Ready-to-use supplementary food increases fat mass and BMI in Haitian school-aged children

Investigating the Effects of Dietary Supplementation and High-Intensity Motor Learning on Nutritional Status, Body Composition, and Muscle Strength in Children with Moderate Thinness in Southwest Ethiopia: A Cluster-Randomized Controlled Trial

BACKGROUND

In Ethiopia, moderate thinness (MT) is a persistent issue among children. Yet, evidence on the effects of dietary supplementation and motor skills training in these children is limited.

OBJECTIVE

This study aimed to assess the effect of Ready-to-Use Supplementary Food (RUSF), whether or not combined with high-intensity motor learning (HiML), on weight, height, body composition, and muscle strength in children 5-7 years old with MT living in Jimma Town, Ethiopia.

METHODS

A cluster-randomized controlled trial was carried out among 69 children (aged 5-7) with MT assigned to receive RUSF (n = 23), RUSF + HiML (n = 25), or no intervention (control group, n = 21). A multivariable Generalized Estimating Equations model was used and the level of significance was set at alpha < 0.05.

RESULTS

At baseline, there were no significant differences in the outcome measurements between the RUSF, RUSF + HiML, and control groups. However, after 12 weeks of intervention, there were significant mean differences in differences (DIDs) between the RUSF group and the control arm, with DIDs of 1.50 kg for weight (p < 0.001), 20.63 newton (N) for elbow flexor (p < 0.001), 11.00 N for quadriceps (p = 0.023), 18.95 N for gastrocnemius sup flexor of the leg (p < 0.001), and 1.03 kg for fat-free mass (p = 0.022). Similarly, the mean difference in differences was higher in the RUSF + HiML group by 1.62 kg for weight (p < 0.001), 2.80 kg for grip strength (p < 0.001), 15.93 for elbow flexor (p < 0.001), 16.73 for quadriceps (p < 0.001), 9.75 for gastrocnemius sup flexor of the leg (p = 0.005), and 2.20 kg for fat-free mass (p < 0.001) compared the control arm.

CONCLUSION

RUSF alone was effective, but combining it with HiML had a synergistic effect. Compared to the control group, the RUSF and RUSF + HiML interventions improved the body composition, height, weight, and muscle strength of the studied moderately thin children. The findings of this study suggest the potential that treating moderately thin children with RUSF and combining it with HiML has for reducing the negative effects of malnutrition in Ethiopia. Future research should explore these interventions in a larger community-based study. This trial has been registered at the Pan African Clinical Trials Registry (PACTR) under trial number PACTR202305718679999.

Prevalence of diarrheagenic Escherichia coli and impact on child health in Cap-Haitien, Haiti

BACKGROUND

Diarrheagenic Escherichia coli (DEC) are common pathogens infecting children during their growth and development. Determining the epidemiology and the impact of DEC on child anthropometric measures informs prioritization of prevention efforts. These relationships were evaluated in a novel setting, Cap-Haitien, Haiti.

METHODS

We performed pre-specified secondary analysis of a case-control study of community-dwelling children, 6-36 months of age, enrolled 96 cases with diarrhea and 99 asymptomatic controls. Assessments were performed at enrollment and one month later at follow-up. Established endpoint PCR methodologies targeted DEC gDNA isolated from fecal swabs. The association between DEC and anthropometric z-scores at enrollment was determined using multivariate linear regression. Lastly, we assessed the association between specific biomarkers, choline and docosahexaenoic acid (DHA) and diarrheal burden.

RESULTS

Enterotoxigenic Escherichia coli (ETEC) was identified in 21.9% of cases vs. 16.1% of controls with heat-stable producing ETEC significantly associated with symptomatic disease. Enteroaggregative E. coli (EAEC) was found in 30.2% of cases vs. 27.3% of controls, and typical enteropathogenic E. coli in 6.3% vs. 4.0% of cases and controls, respectively. Multivariate linear regression, controlled for case or control status, demonstrated ETEC and EAEC were significantly associated with reduced weight-age z-score (WAZ) and height-age z-score (HAZ) after adjusting for confounders. An interaction between ETEC and EAEC was observed. Choline and DHA were not associated with diarrheal burden.

