Translating the impact of quality protein maize into improved nutritional status for Ethiopian children: study protocol for a randomized controlled trial

Enhancement of nutritional quality in maize kernel through marker-assisted breeding for vte4, crtRB1, and opaque2 genes

Traditional maize is poor in vitamin-E [α-tocopherol (α-T): 6-8 ppm], vitamin-A [provitamin-A (proA): 1-2ppm], lysine (0.150-0.2-50%), and tryptophan (0.030-0.040%). Here, we combined favourable alleles of vte4, crtRB1, and opaque2 (o2) genes in the parents of maize hybrids, viz., APQH-10 (PMI-PV-9 × PMI-PV-14) and APQH-11 (PMI-PV-9 × PMI-PV-15) using molecular breeding. Gene-specific markers were successfully used to select vte4, crtRB1, and o2 in BC1F1, BC2F1, and BC2F2 generations. Simple sequence repeats (104-109) were used for background selection, leading to an average recovery of 94% recurrent parent genome. The introgressed inbreds possessed significantly higher α-T: 18.38 ppm, α-/γ-tocopherol (α-/γ-T: 52%), and α-/total tocopherol (α-/TT: 32%) compared to original inbreds (α-T: 8.17 ppm, α-/γ-T: 25%, α-/TT: 18%). These newly derived inbreds also possessed higher β-carotene (BC: 8.91 ppm), β-cryptoxanthin (BCX: 1.27 ppm), proA (9.54 ppm), lysine (0.348%), and tryptophan (0.082%) compared to traditional maize inbreds. The reconstituted hybrids recorded higher α-T (2.1-fold), α-/γ-T (1.9-fold), and α-/TT (1.6-fold) over the original hybrids. These reconstituted hybrids were also rich in BC (5.7-fold), BCX (3.3-fold), proA (5.3-fold), lysine (1.9-fold), and tryptophan (2.0-fold) over the traditional hybrids. The reconstituted hybrids had similar grain yield and phenotypic characteristics to original versions. These multinutrient-rich maize hybrids hold great potential to alleviate malnutrition in sustainable and cost-effective manner.

Identifying effective message-framing techniques in behaviour change communication for healthy diets: An experimental study of promoting biofortified maize adoption in Ethiopia

There is an increasing interest in using insights from behavioural economics and psychology to influence people's decisions. However, little is known as to how to leverage these insights to inform educational campaigns in the context of nutrition-sensitive agriculture. We help to fill this void by investigating the effect of framed messages (gain vs loss) in stimulating demand for nutritionally enhanced crops. We conducted a field experiment with 648 farmers and found the following key results. First, nutrition education stimulates demand for nutritionally enhanced crops among smallholder farmers. Without nutrition education, farmers are less likely to switch from producing conventional maize to nutritionally enhanced maize. Second, gain-framed messages are slightly more effective: they result in a higher willingness to pay for nutritionally enhanced maize than loss-framed messages. Third, motivational orientations and risk perceptions of individuals moderate the effect of the framed messages.

Caregivers Systematically Overestimate Their Child's Height-for-Age Relative to Other Children in Rural Ethiopia

BACKGROUND

Stunting affects one-quarter of children <5 y of age, yet little is known about the accuracy of caregivers' perceptions regarding their child's linear growth. Most existing quantitative research on this topic has been conducted in high-income countries and has examined perceptions of children's weight rather than height.

OBJECTIVES

In rural Ethiopia where linear growth faltering is highly prevalent, this study aimed to better understand how caregivers perceive their child's growth. The objectives of this analysis were to 1) assess caregivers' perceptions of their child's height; 2) investigate whether there is a discrepancy between a child's actual height and caregivers' perceptions of their child's height; and 3) examine the factors that influence discrepancies in estimating a child's height (secondary outcomes), including the role of the average height in the community (primary outcome).

