
- Child Survival and Development Section, UNICEF, Phnom Penh, Cambodia
| | - Frank T Wieringa
- UMR-204 Nutripass, Institut de Recherche pour le Développement, IRD/UM/SupAgro, Montpellier, France
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45
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Campos Ponce M, Polman K, Roos N, Wieringa FT, Berger J, Doak CM. What Approaches are Most Effective at Addressing Micronutrient Deficiency in Children 0-5 Years? A Review of Systematic Reviews. Matern Child Health J 2019; 23:4-17. [PMID: 29868936 PMCID: PMC6373288 DOI: 10.1007/s10995-018-2527-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction Even though micronutrient deficiency is still a major public health problem, it is still unclear which interventions are most effective in improving micronutrient status. This review therefore aims to summarize the evidence published in systematic reviews on intervention strategies that aim at improving micronutrient status in children under the age of five. Methods We searched the literature and included systematic reviews that reported on micronutrient status as a primary outcome for children of 0-5 years old, had a focus on low or middle income countries. Subsequently, papers were reviewed and selected by two authors. Results We included 4235 reviews in this systematic review. We found that (single or multiple) micronutrient deficiencies in pre-school children improved after providing (single or multiple) micronutrients. However home fortification did not always lead to significant increase in serum vitamin A, serum ferritin, hemoglobin or zinc. Commercial fortification did improve iron status. Cord clamping reduced the risk of anemia in infants up to 6 months and, in helminth endemic areas, anthelminthic treatment increased serum ferritin levels, hemoglobin and improved height for age z-scores. Anti-malaria treatment improved ferritin levels. Discussion Based on our results the clearest recommendations are: delayed cord clamping is an effective intervention for reducing anemia in early life. In helminth endemic areas iron status can be improved by anthelminthic treatment. Anti-malaria treatment can improve ferritin. In deficient populations, single iron, vitamin A and multimicronutrient supplementation can improve iron, vitamin A and multimicronutrient status respectively. While the impact of home-fortification on multimicronutrient status remains questionable, commercial iron fortification may improve iron status.
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Affiliation(s)
- M Campos Ponce
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
| | - K Polman
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - N Roos
- Department of Human Nutrition, University of Copenhagen, Copenhagen, Denmark
| | - F T Wieringa
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - J Berger
- French National Research Institute for Sustainable Development (IRD), Montpellier, France
| | - C M Doak
- Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands
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Hinnouho GM, Bernstein RM, Barffour MA, Arnold CD, Wessells KR, Ratsavong K, Bounheuang B, Kounnavong S, Hess SY. Impact of Two Forms of Daily Preventive Zinc or Therapeutic Zinc Supplementation for Diarrhea on Hair Cortisol Concentrations Among Rural Laotian Children: A Randomized Controlled Trial. Nutrients 2018; 11:E47. [PMID: 30591656 PMCID: PMC6356851 DOI: 10.3390/nu11010047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 01/19/2023] Open
Abstract
Zinc supplementation has been shown to reduce the morbidity burden among young children, and may reduce chronic stress. Hair cortisol has been promoted as an indicator of chronic stress. We assessed the impact of different strategies for delivering supplementary zinc on hair cortisol concentrations (HCC) in young Laotian children and examined risk factors associated with HCC. In a randomized double-blind controlled trial (NCT02428647), children aged 6⁻23 mo were randomized to one of four intervention groups and followed for ~36 weeks: daily preventive zinc (PZ) tablets (7 mg/day), daily multiple micronutrient powder (MNP) sachets (containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days) or daily placebo powder. HCC of 512 children was assessed at baseline and endline. ANCOVA and linear regression models were used to assess group differences in HCC and to examine the risk factors associated with HCC, respectively. At enrollment, mean HCC was 28.8 ± 43.9 pg/mg. In models adjusted for age at enrollment, health district, and baseline HCC there was no overall effect of the interventions on endline HCC and change in HCC. When controlling for additional predetermined covariates, there was a marginally significant effect on change in HCC (p = 0.075) with a slightly lower reduction of HCC in TZ compared to PZ (mean change (95% CI): -4.6 (-7.0; -2.3) vs. -9.4 (-11.7; -7.0) pg/mg; p = 0.053). At baseline, consumption of iron rich foods was negatively associated with HCC, whereas AGP (α1-acid glycoprotein) levels, elevated AGP and C-reactive protein and high soluble transferrin receptor were positively associated with HCC. In young Laotian children, MNP, PZ and TZ had no impact on HCC. The marginal difference in change in HCC between the PZ and TZ groups was too small to be considered of health significance.
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Affiliation(s)
- Guy-Marino Hinnouho
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA.
| | - Robin M Bernstein
- Department of Anthropology, University of Colorado, Boulder, CO 80309, USA.
- Health and Society Program, Institute for Behavioral Science, University of Colorado, Boulder, CO 80309, USA.
| | - Maxwell A Barffour
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA.