CONCLUSIONS

DEC are prevalent in north Haitian children. ETEC, EAEC, household environment, and diet are associated with unfavorable anthropometric measures, with possible synergistic interactions between ETEC and EAEC. Further studies with longer follow up may quantify the contribution of individual pathogens to adverse health outcomes.

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to ‘over’ nutrition versus ‘under’ nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Differences in factors associated with anemia in Haitian children from urban and rural areas

BACKGROUND

In Haiti, differences in the prevalence of anemia between urban and rural areas have been observed.

OBJECTIVE

To identify moderating factors that may help explain the difference in the prevalence of anemia in children from poor urban vs. rural areas of Haiti.

METHODS

This cross-sectional study used secondary data from urban and rural school-based trials that assessed the effectiveness of a nutrition intervention. The study was registered at ClinicalTrials.gov as NCT02747524. A total of 300 rural- and 981 urban- children between 2.5-13 years of age were included in this analysis. Effect modification in a binary logistic generalized linear mixed model was conducted using sample weights in SPSS® version 26. Models were adjusted for age and income. School cluster was included as random effect.

RESULTS

In rural areas, stunting was more prevalent in children with anemia vs. no anemia, (16.6%, and 6.3%, P = 0.008), respectively. Also, rural children with anemia lived with fewer adults vs. rural children with no anemia, ([Formula: see text] = 2.83±1.29, and 3.30±1.54, P = 0.005), respectively. In poor urban areas, helminth morbidities were more frequent in children with anemia vs. no anemia, (21.9% vs. 13.9, P = 0.011), respectively. In the combined sample, stunting, [AOR = 2.05; 95%CI (1.32-3.18)], age [AOR = 0.89; 95%CI (0.85-0.93)], and households with more adults [AOR = 0.77; 95%CI (0.67-0.87)] were associated with anemia. Effect modification by place of residence was observed in households with more adults (t = 3.83, P<0.001). No other nutritional, dietary, sanitation or morbidity factors or effect modifiers were observed.

CONCLUSIONS

In this sample, factors associated with anemia differed in poor urban and rural children from Haiti including family structure and helminth morbidities. Stunting and lower age increased the odds of anemia in the combined sample. Family structure appears to have an important role in anemia, and further research understanding the influence of family structures in anemia is needed.

The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews

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.

Water metal contaminants in a potentially mineral-deficient population of Haiti

This study aimed to characterize metal contaminant concentrations and assess temporal and spatial variability in the main drinking water sources of Cap-Haïtien, Haiti. Water sources from five communities were sampled in two seasons, June (2014) and October (2014), and analysed for a suite of metals. A geographic information system was used to examine the spatial distribution of sampling points. Metal concentrations were below the US Environmental Protection Agency (USEPA) primary drinking water standards. Mean manganese concentrations were comparatively higher in wells (254.5 µg/L), exceeding the USEPA secondary drinking water standard (50 µg/L). Higher mean Mg/Ca and Ba/Ca ratios (range 2.3-3.4) may indicate different interactions between seawater and groundwater throughout the year. Although metal concentrations were within the limits of the USEPA drinking water standards, emerging contaminants, such as manganese, showed concentrations in excess of recommended limits. These metals may interact with background nutritional status with potential implications for growth and development.

Maternal Diet and Morbidity Factors Associated with Low Birth Weight in Haiti: A Case-Control Study

Objective: A matched, case–control study was conducted to examine the association between development of low birth weight (LBW) and maternal factors, including dietary intake, comorbidities, and socioeconomic factors, among women in Cap Haitien, Haiti.

Design: Mothers who delivered LBW babies; defined as ≤2.5 kg, were identified by review of the medical record and matched to mothers of similar age, parity, with normal birth weight (NBW) babies. A survey was administered consisting of Women's Dietary Diversity Score (WDDS), maternal reporting of comorbidities, income, and educational level.

Subjects: Women were eligible if they delivered and had newborns weighed within the last 2 years. Total study participants consisted of 32 cases and 34 controls matched for age, parity, and month of delivery.

Results: Mothers who consume eggs were 78% less likely to have given birth to a LBW infant (OR 0.22 (95% CI: 0.05–0.87). Mothers with NBW babies had a nonsignificant trend towards higher WDDS. The prevalence of hypertension in mothers who were seen in the clinic at least once over the past 2 years was found to be 27%, and 78% of mothers were not aware of their diagnosis.

