The Effect of the Yingyangbao Complementary Food Supplement on the Nutritional Status of Infants and Children: A Systematic Review and Meta-Analysis

Intervention Effect of a Soybean-Based Complementary Food Supplement on Anemic Infants in a Poor Rural Region in China: Evidence from Quasi-RCT

The soybean-based Yingyang Bao complementary food supplement represents a special nutritional improvement method for anemic infants in many intervention projects across China, while its benefits lack rigorous evidence. Using a quasi-randomized controlled trial design, which adhered to randomization and control except for the blinding method, 248 anemic infants were divided randomly into an intervention group (128 cases received the Yingyang Bao intervention based on routine feeding) and a control group (120 cases only received routine feeding). Anthropometric indicators and 16 blood indicators were measured at baseline and 1 year after intervention. The levels of hemoglobin, 1,25-dihydroxy vitamin D, homocysteine, retinol, vitamin D3, and soluble transferrin receptor and the height-age-Z score and weight-age-Z score of the intervention group were significantly improved after the intervention (p < 0.05). The homocysteine level improvement appeared to be moderately negatively correlated with the cobalamin level improvement (p < 0.05). The improvements of five indicators were significant correlated with the intervention duration (p < 0.05), and the corresponding three significant regression equations could predict the intervention effect and the intervention duration to a certain extent. This quasi-randomized controlled trial provided more convincing evidence that Yingyang Bao can effectively improve three kinds of malnutrition compared to previous research which only adopted self before and after comparison.

Health inequalities of global protein-energy malnutrition from 1990 to 2019 and forecast prevalence for 2044: data from the Global Burden of Disease Study 2019

OBJECTIVES

Protein-energy malnutrition poses a serious medical problem worldwide. This study aims to describe the global burden, trends, and health inequalities of protein-energy malnutrition and forecasts for future prevalence.

STUDY DESIGN

This was a comprehensive analysis based on data provided by the Global Burden of Disease Study 2019.

METHODS

Data were obtained from the Global Health Data Exchange query tool, including prevalence, deaths, disability-adjusted life years (DALYs) and sociodemographic index (SDI). The estimated annual percentage changes were calculated to evaluate temporal trends. We quantified cross-country inequalities in protein-energy malnutrition burden and predicted the prevalence number and rate to 2044.

RESULTS

Globally, there were 147,672,757 (130,405,923 to 167,471,359) cases of protein-energy malnutrition in 2019, with 212,242 (185,403 to 246,217) deaths. Eastern Sub-Saharan Africa had the highest age-standardised death and DALY rates in 2019. From 1990 to 2019, the global age-standardised prevalence rate of protein-energy malnutrition showed an upward trend, while the age-standardised death rate showed a downward trend. A significant decline occurred in SDI-related health inequality, from 2126.1 DALYs per 100,000 persons between the poorest and richest countries in 1990 to 357.9 DALYs per 100,000 persons in 2019. There was a trend of decreasing age-standardised death and DALY rates along with increases in the SDI. Frontier analyses showed that there is much room for improving the current situation of protein-energy malnutrition in some countries. In the next 35 years, the prevalence of protein-energy malnutrition will continue to increase.

CONCLUSION

Although the disease burden of protein-energy malnutrition has greatly decreased since 1990 and health inequalities between countries are shrinking, the prevalence in Asian and African countries may continue to increase. Focussing on regional differences and strengthening the nutritional intake of people in underdeveloped areas are necessary to reduce future burdens.

Approaches to Address the Anemia Challenge

Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.