METHODS

We conducted a cross-sectional analysis using data from 808 woman caregivers of children ages 6-35 mo in the Oromia region of Ethiopia. We assessed caregivers' rankings (from 1 to 10) of their child's height relative to other children their age in their village. We then converted these rankings to z scores based on an age- and region-specific distribution in order to calculate their difference with the child's actual height-for-age z score and to determine the degree of overestimation. Lastly, we used multivariate log Poisson regressions to determine factors associated with overestimating a child's height.

RESULTS

Forty-three percent of caregivers scored their child's height as the median; 37% overestimated their child's height relative to other children. Regression results showed caregivers who were poorer, and had children who were female, older, and stunted, were more likely to overestimate.

CONCLUSIONS

Our findings suggest that caregivers of young children in Oromia systematically overestimated their children's height, which could adversely affect child health if these misperceptions translate to insufficient care-seeking behavior or feeding choices for children.

The Association of Feeding Practices and Sociodemographic Factors on Underweight and Wasting in Children in Ethiopia: A Secondary Analysis of Four Health Surveys from 2000 to 2016

BACKGROUND

Feeding practices highly influence the nutritional status of children between 6 and 23 months of age in developing countries, including Ethiopia. Therefore, this study was conducted to investigate the association of feeding practices and sociodemographic factors on underweight and wasting of children aged 6-23 months in Ethiopia.

METHODS

Data on 8003 children 6-23 months of age from four Ethiopia demographic and health surveys (EDHS) from 2000 to 2016 were analyzed using complex sample crosstabs for multivariate analysis. The association of feeding practices and sociodemographic factors on underweight and wasting was assessed via multiple logistic regression analyses adjusting the covariates. The outcomes were reported based on the adjusted odds ratios (ORs) with 95% confidence interval (CI).

RESULTS

Male children, very small at birth size children, diarrhea and fever, and short stature mother were risk factors for underweight and wasting (p < 0.05-0.001). Also, minimum dietary diversity, rich and middle-income families, vitamin A in the previous 6 months and antenatal care visits during pregnancy were protective factors for both underweight and wasting (p < 0.05-0.001). Minimum meal frequency was significantly related to lower odds of wasting (p < 0.001). Higher age of the child was significantly associated with underweight (p < 0.05-0.001); however, it was less likely wasted (p < 0.05-0.01).

CONCLUSION

The present study depicted that among infant young children feeding core indicators except breastfed, all the other indicators did not met the required standard; however, sociodemographic factors on four health surveys from 2000 to 2016 were associated with underweight and wasting in children in Ethiopia.

LAY SUMMARY

• Over the years the prevalence of underweight in children aged 6-23 months in the country has shown a significant improvement from 40.2% in 2000 to 34.7% in 2005, then further reduced to 28.9% and 20.0% in 2011 and 2016 EDHS, respectively.• In the same manner, the prevalence of wasting in children aged 6-23 months in Ethiopia also observed improvement from 18.9% in 2000 to 16.7% in 2005, then further reduced to 15.4% and 13.9% in 2011 and 2016 EDHS, respectively.• Male children, very small at birth size children, diarrhea and fever (for the last 2 weeks), and short stature mother were risk factors for underweight and wasting.• Minimum dietary diversity, rich and middle-income families, vitamin A in the previous 6 months and antenatal care visits during pregnancy were protective factors for both underweight and wasting.• Minimum meal frequency was significantly related to lower odds of wasting.• Higher age of the children was significantly associated with underweight; however, less likely wasted.

Behavioural insights to support increased consumption of quality protein maize by young children: a cluster randomised trial in Ethiopia

Introduction

Biofortified crops have tremendous potential to improve child nutrition. We tested whether complementing the distribution of quality protein maize (QPM) with a package of interventions informed by behavioural insights could support greater consumption of QPM by young children and translate into improved growth.

Methods

We conducted a cluster-randomised trial in Oromia, Ethiopia. Clusters of households with a child between 6 and 35 months were randomised into an arm receiving QPM seed only (320 households, 203 clusters) or an arm receiving QPM seed and a child consumption targeting intervention (290 households, 183 clusters). The intervention package included tools to help caregivers keep QPM separate from conventional maize and to earmark QPM specifically for child consumption, as well as encouragement regarding cooking QPM specifically for young children. We analysed the impact of the intervention on food storage, cooking and consumption behaviours and on anthropometric measures (weight-for-age, height-for-age z scores).