- Public Health Program, College of Health and Human Services, Missouri State University, Springfield, MO 65897, USA.
| | - Charles D Arnold
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA.
| | - K Ryan Wessells
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA.
| | - Kethmany Ratsavong
- Lao Tropical and Public Health Institute, Ban Kaognot, Sisattanack District, Vientiane 01030, Laos.
| | - Bangone Bounheuang
- Lao Tropical and Public Health Institute, Ban Kaognot, Sisattanack District, Vientiane 01030, Laos.
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Ban Kaognot, Sisattanack District, Vientiane 01030, Laos.
| | - Sonja Y Hess
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA.
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Effectiveness of a Program Intervention with Reduced-Iron Multiple Micronutrient Powders on Iron Status, Morbidity and Growth in Young Children in Ethiopia. Nutrients 2018; 10:nu10101508. [PMID: 30326609 PMCID: PMC6212941 DOI: 10.3390/nu10101508] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 01/03/2023] Open
Abstract
Despite the potential for improving iron status and child growth in low- and middle-income settings, concerns on the safety of high iron dosages of Micronutrient Powders (MNP currently limit their applicability in programs. We examined the effectiveness and risks of an integrated complementary feeding program with low iron dose (6 mg/serving) MNP among 6–23-month-old Ethiopian children using a quasi-experimental study design comparing children from five intervention districts (n = 1172) to those from four matched non-intervention districts (n = 1137). Haemoglobin concentrations increased in intervention and decreased in non-intervention children (group-difference +3.17 g/L), but without improvement in iron stores. Intervention children were 2.31 times more likely to have diarrhoea and 2.08 times more likely to have common cold and flu, but these differences decreased towards the end of the intervention. At end line, intervention children had higher mean Height-for-Age Zscore (HAZ) and a 51% reduced odds of being stunted compared to non-intervention children. MNP with low iron dose, when provided combined with other Infant and Young Child Feeding (IYCF) interventions, marginally improved haemoglobin status and resulted in a remarkable improvement in linear growth in 6–23-month-old children. These benefits likely outweigh the relatively small increase in the risk of diarrhoea.
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Matias SL, Mridha MK, Young RT, Hussain S, Dewey KG. Daily Maternal Lipid-Based Nutrient Supplementation with 20 mg Iron, Compared with Iron and Folic Acid with 60 mg Iron, Resulted in Lower Iron Status in Late Pregnancy but Not at 6 Months Postpartum in Either the Mothers or Their Infants in Bangladesh. J Nutr 2018; 148:1615-1624. [PMID: 30204885 DOI: 10.1093/jn/nxy161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/02/2018] [Indexed: 12/16/2022] Open
Abstract
Background Maternal anemia and iron deficiency are prevalent in low- and middle-income countries. Objective We aimed to determine the effects of lipid-based nutrient supplements for pregnant and lactating women (LNS-PL) on hemoglobin (Hb), anemia, and iron status (nonprimary outcomes) at 36 weeks of gestation (women) and 6 mo postpartum (women and infants). Methods The Rang-Din Nutrition Study, a cluster-randomized effectiveness trial, enrolled 4011 Bangladeshi pregnant women at ≤20 weeks of gestation to receive either daily LNS-PL (20 mg Fe) during pregnancy and the first 6 mo postpartum, or iron and folic acid (IFA, 60 mg Fe + 400 µg folic acid) daily during pregnancy and every other day during the first 3 mo postpartum. Biochemical measurements from a subsample of women (n = 1128) and their infants (n = 1117) included Hb (g/L), serum ferritin (µg/L), and soluble transferrin receptor (sTfR; mg/L). Anemia was defined as maternal Hb <110 g/L at 36 weeks of gestation, <120 g/L at 6 mo postpartum, or infant Hb <105 g/L; iron deficiency (ID) was defined as ferritin <12 µg/L or elevated sTfR (>8.3 mg/L for women and >11 mg/L for infants). Results Compared with the IFA group, women in the LNS-PL group had lower ferritin (-6.2 µg/L; P < 0.001) and higher sTfR concentrations (+0.5 mg/L; P < 0.001), and higher risk of ID (OR = 1.93; P < 0.05) at 36 weeks of gestation but not at 6 mo postpartum, whereas no consistent differences were observed for Hb or anemia. Among infants at 6 mo, there were no group differences except for a lower risk of elevated sTfR (OR = 0.61; P < 0.05) in the LNS-PL group than in the IFA group. Conclusions Provision of LNS-PL including a lower dose of iron than what is recommended during pregnancy resulted in differences in maternal iron status in late pregnancy that disappeared by 6 mo postpartum, and caused no undesirable effects regarding anemia or iron status of infants. This trial was registered at clinicaltrials.gov as NCT01715038.