Yingyangbao Reduced Anemia among Infants and Young Children Aged 6-23 Months When Delivered through a Large-Scale Nutrition Improvement Program for Children in Poor Areas in China from 2015 to 2020

The purpose of this study was to assess the effectiveness of intervention with Yingyangbao (YYB) on hemoglobin (Hb) and anemia status among infants and young children (IYC) aged 6-23 months (mo) through a large-scale Nutrition Improvement Program for Children in Poor Areas (NIPCPA) in China from 2015 to 2020. Five rounds of cross-sectional surveys were conducted using a stratified and multi-stage probability proportional to size sampling of IYC in 2015, 2017, 2018, 2019 and 2020. Multivariable regression analyses were fitted to determine the effectiveness of the YYB intervention on Hb and anemia, respectively. A total of 36,325, 40,027, 43,831, 44,375 and 46,050 IYC aged 6-23 mo were included, and the prevalence of anemia was 29.7%, 26.9%, 24.1%, 21.2% and 18.1% in 2015, 2017, 2018, 2019 and 2020, respectively. Compared with the results in 2015, the Hb concentrations significantly improved and anemia prevalence significantly decreased among IYC in 2017, 2018, 2019, and 2020 (p < 0.001). Regression analysis showed that higher YYB consumption was significantly associated with the increment in Hb concentration and reduction in anemia stratified by age group (p < 0.001). The most significant increment in Hb concentration of 2.189 mg/L and the most significant reduction in odds of anemia were observed among IYC aged 12-17 mo who consumed 270 to 359 sachets of YYB (OR: 0.671; 95% CI: 0.627, 0.719; p < 0.001). This study suggests that YYB intervention is a successful public health strategy for reducing the risk of anemia among IYC when delivered through a large-scale NIPCPA in China. It is necessary to continue to advance the program and increase the adherence of YYB.

Effectiveness of Food-Based Intervention to Improve the Linear Growth of Children under Five: A Systematic Review and Meta-Analysis

Food-based interventions to improve linear growth are most often applied in low- and middle-income countries. However, not all food interventions have been proven to be effective in promoting linear growth. This study aimed to assess the impact and effectiveness of food interventions for improving linear growth in children under five years old. This study was conducted by following the PRISMA guidelines and the data were extracted and presented following the PRISMA recommendations. Studies were identified through a literature search of the SCOPUS, Web of Science, PubMed, ScienceDirect, and ProQuest databases from 2000 to 2022. Only randomized control studies were included in this review based on the inclusion and exclusion criteria. Out of 1125 studies identified, a total of 15 studies were included in this systematic review and meta-analysis. The review result indicated that food-based intervention can help to improve linear growth (MD: 0.20, 95% CI: 0.04 to 0.35, p = 0.01) among children under five. However, there was no significant difference in changes in underweight status (MD: 0.25; CI: -0.15 to 0.64; p = 0.22) and wasting status (MD: 0.09; CI: -0.02 to 0.20; p = 0.12) between the intervention and control groups. Overall, food-based interventions were found to be helpful for improving children's linear growth.

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

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.

Associations between life-course household wealth mobility and adolescent physical growth, cognitive development and emotional and behavioral problems: A birth cohort in rural western China

Background

Parental household wealth has been shown to be associated with offspring health conditions, while inconsistent associations were reported among generally healthy population especially in low- and middle- income countries (LMICs). Whether the household wealth upward mobility in LMICs would confer benefits to child health remains unknown.

Methods

We conducted a prospective birth cohort of children born to mothers who participated in a randomized trial of antenatal micronutrient supplementation in rural western China. Household wealth were repeatedly assessed at pregnancy, mid-childhood and early adolescence using principal component analysis for household assets and dwelling characteristics. We used conditional gains and group-based trajectory modeling to assess the quantitative changes between two single-time points and relative mobility of household wealth over life-course, respectively. We performed generalized linear regressions to examine the associations of household wealth mobility indicators with adolescent height- (HAZ) and body mass index-for-age and sex z score (BAZ), scores of full-scale intelligent quotient (FSIQ) and emotional and behavioral problems.

Results

A total of 1,188 adolescents were followed, among them 59.9% were male with a mean (SD) age of 11.7 (0.9) years old. Per SD conditional increase of household wealth z score from pregnancy to mid-childhood was associated with 0.11 (95% CI 0.04, 0.17) SD higher HAZ and 1.41 (95% CI 0.68, 2.13) points higher FSIQ at early adolescence. Adolescents from the household wealth Upward trajectory had a 0.25 (95% CI 0.03, 0.47) SD higher HAZ and 4.98 (95% CI 2.59, 7.38) points higher FSIQ than those in the Consistently low subgroup.

