Consumption of Iron-Fortified Lentils Is Protective against Declining Iron Status among Adolescent Girls in Bangladesh: Evidence from a Community-Based Double-Blind, Cluster-Randomized Controlled Trial

BACKGROUND

In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical.

OBJECTIVES

This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status.

METHODS

A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation.

RESULTS

Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 μg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 μg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 μg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 μg/L) compared with the usual intake group.

CONCLUSIONS

Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health.

TRIAL REGISTRATION NUMBER

This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734.

The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh

BACKGROUND

Iron deficiency is highly prevalent in South Asia, especially among women and children in Bangladesh. Declines in cognitive performance are among the many functional consequences of iron deficiency.

OBJECTIVE

We tested the hypothesis that, over the course of a 4-month iron fortification trial, cognitive performance would improve, and that improvement would be related to improvements in iron status.

METHODS

Participants included 359 adolescent girls attending Bangladesh Rural Advancement Committee (BRAC) clubs as a subsample of a larger double-blind, cluster-randomized community trial in which participants were assigned to one of three conditions: a condition in which no lentils were supplied (NL, n = 118, but which had the usual intake of lentils), a control (non-fortified) lentil condition (CL, n = 124), and an iron-fortified lentil condition (FL, n = 117). In the FL and CL conditions, approximately 200 g of cooked lentils were served five days per week for a total of 85 feeding days. In addition to biomarkers of iron status, five cognitive tasks were measured at baseline (BL) and endline (EL): simple reaction time task (SRT), go/no-go task (GNG), attentional network task (ANT), the Sternberg memory search Task (SMS), and a cued recognition task (CRT).

RESULTS

Cognitive performance at EL was significantly better for those in the FL relative to the CL and NL conditions, with this being true for at least one variable in each task, except for the GNG. In addition, there were consistent improvements in cognitive performance for those participants whose iron status improved. Although there were overall declines in iron status from BL to EL, the declines were smallest for those in the FL condition, and iron status was significantly better for those in FL condition at EL, relative to those in the CL and NL conditions.

CONCLUSIONS

the provision of iron-fortified lentils provided a protective effect on iron status in the context of declines in iron status and supported higher levels of cognitive performance for adolescent girls at-risk of developing iron deficiency.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review

Background

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s.

Objectives

We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes.

Search Methods

We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search.

Selection Criteria

We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs.

Data Collection and Analysis

Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately.

Main Results

Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment).

Authors’ Conclusions

Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Micronutrient Status and Select Characteristics of Adolescents: Results From a School Nutrition Program in Bangladesh

Objectives

To describe select characteristics of adolescent girls and boys and micronutrient status of adolescent girls at baseline prior to starting a school nutrition intervention.

Methods

Girls (n = 2244) and boys (n = 773) in grades 8–9 attending 74 schools participated in a baseline survey including questions on individual and household characteristics, nutrition knowledge and experience and dietary diversity. Venous blood was collected from girls for micronutrient status assessment. Iron status was assessed using inflammation-adjusted serum ferritin. Vitamin A status was based on retinol binding protein. Folate status was defined using serum and red blood cell folate (RBCF). In-school observations of WASH infrastructure resources and drinking water quality testing were conducted. All estimates accounted for clustering.

Results

Girls and boys, respectively, had ever heard of anemia 34% and 27%, iron-folic acid (IFA) tablets 31% and 14%, deworming tablets 84% and 85% and worm infestation 49% and 52%. Reported IFA use in the last month and deworming tablet intake in the last 6 months were 4% and 1% and 81% and 86%, among girls and boys, respectively. Mean dietary diversity score suggested adequacy among girls (5.2) and boys (5.3) with 63%–68% having scores > 5, and 36%–39% consuming rich sources of heme iron. Adolescents perceived the existence of iron in household tubewell (21%–24%), with 5–9% describing the taste, smell, or color of rust in drinking water. The prevalence of micronutrient deficiencies and severity varied: anemia 24.7%, iron deficiency 9.1%, iron deficiency anemia 3.9%, vitamin A deficiency 3.3%, RBCF insufficiency 76.1%, risk of RBCF deficiency 8.9%, RBCF deficiency 2.5%, and serum folate deficiency 9.5%. In schools, 70% met the sustainable development goals (SDG) indicator for basic drinking water service, 59% of all sampled drinking water sources complied with WHO standards for E. coli, 42% met the SDG indicator for basic sanitation service, and 3% met the SDG indicator for basic hygiene service.