Conclusion: Enhancing maternal nutrition during pregnancy has broad implications for reducing LBW, improving fetal health and reducing fetal predilection for chronic diseases in adulthood. Longitudinal prospective studies are needed to evaluate the selective benefit of eggs and other high-quality foods in protecting fetal growth. Efforts to improve knowledge and awareness of hypertension in Haiti should be undertaken.

Health Outcomes for Children in Haiti Since the 2010 Earthquake: A Systematic Review

BACKGROUND

Haiti remains the poorest country in the Americas and one of the poorest in the world. Children in Haiti face many health concerns, some of which were exacerbated by the 2010 earthquake. This systematic review summarizes published research conducted since the 2010 earthquake, focusing on health outcomes for children in Haiti, including physical, psychological, and socioeconomic well-being.

METHODS

A literature search was conducted identifying articles published from January 2010 through May 2016 related to pediatric health outcomes in Haiti. Two reviewers screened articles independently. Included research articles described at least one physical health, psychological health, or socioeconomic outcome among children less than 18 years of age in Haiti since the January 2010 earthquake.

RESULTS

Fifty-eight full-length research articles were reviewed, covering infectious diseases (non-cholera [N=12] and cholera [N=7]), nutrition (N=11), traumatic injuries (N=11), mental health (N=9), anemia (N=4), abuse and violence (N=5), and other topics (N=3). Many children were injured in the 2010 earthquake, and care of their injuries is described in the literature. Infectious diseases were a significant cause of morbidity and mortality among children following the earthquake, with cholera being one of the most important etiologies. The literature also revealed that large numbers of children in Haiti have significant symptoms of posttraumatic stress disorder (PTSD), peri-traumatic stress, depression, and anxiety, and that food insecurity and malnutrition continue to be important issues.

CONCLUSIONS

Future health programs in Haiti should focus on provision of clean water, sanitation, and other measures to prevent infectious diseases. Mental health programming and services for children also appear to be greatly needed, and food insecurity/malnutrition must be addressed if children are to lead healthy, productive lives. Given the burden of injury after the 2010 earthquake, further research on long-term disabilities among children in Haiti is needed. Dube A , Moffatt M , Davison C , Bartels S . Health outcomes for children in Haiti since the 2010 earthquake: a systematic review. Prehosp Disaster Med. 2018;33(1):77-88.

Fortified Snack Reduced Anemia in Rural School-Aged Children of Haiti: A Cluster-Randomized, Controlled Trial

BACKGROUND

Nutrition in the school-aged child matters for brain development and public policy investments globally. Our group previously conducted a trial in urban schools of Haiti to examine the effects of a fortified peanut butter snack, Vita Mamba, with limited findings for anemia.

OBJECTIVE

We aimed to test the hypothesis that Vita Mamba, with systematic deworming in both study arms, would significantly reduce anemia among rural, school-aged children.

METHODS

A cluster, randomized longitudinal study was conducted in two rural communities of the North-East Department of Haiti, 2014-2015. Healthy children ages 3-16 years were enrolled (n = 321) and assigned by school to intervention (Vita Mamba and deworming) and control (deworming). Vita Mamba contains 260 kcal and meets >75% of the Recommended Dietary Allowance for critical micronutrients. Multivariate regression analyses including propensity score matching techniques to correct for potential group imbalance (Kernel-based Matching and Propensity Score Weighting) were applied to examine difference-in-difference intervention effects.

RESULTS

At baseline, 51% of the children were anemic with no significant differences between study groups. Vita Mamba supplementation showed a consistent, positive effect across regression models on increasing Hb concentration and reducing the odds of anemia compared to the control group after adjusting for child age, vitamin A supplementation, milk consumption, and height-for-age z score. The average treatment effect for the treated in the Propensity Score Weighting models was 0.62±0.27 grams per 100 milliliters (g/dL) for Hb concentration (F = 4.64, P = 0.001), and the odds of anemia were reduced by 88% (Wald χ² = 9.77, P = 0.02). No differences in change in anthropometric markers were evident.