Results

The consumption targeting intervention increased the probability of child consumption of QPM in the past week by 17.3 percentage points (pp) (95% CI 9.4 pp to 25.1 pp; p<0.01), increased the probability that QPM flour was stored separately from conventional maize by 46.5 pp (95% CI 38.3 pp to 54.7 pp; p<0.01) and increased the probability that caregivers cooked QPM specifically for young children in the past week by 14.4 pp (95% CI 7.9 pp to 20.9 pp; p<0.01). These effects persisted, but were attenuated, 10 months postintervention. No significant effects on anthropometric outcomes were found.

Conclusions

Enhancing the distribution of new, biofortified crop varieties with a consumption targeting campaign can change storage, cooking and consumption behaviours. However, these improved behaviours did not translate into increased growth in this setting.

Trial registration number

NCT02710760 and AEARCTR0000786.

Multinutrient Biofortification of Maize (Zea mays L.) in Africa: Current Status, Opportunities and Limitations

Macro and micronutrient deficiencies pose serious health challenges globally, with the largest impact in developing regions such as subSaharan Africa (SSA), Latin America and South Asia. Maize is a good source of calories but contains low concentrations of essential nutrients. Major limiting nutrients in maize-based diets are essential amino acids such as lysine and tryptophan, and micronutrients such as vitamin A, zinc (Zn) and iron (Fe). Responding to these challenges, separate maize biofortification programs have been designed worldwide, resulting in several cultivars with high levels of provitamin A, lysine, tryptophan, Zn and Fe being commercialized. This strategy of developing single-nutrient biofortified cultivars does not address the nutrient deficiency challenges in SSA in an integrated manner. Hence, development of maize with multinutritional attributes can be a sustainable and cost-effective strategy for addressing the problem of nutrient deficiencies in SSA. This review provides a synopsis of the health challenges associated with Zn, provitamin A and tryptophan deficiencies and link these to vulnerable societies; a synthesis of past and present intervention measures for addressing nutrient deficiencies in SSA; and a discussion on the possibility of developing maize with multinutritional quality attributes, but also with adaptation to stress conditions in SSA.

Exposure to aflatoxins and fumonisins and linear growth of children in rural Ethiopia: a longitudinal study

Objective:

We hypothesise that exposure to aflatoxins and fumonisins, measured in serum, alters protein synthesis, reducing serum protein and insulin-like growth factor 1 (IGF-1), increasing inflammation and infection, leading to child’s linear growth failure.

Design:

Children 6–35 months, stratified by baseline stunting, were subsampled from an intervention trial on quality protein maize consumption and evaluated at two time-points.

Setting:

Blood samples and anthropometric data were collected in the pre-harvest (August–September 2015) and post-harvest (February 2016) seasons in rural Ethiopia.

Participants:

102 children (50 stunted and 52 non-stunted).

Results:

Proportions of children exposed to aflatoxin G1, aflatoxin G2 and aflatoxin M1 were higher in the pre-harvest (8, 33 and 7, respectively) compared to post-harvest season (4, 28 and 4, respectively). The proportion of children exposed to any aflatoxin was higher in the pre-harvest than post-harvest season (51 % v. 41 %). Fumonisin exposure ranged from 0 % to 11 %. In joint statistical tests, aflatoxin exposure was associated with serum biomarkers of inflammation (C-reactive protein, α-1-glycoprotein) and protein status (transthyretin, lysine, tryptophan), IGF-1 and linear growth (all P < 0·01). However, exposure to specific aflatoxins was not significantly associated with any biomarkers or outcomes (all P > 0·05).

Conclusions:

Aflatoxin exposure among rural Ethiopian children was high, with large variation between seasons and individual aflatoxins. Fumonisin exposure was low. There was no clear association between aflatoxin exposure and protein status, inflammation or linear growth. A larger study may be needed to examine the potential biological interactions, and the assessment of aflatoxins in food is needed to determine sources of high exposure.