Conclusions

The baseline results show variable awareness and coverage of interventions, adequate dietary diversity, micronutrient deficiencies among girls, and room for improvement to achieve SDG basic WASH services and reduce E coli. contamination of drinking water sources in schools.

Funding Sources

Nutrition International, Ottawa, Canada.

Girl-Powered Nutrition Program: Key Themes from a Formative Evaluation of a Nutrition Program Co-designed and Implemented by Adolescent Girls in Low- and Middle-Income Countries

BACKGROUND

To improve nutritional knowledge and attitudes of girls and young women, Nutrition International (NI) partnered with the World Association of Girl Guides and Girl Scouts (WAGGGS) to pilot the Girl-Powered Nutrition (GPN) program from 2018 to 2020 in 4 countries (Madagascar, the Philippines, Sri Lanka, and Tanzania).

OBJECTIVE

The aim was to share adolescent girls' and programmers' experiences with co-designing and implementing the GPN program in low- and middle-income countries (LMICs).

METHODS

A formative evaluation of the GPN program was commissioned by NI and undertaken by Universalia Management Group (Universalia). The evaluation was largely qualitative (employing focus groups, interviews, and document analysis). Based on the results of the formative evaluation, themes related to working with adolescent girls were identified.

RESULTS

The involvement of adolescents in the design, implementation, and evaluation of nutrition programming that targets them is essential for meaningful uptake. Sufficient time and respect must be given to the co-design process, including clearly defining adolescents' roles, ensuring transparency and clear communication, and managing adolescents' expectations. Ensuring adequate exposure and suitable timing for adolescent nutrition programming from adequately trained staff were identified as good practices from the evaluation. Program curriculum and activities must be appropriately tailored to adolescent age and stage, target adolescents and their gatekeepers and duty-bearers, and address the underlying issues of poverty, gender inequality, and structural norms that negatively impact adolescents' agency and nutrition.

CONCLUSIONS

This research supports and elaborates on several documented and accepted good practices for working with adolescents to improve nutrition knowledge and attitudes. Similar programs with key features such as co-design, suitable timing, curriculum, and exposure of programs by age group, addressing underlying structural issues, the involvement of gatekeepers and duty-bearers, and confidence-building can increase adolescent girls' nutrition knowledge and attitudes.

The Efficacy of Consuming Iron-Fortified Lentils on Body Iron (Fe) Status in Bangladeshi Adolescent Girls: A Sustainable, Food-Based Solution to Iron Deficiency

Objectives

Iron deficiency (ID) and iron deficiency anaemia (IDA) remain a public health concern among women and girls globally, and have numerous impacts on health, nutrition and socioeconomic status. Our objective was to investigate the efficacy of consuming iron-fortified lentils on iron status among rural Bangladeshi adolescent girls.

Methods

In this community-based, double-blind, cluster-randomized controlled trial, girls (13.5 ± 2.0 years) were randomly assigned to three groups that received 1)cooked iron-fortified lentils (160 ppm Fe NaFeEDTA per kg of lentils); 2)cooked non-iron-fortified lentils; or 3)no lentils (usual intake group). We served 200 g of cooked lentils using a local daal recipe on five days/week, for 4 months. Iron status (sFer, sTfR, and Hgb) was assessed at baseline, 2 and 4 months. All analyses were adjusted for inflammation.

Results

There were no differences in baseline iron status among the three groups. sFer significantly increased by 21.9% (+5.7 μg/L, p &lt; 0.001; 95% CI: 1.7, 9.5 μg/L) from baseline to 4 months in the iron-fortified lentil group, compared to a decline in sFer observed in the non-iron fortified lentil (53.3 vs. 38.6 μg/L, p &lt; 0.01) and no lentil groups (53.6 vs. 39.5 μg/L, p &lt; 0.01). Examining overall changes in iron status over 4 months, we observed maintenance in the iron-fortified group from baseline, compared to a decline in the other groups.

Conclusions

We observed improvement in and maintenance of iron status in a population vulnerable to ID and IDA who consumed iron-fortified lentils for 4 months. Additionally, girls who consumed iron-fortified lentils had a 60% lower chance of developing clinical and subclinical ID (sFer &lt; 15, 15–30 μg/L), and a 70% lower chance of developing sub-clinical IDA (sFer 15–30 μg/L + Hgb &lt; 12 g/dL) compared to those who did not.

Funding Sources

Global Institute for Food Security.