CONCLUSIONS

School feeding programs that integrate fortified foods with deworming could reduce anemia burden with important implications for learning, health, and well-being. The rural-urban differences in anemia require further study.

Early nutrition transition in Haiti: linking food purchasing and availability to overweight status in school-aged children

Objective

The primary aim was to examine the association of socio-economic factors and diet with overweight (including obesity) among school-aged children in Haiti. The secondary aim was to describe food availability and the physical activity built environment in participating schools.

Design

This cross-sectional study examined baseline data from the intervention Mamba study assessing the effectiveness of a fortified peanut butter paste in school-aged children. Logistic regression modelling was used to test hypothesized factors in association with overweight status.

Setting

Six primary schools in Cap-Haitien, the second largest city in Haiti.

Subjects

Children (n 968) aged 3–13 years, in good health and enrolled in a participating school for the 2012/13 school year.

Results

Child age (adjusted OR (AOR); 95 % CI=0·25; 0·12, 0·56), child age squared (1·08; 1·03, 1·13), always purchasing food at school (3·52; 1·12, 11·08), mother’s BMI (1·10; 1·04, 1·16) and household ownership of a bicycle (0·28; 0·11, 0·71) were significantly associated with overweight (likelihood ratio=36, P<0·0001). Consumption of fish was significantly lower in overweight children in the binary analysis (P=0·033) and improved the fit of the model. Schools had limited time and space for physical activity and foods sold by vendors were predominantly high in sugar or fat.

Conclusions

To our knowledge the present study is the first to examine the covariates of childhood overweight or describe school food availability and physical activity built environments in Haiti. Further research is necessary to identify intervention targets and feasible, cost-effective approaches for prevention of obesity in Haiti children.

Delivering Improved Nutrition: Dairy Ingredients in Food Aid Products

The United States has a long history of food assistance for humanitarian need. The Food for Peace Act of 1954 established the United States' permanent food assistance program which has fed over 3 billion people in 150 countries worldwide through thousands of partner organizations. In 60 years, the program has evolved and will continue to do so. Recently, the program has gone from a focus on quantity of food shipped to quality food assistance from improved products, programs, and processes to effectively meet the needs of different vulnerable groups. The current debate focuses on the appropriateness of using fortified blended foods to prevent and treat malnutrition during the first 1000 days of life. Dairy ingredients have been at the center of this debate; they were included initially in fortified blended, removed in the 1980s, and now reincorporated into fortified therapeutic and supplemental foods. Improved quality food baskets and effective nutrition programming to prevent and treat malnutrition were developed through multisectoral collaboration between government and nongovernment organizations. The US Agency for International Development has focused on improving nutrition through development programs often tied to health, education, and agriculture. The years since 2008 have been a particularly intense period for improvement. The Food Aid Quality Review was established to update current food aid programming products, program implementation, cost-effectiveness, and interagency processes. Trials are underway to harmonize the areas of multisectoral nutrition programming and gather more evidence on the effects of dairy ingredients in food aid products.

Determinants of Anemia and Hemoglobin Concentration in Haitian School-Aged Children

Anemia diminishes oxygen transport in the body, resulting in potentially irreversible growth and developmental consequences for children. Limited evidence for determinants of anemia exists for school-aged children. We conducted a cluster randomized controlled trial in Haiti from 2012 to 2013 to test the efficacy of a fortified school snack. Children (N = 1,047) aged 3-13 years were followed longitudinally at three time points for hemoglobin (Hb) concentrations, anthropometry, and bioelectrical impedance measures. Dietary intakes, infectious disease morbidities, and socioeconomic and demographic factors were collected at baseline and endline. Longitudinal regression modeling with generalized least squares and logit models with random effects identified anemia risk factors beyond the intervention effect. At baseline, 70.6% of children were anemic and 2.6% were severely anemic. Stunting increased the odds of developing anemia (adjusted odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.05-2.08) and severe anemia (adjusted OR: 2.47, 95% CI: 1.30-4.71). Parent-reported vitamin A supplementation and deworming were positively associated with Hb concentrations, whereas fever and poultry ownership showed a negative relationship with Hb concentration and increased odds of severe anemia, respectively. Further research should explore the full spectrum of anemia etiologies in school children, including genetic causes.