Biofortified Maize Can Improve Quality Protein Intakes among Young Children in Southern Ethiopia

Quality protein maize (QPM) varieties are biofortified, or nutritionally improved, to have higher lysine and tryptophan levels to increase quality protein intakes particularly among young children. This study assesses adequacy of children’s protein intakes in Ethiopia, where QPM is being promoted, accounting for protein quality and seasonal dietary changes, and estimates potential increases in intakes if QPM replaced conventional maize in diets. Diets of randomly sampled children aged 12–36 months in rural southern Ethiopia (n = 218) were assessed after harvest during relative food security and 3–4 months later during relative food insecurity using 24-h weighed food records. Diets were analyzed for protein adequacy, accounting for protein quality using the protein digestibility corrected amino acid score (PDCAAS) method, and potential improvements from QPM substitution were estimated. Stunting was prevalent (38%) at the first assessment. Across seasons, 95–96% of children consumed maize, which provided 59–61% of energy and 51–55% of total protein in 24 h. Dietary intakes decreased in the food insecure season, though children were older. Among children no longer breastfeeding, QPM was estimated to reduce inadequacy of utilizable protein intakes from 17% to 13% in the food secure season and from 34% to 19% in the food insecure season. However, breastfed children had only 4–6% inadequate intakes of utilizable protein, limiting QPM’s potential impact. Due to small farm sizes, maize stores from home production lasted a median of three months. Young Ethiopian children are at risk of inadequate quality protein intakes, particularly after breastfeeding has ceased and during food insecurity. QPM could reduce this risk; however, reliance on access through home production may result in only short-term benefits given the limited quantities of maize produced and stored.

Associations among High-Quality Protein and Energy Intake, Serum Transthyretin, Serum Amino Acids and Linear Growth of Children in Ethiopia

Limited evidence is available on the associations of high-quality protein and energy intake, serum transthyretin (TTR), serum amino acids and serum insulin-like growth factor-1 (IGF-1) with linear growth of young children. Data collected during the baseline of a randomized control trial involving rural Ethiopian children aged 6⁻35 months (n = 873) were analyzed to evaluate the associations among height/length-for-age z-scores, dietary intakes, and these biomarkers (i.e., serum level of TTR, IGF-1, tryptophan and lysine, and inflammation). The prevalence of stunting was higher for children >23 months (38%) than ≤23 months (25%). The prevalence of inflammation was 35% and of intestinal parasites 48%. Three-quarters of the children were energy deficient, and stunted children had lower daily energy intake that non-stunted children (p < 0.05). Intakes of tryptophan, protein, and energy, and serum levels of tryptophan and IGF-1 were positively correlated with the linear growth of children. Controlling for inflammation, intestinal parasites, and sociodemographic characteristics, daily tryptophan (b = 0.01, p = 0.001), protein (b = 0.01, p = 0.01) and energy (b = 0.0003, p = 0.04) intakes and serum TTR (b = 2.58, p = 0.04) and IGF-1 (b = 0.01, p = 0.003) were positively associated with linear growth of children. Linear growth failure in Ethiopian children is likely associated with low quality protein intake and inadequate energy intake. Nutrition programs that emphasize improved protein quantity and quality and energy intake may enhance the linear growth of young children and need to be further investigated in longitudinal and interventional studies.

Diversifying Food Systems in the Pursuit of Sustainable Food Production and Healthy Diets

Increasing demand for nutritious, safe, and healthy food because of a growing population, and the pledge to maintain biodiversity and other resources, pose a major challenge to agriculture that is already threatened by a changing climate. Diverse and healthy diets, largely based on plant-derived food, may reduce diet-related illnesses. Investments in plant sciences will be necessary to design diverse cropping systems balancing productivity, sustainability, and nutritional quality. Cultivar diversity and nutritional quality are crucial. We call for better cooperation between food and medical scientists, food sector industries, breeders, and farmers to develop diversified and nutritious cultivars that reduce soil degradation and dependence on external inputs, such as fertilizers and pesticides, and to increase adaptation to climate change and resistance to emerging pests.