Conclusion

Household wealth upward mobility particularly during early life has benefits on adolescent HAZ and cognitive development, which argues for government policies to implement social welfare programs to mitigate or reduce the consequences of early-life deprivations. Given the importance of household wealth in child health, it is recommended that socioeconomic circumstances should be routinely documented in the healthcare record in LMICs.

Effects of the Duration of Ying Yang Bao Consumption on Hemoglobin Concentration in Infants and Young Children in Less Developed Areas of China

Ying Yang Bao (YYB) is conventionally prescribed as a nutritional supplement to infants and young children (IYC) in less developed areas of China. However, whether 18-month YYB consumption is reasonable needs assessment. This study examined the influence of the duration of YYB consumption on hemoglobin (Hb) levels and anemia prevalence. Data from the Nutrition Improvement Project on Children in Poor Areas of China in 2018-2019 were used. Questionnaires were used to collect information on basic characteristics, dietary status, and YYB consumption. Propensity score matching (PSM) was used to balance confounders. Hb levels and anemia prevalence in IYC with different durations of YYB consumption were compared. After PSM, all covariates were well-balanced, and 1151 pairs of IYC were included in subsequent analyses. During the 1st-9th months of intervention, YYB effectively increased Hb levels and reduced anemia prevalence in the intervention group. During the 10th-18th months of intervention, Hb levels in the control group increased and anemia prevalence decreased, while Hb levels and anemia prevalence fluctuated in the intervention group. In conclusion, YYB was effective in improving nutritional status of infants, but had a limited effect in young children. Nutritional supplements with different quantities or nutrients should be considered for young children.

Complementary Feeding and Malnutrition among Infants and Young Children Aged 6-23 Months in Rural Areas of China

This study investigated the nutrition and complementary feeding (CF) of infants and young children (IYC) aged 6–23 months in rural areas of China in 2018 and explored the relationship between CF and nutritional status. We measured the length and weight, calculated the z-scores, and detected micronutrients in the hair. The status of CF was obtained from the respondents by a 24-h dietary recall. IYC were classified into clusters using a two-step cluster analysis. The CF and nutritional status of each cluster were analyzed and compared. The prevalence of stunting, wasting, and overweight in the IYC in rural Chinese areas was 7.1%, 3.0%, and 3.7%, respectively. The median levels of Ca, Fe, and Zn in hair were 550.10 µg/g, 62.94 µg/g, and 132.86 µg/g, respectively. The prevalence of meeting the requirements of minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) was 68.9%, 77.9%, and 46.4%, respectively. IYC with a higher prevalence of MDD, MMF, and MAD were more inclined to maintain a healthy status. The prevalence of undernutrition and overweight of 6- to 23-month-old IYC in rural areas of China was low. However, lack of trace elements was evident, and MAD prevalence remained low.

Household Water Access, Dietary Diversity and Nutritional Status among Preschoolers in Poor, Rural Areas of Central and Western China

Poor child feeding and childhood malnutrition are major public health problems in rural central and western China, with little evidence about their environmental determinants. This study aimed to investigate whether household water access is associated with dietary diversity and nutritional outcomes. We analyzed the cross-sectional data of 3727 children aged 6 to 59 months in rural central and western China, applying multivariate linear and logistic models to estimate the effect of water access on children’s anthropometric indices, hemoglobin, and dietary diversity. We found that unimproved water access was linked to a lower likelihood of achieving dietary diversity (OR = 0.65, 95% CI 0.44 to 0.98, p = 0.039); lower height-for-age z-score (β = −0.34, 95% CI −0.49 to −0.19, p < 0.001) and hemoglobin concentration (β = −2.78, 95% CI −5.16 to −0.41, p = 0.022); higher odds of stunting (OR = 1.50, 95% CI 1.01 to 2.25, p = 0.047) and anemia (OR = 1.34, 95% CI 1.02 to 1.77, p = 0.037). The associations between water access and nutritional outcomes were not explained by dietary diversity and were stronger in children who did not receive iron supplementation. These findings provide evidence for designing water-based nutritional interventions in China.