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Affiliation(s)
- Susana L Matias
- Department of Nutrition, University of California, Davis, Davis, CA
| | - Malay K Mridha
- Department of Nutrition, University of California, Davis, Davis, CA.,James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Rebecca T Young
- Department of Nutrition, University of California, Davis, Davis, CA
| | | | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, CA
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49
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Matias SL, Mridha MK, Young RT, Khan MSA, Siddiqui Z, Ullah MB, Vosti SA, Dewey KG. Prenatal and Postnatal Supplementation with Lipid-Based Nutrient Supplements Reduces Anemia and Iron Deficiency in 18-Month-Old Bangladeshi Children: A Cluster-Randomized Effectiveness Trial. J Nutr 2018; 148:1167-1176. [PMID: 29901736 DOI: 10.1093/jn/nxy078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/26/2018] [Indexed: 11/13/2022] Open
Abstract
Background Anemia, iron deficiency (ID), and iron deficiency anemia (IDA) among young children are public health concerns in developing countries. Objective We evaluated the effects of small-quantity lipid-based nutrient supplements (LNSs) and micronutrient powder (MNP) on anemia, ID, and IDA in 18-mo-old Bangladeshi children. Methods We enrolled 4011 pregnant women in a cluster-randomized effectiveness trial with 4 arms-1) LNS-LNS: LNSs (including 20 mg Fe) for women daily during pregnancy and 6 mo postpartum and LNSs (including 9 mg Fe) for children daily from 6 to 24 mo of age (LNS-C); 2) IFA-LNS: iron (60 mg) and folic acid (IFA) for women daily during pregnancy and every other day for 3 mo postpartum and LNS-C for children; 3) IFA-MNP: IFA for women, and MNP (including 10 mg Fe) for children daily from 6 to 24 mo; and 4) IFA-Control: IFA for women and no child supplement. Hemoglobin, serum ferritin, and soluble transferrin receptor (sTfR) were assessed in a subsample of children (n = 1121) at 18 mo to identify anemia (hemoglobin <110g/L), ID (ferritin <12 µg/L or sTfR >8.3 mg/L), and IDA. Data were analyzed with the use of mixed-effects modeling. Results Compared with the IFA-Control arm, hemoglobin was higher in the LNS-LNS and IFA-LNS arms and ferritin was higher and sTfR was lower in the LNS-LNS, IFA-LNS, and IFA-MNP arms; LNS-LNS children had reduced odds of anemia (OR: 0.46; 95% CI: 0.25, 0.84), high sTfR (OR: 0.47; 95% CI: 0.29, 0.73), and ID (OR: 0.45; 95% CI: 0.28, 0.71); and all 3 groups had lower odds of low ferritin [corrected for inflammation; OR (95% CI)-LNS-LNS: 0.29 (0.13, 0.63); IFA-LNS: 0.25 (0.11, 0.59); and IFA-MNP: 0.37 (0.18, 0.76)] and IDA [LNS-LNS: 0.35 (0.18, 0.67); IFA-LNS: 0.45 (0.24,0.85); and IFA-MNP: 0.47 (0.26, 0.87)]. Conclusions Home fortification using LNSs or MNP reduced IDA in 18-mo-old Bangladeshi children. The provision of LNSs in both pregnancy and childhood also reduced child anemia and ID. These findings are relevant to programs targeting similar populations. This trial was registered at www.clinicaltrials.gov as NCT01715038.
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Affiliation(s)
| | - Malay K Mridha
- Department of Nutrition, BRAC University, Dhaka, Bangladesh
| | | | - Md Showkat A Khan
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Zakia Siddiqui
- Initiative for Climate Change and Health, Health System and Population Studies Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Stephen A Vosti
- Agricultural and Resource Economics, University of California, Davis, Davis, CA
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50
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Arcanjo FPN, da Costa Rocha TC, Arcanjo CPC, Santos PR. Micronutrient Fortification at Child-Care Centers Reduces Anemia in Young Children. J Diet Suppl 2018; 16:689-698. [PMID: 29958044 DOI: 10.1080/19390211.2018.1474987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The aim of this study was to evaluate the effectiveness of NutriSUS micronutrient fortification, in infants aged 12-36 months, for the prophylaxis and treatment of iron deficiency anemia. In this cluster-randomized clinical trial study, we evaluated infants aged 12-36 months. Length of intervention was 12 weeks. Children were cluster randomized to either NutriSUS micronutrient fortification (Group A) or control (Group B). Primary outcome variables were change in hemoglobin concentration and anemia prevalence. Two biochemical evaluations were performed to determine hemoglobin concentrations: before and after intervention. This study was conducted in eight child-care centers located within the urban perimeter of the municipality of Sobral, Ceará, in the northeast of Brazil. For Group A, baseline mean hemoglobin concentration was 11.4 ± 1.01 g/dL; after intervention it was 11.9 ± 0.90 g/dL (p = .006); 15 of 20 participants who were anemic at baseline had normal Hb levels after intervention. Number needed to treat = 2. In group B, mean baseline hemoglobin was 11.9 ± 0.89 g/dL; after intervention it was 12.2 ± 0.92 g/dL (p = .58); 4 of 5 participants who were anemic at baseline remained anemic after intervention. In our study, NutriSUS micronutrient fortification provided a beneficial effect on Hb values, reducing the prevalence of anemia. However, further studies are necessary to confirm the effectiveness of this intervention in populations on a larger scale.
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Affiliation(s)
| | | | | | - Paulo Roberto Santos
- Department of Master's Degree in Family Health, Federal University of Ceará , Sobral , Brazil
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