Determination of an Acceptable Portion Size of Daal for a Bangladeshi Community-Based Iron Intervention in Adolescent Girls: A Feasibility Study

Widely consumed daal (lentils) in Bangladesh are an ideal vehicle for iron (Fe) fortification; however, an acceptable portion size in meals needs to be determined to carry out a community feeding study in at-risk adolescent girls. A non-randomized crossover trial was conducted with n = 100 Bangladeshi girls (12.9 ± 2.0 years of age). Two recipes (thin and thick) and three portion sizes (25 g, 37.5 g, 50 g of raw lentil) of daal were served with 250 g of cooked white rice in a counter-balanced manner over 12 weeks. Each meal was fed to participants 5 days/week for two weeks. Ratings of hunger, satiety, and palatability were measured before and after each meal using Visual Analog Scales (VAS). The thick preparation in the 37.5 g portion (~200 g cooked) elicited higher VAS ratings of hunger, satiety, and palatability compared to all other meals. The 50 g portion of the thin preparation had VAS ratings similar to those of the 37.5 g thick preparation. Consuming the 37.5 g portion of fortified daal would provide 6.9 mg Fe/day to girls in a community-based effectiveness study. This would meet ~86% and ~46% of the Recommended Dietary Allowance (RDA) for Fe for girls aged 9-13 and 14-18 years, respectively.

A Community Trial Examining the Effectiveness of Iron-fortified Lentils to Improve Iron Status Among Bangladeshi Adolescent Girls: Results from a Baseline Survey (P10-099-19)

Objectives

Despite all efforts, iron deficiency (ID) and iron deficiency anaemia (IDA) among adolescent girls remains a public health concern for Bangladesh. The objective of the current analysis was to examine baseline data from an effectiveness trial with the aim to compare prevalence of anemia, ID and IDA with Bangladesh's National Micronutrients Status Survey 2011–12.

Methods

A community-based, double-blind, cluster randomized controlled trial is being conducted among n = 1260 Bangladeshi adolescent girls (10–17 years). Treatment groups include: 1) Fe-fortified lentils; 2) unfortified lentils and 3) usual intake (no intervention). Within the lentil groups, participants are being served 250 g cooked lentils with half a cup of cooked rice 5 days/week for 85 feeding days. All Fe-fortification and processing of lentils were carried out at the University of Saskatchewan. Anemia, ID and IDA were defined according to WHO (2011) cut-off values.

Results

At baseline, age of participants was 13.5 ± 2.0 years; BMI 18.2 ± 3.0 kg/m2 (or 38th percentile BMI-for-age); hemoglobin 12.4 ± 1.1 g/dL, serum ferritin 54.2 ± 36.3 ng/mL, sTfR 3.7 ± 2.6 µg/mL, and CRP 1.2 ± 3.9 mg/L. 26.6% girls were clinically anemic (non-pregnant-Hb <12 g/dl), 19.9% of those were mildly anemic (non-pregnant-Hb: 11–11.9 g/dl), 5.9% were moderately anemic (non-pregnant-Hb: 8.0–10.9 g/dl) anemic, and 0.8% were severely anemic (<8.0 g/dL). We found 9.2% of girls were ID (serum ferritin <15 µg/l).

Conclusions

One-fourth of rural Bangladeshi adolescent girls were anemic, and one-tenth were ID. This shows that rural anemia prevalence has increased ∼8.5% (26.6% vs 18.1%), ID has slightly increased (9.2% vs 10.0%) and IDA has increased (6.1% vs 1.8%) over the 7 years since the Bangladesh National Micronutrients Status Survey 2011–12. We can conclude from these baseline data that Bangladesh has made poor progress in reducing adolescent girls’ anemia with public policy efforts.

Funding Sources

Global Institute for Food Security; Nutrition International.

Iron-fortified lentils to improve iron (Fe) status among adolescent girls in Bangladesh - study protocol for a double-blind community-based randomized controlled trial

Background

Lentils are generally considered to be a nutrient-dense food, and a good source of iron (Fe). This study aims to establish novel evidence of the effectiveness of the consumption of Fe-fortified lentils in improving the body Fe status and thus cognitive performance in non-pregnant adolescent girls in rural Bangladesh, compared to consumption of ordinary lentils.

Methods

We have designed a double-blind (both trial participants and outcome assessors), community-based, cluster-randomized controlled trial among 1260 Bangladeshi adolescent girls between the ages of 10–17 years who are non-smoking, not married, not pregnant, not breastfeeding, and generally healthy at the time of enrollment. The intervention will include three arms who will receive: (1) Fe-fortified lentils; (2) unfortified lentils; or (3) usual intake. Participants will be served a thick preparation of cooked Fe-fortified lentils (37.5 g raw lentils, approximately 200 g cooked lentils) 5 days per week for 85 feeding days (around 4 months) using a locally acceptable recipe. Lentils were fortified with Fe in the laboratory at the Department of Plant Sciences at the University of Saskatchewan in Canada. A subsample of participants (n = 360) will be randomly invited to be included in cognitive testing.