High adherence and its influencing factors on multiple micronutrient powders (MNPs)

Adherence to home fortification of foods with multiple micronutrient powders (MNPs) is an essential indicator of effective implementation of MNP programmes. A meta‐analysis was conducted to evaluate the high adherence rate (HAR) to MNPs and further investigate the factors that influence HAR. We searched PubMed, Web of Science, Embase, CAB Abstracts, MEDLINE (OVID), Cochrane Library, China National Knowledge Infrastructure, Wanfang and VP, from the date of database inception to 9 November 2020. We included peer‐reviewed observational studies that investigated adherence to MNPs. Data on the HAR to MNPs and influencing factors on HAR were extracted and then pooled together. A total of 10 studies were included. The pooled HAR to MNPs was 63.28% (51.12%–74.64%). Among HARs, rates were higher in middle‐income countries (65.21%) than low‐income countries (55.23%). Parental age over 30 years (maternal age OR = 1.25, 95% CI: 1.08–1.44; paternal age OR = 1.17, 95% CI: 1.04–1.32), children aged 18–36 months (OR = 1.45, 95% CI: 1.12–1.88), maternal educational attainment of college or above (OR = 1.38, 95% CI:1.10–1.73), caregiver with the perception that other mothers use MNPs (OR = 1.52, 95% CI:1.19–1.95), caregiver being aware of the importance of iron (OR = 1.42, 95% CI: 1.18–1.71), caregiver having correct knowledge of MNPs (OR = 1.36, 95% CI:1.19–1.57) and caregiver reporting children have no side effects from MNPs (OR = 2.77, 95% CI: 2.46–3.11) were contributing factors to high adherence to MNPs. The overall HAR to MNPs was relatively low; hence, effective and trusted communication channels need to be established, along with more thorough dissemination of the knowledge of MNPs to caregivers, to improve MNPs adherence rates, especially in low‐income countries.

Effect of a community-based child health counselling intervention on health-seeking behaviours, complementary feeding and nutritional condition among children aged 6-23 months in rural China: A pre- and post-comparison study

In China, the prevalence of undernutrition among children under 5 years of age has declined significantly during recent decades. However, noticeable gaps exist between rural and urban areas. Since 2012, a government-funded nutrition programme, Ying Yang Bao (YYB; soybean powder-based iron-rich supplement) programme, has been implemented in poor rural areas to decrease the risk of developing anaemia among children aged 6-23 months, but there are still inadequate health care awareness, feeding knowledge and skills among caregivers. From June 2018 to December 2020, a child health counselling intervention was delivered through a home visit based on the YYB programme in Liangshan. Child health messages were given by trained village child health assistants while distributing YYB. Surveys were conducted before and after the intervention to analyse changes in child health check-up frequency, complementary feeding practice and prevalence of undernutrition. After the intervention, the proportion of children who had regular health check-ups, who were vaccinated and who met the minimum YYB consumption significantly increased from 26.0%, 81.6%, and 67.8% to 59.7%, 95.0%, and 79.2%. Increased rates of IYCF indicators (introduction of solid, semisolid, or soft foods, minimum dietary diversity and consumption of iron-rich or iron-fortified foods) were observed after the intervention. The prevalence of stunting, underweight, wasting, and anaemia significantly decreased from 26.3% to 10.8%, 13.4% to 8.7%, 14.0% to 10.5%, and 52.1% to 43.9%. This intervention can be well integrated into the YYB programme with less additional resources. Children in resource-limited areas will benefit more from a comprehensive nutritional package, including food supplements and child health education.

Assessing the Inequality of Early Child Development in China - A Population-Based Study

Background

As a country with the second largest child population in the world, China has little population-level evidence on who has been left behind in early childhood development (ECD). Knowledge of inequalities in ECD will inform the Chinese government in policies on promoting ECD and guide global-level monitoring on ECD progress.

Methods

Using data from the first wave of ECD surveys conducted in China at the least-developed region, most-developed region, and a megacity (Shanghai) in 2017 and 2018, we measured population-level ECD with early Human Capability Index for a total of 63,559 children aged 36-59 months old. A child was classified as developmentally on track if his/her overall development score was above the 20^th percentile of the pooled populations. We measured inequalities in ECD with the absolute inequality in five domains: gender/sex, family income, maternal schooling, residential Hukou, and migrant- or left-behind status. Besides observed inequalities, we used a multilevel logistic regression model to generate adjusted inequalities.

Findings

Children developmentally on track ranges from 71% (95% CI 70 to 72%) in the least-developed region, 82% (95% CI 81 to 83%) in the most-developed region, and 86% (95% CI 85 to 87%) in Shanghai. Significant unadjusted inequalities in ECD were observed in all five dimensions. After controlling for other socioeconomic factors, significant differences remained in three dimensions: those living in the poorest families, or with lower maternal schooling, or boys were less likely to be developmentally on track than their counterparts (lower by 10[95% CI 8 to 11]-15[95% CI 13 to 17], 7[95% CI 5 to 10]-10[95% CI 7 to 12], and 5[95% CI 4 to 6]-6[95% CI 5 to 8] percentage points respectively).

Interpretation

Efforts of reducing ECD inequalities in China shall focus primarily on reducing poverty and improving maternal education.

Funding

National Natural Science Foundation of China (81773443), Shanghai Committee of Science and Technology (2018SHZDZX05), Shanghai Municipal Health Commission (GWV-10.1-XK07; GDEK201708), Shanghai Education Committee, Chinese Social Science Foundation (BFA140046), Macao Tong Chai Charity Association, Beijing Sany Charitable Foundation, China Medical Board (#20-388), UNICEF, Faculty Grant of Brigham & Women's Hospital, Economic and Social Research Council [grant reference number ES/T003936/1’] as a UKRI Collective Fund Award “UKRI GCRF Harnessing the Power of Global Data to Support Young Children's Learning and Development Collaborative."

Prevalence and Temporal Trend (2016-2018) of Anaemia among 6-23-Month-Old Infants and Young Children in China

Anaemia is a public health problem that can lead to various harmful effects on physical and neurodevelopment in infants and young children (IYC). This study aimed to investigate trends of anaemia and haemoglobin concentration among 6- to 23-month-old Chinese IYC from 2016 to 2018. We used data from the China Nutrition Improvement Project on Children in Poor Areas (CNIPCPA), conducted in 142 national-level poor counties of 20 provinces, autonomous regions, and municipalities from 2016 to 2018. Our study included 103,621 6- to 23-month-old IYC selected by a stratified multistage cluster sampling design. There were 26,303, 33,443, and 43,875 IYC in the survey in 2016, 2017, and 2018, respectively. The overall prevalence of anaemia was 27.0% in the three years. The prevalence of anaemia was 28.0%, 27.2%, and 26.2%, and the mean haemoglobin (Hb) was 11.82, 11.81, and 11.88 g/dL in 2016, 2017, and 2018, respectively. The prevalence of anaemia was highest in 6- to 11-month-olds, and declined with age. There was a gap in the education level between parents. However, the percentage of education improved in the rural areas of China. The prevalence of anaemia decreased significantly in the three years, which shows that prevention and control actions achieved the initial results.

Equity and Distributional Impact on Stunting of a Nutritional Package Targeting Children Aged 6–36 Months in China: Findings from a Modeling Study

Background: Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. Objective: We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. Methods: We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6–36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. Results: We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6–36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4–6.2 billion ($1.5–1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. Conclusions: YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.