Discussion

Data on socio-demographic characteristics, household food security status, adolescent food habits and cognitive testing will be collected at baseline and endline (4 months). Venous blood samples will be collected at baseline, midline (2 months) and endline to measure adolescents’ Fe status. Computerized cognitive testing will include five common measures of attentional (three of attention) and mnemonic functioning (two of memory) carried out using DMDX software. The results of this study will be used to garner support for and to substantiate large-scale production and market expansion of Fe-fortified lentils, and will contribute to knowledge about how to enhance Fe status in adolescents worldwide in resource-poor settings, using staple food crops.

Trial registration

ClinicalTrials.gov NCT03516734. Registered on 24 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3309-4) contains supplementary material, which is available to authorized users.

Sensory Acceptability of Iron-Fortified Red Lentil (Lens culinaris Medik.) Dal

Panelists in Saskatoon, Canada (n = 45) and Dhaka, Bangladesh (n = 98) participated in sensory evaluations of the sensory properties of both cooked and uncooked dehulled red lentil dal fortified with FeSO₄ ·7H₂ O, NaFeEDTA or FeSO₄ ·H₂ O at fortificant Fe concentrations of 800, 1,600 (both cooked and uncooked), or 2,800 ppm. Appearance, odor, and overall acceptability of cooked and uncooked samples were rated using a 9-point hedonic scale (1 = dislike extremely to 9 = like extremely). Taste and texture were rated for the cooked samples prepared as typical south Asian lentil meals. Significant differences in sensory quality were observed among all uncooked and cooked samples at both locations. Overall, scores for all sensory attributes and acceptability of uncooked lentil decreased with increasing concentration of Fe in the fortificant; however, Fe fortification (particularly with NaFeEDTA) had small effects on acceptability. Panelists from Saskatoon provided a wider range of scores than those from Bangladesh for all attributes of cooked lentil. Overall, sensory evaluation of Fe fortification using NaFeEDTA minimally affected consumer perception of color, taste, texture, odor, and overall acceptability of cooked lentil. Reliability estimates (Cronbach's alpha [CA]) indicated that consumer scores were generally consistent for all attributes of all lentil samples (mean CA > 0.80). NaFeEDTA was found to be the most suitable Fe fortificant for lentil based on consumer acceptability. Consumption of 45 to 50 g of NaFeEDTA-fortified lentil (fortificant Fe concentration of 1,600 ppm) per day meets the estimated average requirements (EARs) of Fe for humans (10.8 to 29.4 mg).

PRACTICAL APPLICATION

Iron fortification of dehulled lentil dal may change organoleptic attributes that can influence consumer acceptability. Sensory evaluation by consumers helps to determine the effect on appearance, odor, taste, texture, and overall acceptability of fortified lentils. In this study, consumer acceptability was evaluated with panelists who consume lentil regularly. Panelists provided significantly different scores for 5 sensory attributes for 10 uncooked and 3 cooked lentil samples. Panelists reliably preferred NaFeEDTA as the most suitable Fe fortificant for dehulled lentils for 5 attributes. Overall, lentil dal fortified with NaFeEDTA can offer a simple and low-cost solution to human health problems associated with iron-related malnutrition.

Estimating nutrient fortification levels in condiments and seasonings for public health programs: considerations and adaptations

Condiments and seasonings have been considered as potential vehicles for fortification in place of, or in addition to, fortifiable staple foods. Methodologies for establishing fortification programs focus primarily on use of staple foods, which are consumed in larger portions than condiments and seasonings. Some fortification models assume self-limiting consumption relative to the maximum energy consumed by target populations. However, this assumption may prove incorrect for estimating fortification concentrations of condiments and seasonings because they may only provide negligible energy. Although flavor or color may limit consumption, these limits would vary across each condiment or seasoning vehicle. In addition, the small volume of condiments and seasonings consumed relative to staple foods can lead to proportionally larger potential errors than with staple foods when measuring usual dietary intakes for establishing safe and effective fortification concentrations. This paper reviews available methods for setting fortification levels, whether or how available methods or conceptual frameworks could be adapted to condiments and seasonings, and gaps in knowledge for appropriately using condiments and seasonings as vehicles for fortification in public health.