Impact of market-based home fortification with micronutrient powder on childhood anemia in Bangladesh: a modified stepped wedge design

Background

Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh.

Methods

We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes.

Results

A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline.

Conclusion

These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers.

Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries

BACKGROUND

Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified.

OBJECTIVES

We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA).

METHODS

In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI).

RESULTS

Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda.

CONCLUSIONS

Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.

Household coverage of vitamin A fortification of edible oil in Bangladesh

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Coverage and Consumption of Micronutrient Powders, Fortified Staples, and Iodized Salt Among Children Aged 6 to 23 Months in Selected Neighborhoods of Nairobi County, Kenya

BACKGROUND

Intake of micronutrient-rich foods among children aged 6 to 23 months in Nairobi is low.

OBJECTIVE

This study aimed to assess existing coverage and utilization of micronutrient powders (MNPs), fortified staples, and iodized salt among children aged 6 to 23 months prior to implementation of an MNP program.

METHODS

A cross-sectional survey among caregivers of children aged 6 to 23 months (n = 618) was implemented in 7 neighborhoods within Nairobi County, representing the implementation area of the new MNP program.

RESULTS

Results for MNP coverage and utilization showed 28.5% of all caregivers were aware of MNP, 18.5% had ever received MNP for their child, and 10.8% had fed MNP to their child in the previous 7 days. Effective coverage (ie, the child had been given the MNP at least 3 times in the previous 7 days) was 5.8%. Effective coverage of infants and young children with poor feeding practices was significantly lower as compared to those with non-poor feeding practices (coverage ratio, 0.34; confidence interval, 0.12-0.70). Most households purchased iodized salt (96.9%), fortified oil (61.0%), and fortified maize flour (93.9%). An estimated 23.9% of vitamin A requirements of children (6-23 months) were provided from fortified oil and 50.7% of iron from fortified maize flour. Most households consumed processed milk (81%).

CONCLUSION

Coverage of MNPs in the surveyed neighborhoods was low. Coverage of fortified salt, oil, and maize flour was high and provided significant amount of micronutrients to children. Processed milk has potential as a vehicle for food fortification.

A Micronutrient Fortified Beverage Given at Different Dosing Frequencies Had Limited Impact on Anemia and Micronutrient Status in Filipino Schoolchildren

This study evaluated the effects of a multi-micronutrient fortified juice drink given in different frequencies of consumption on hemoglobin (Hb) concentration of schoolchildren. Hb was measured in 2423 schoolchildren aged 6- to 9-years-old at baseline. All anemic children (n = 246) were randomly allocated into groups: Daily dose (HD: high dose), 5X/week (MD: Moderate Dose), 3X/week (LD: Low Dose) and unfortified (Control). Pre- and post-study measurements of micronutrients were collected from 228 children. At the endpoint, significant Hb increases were observed in all groups, but there was no significant difference between groups. There was a significant reduction in anemia prevalence in all groups from 100% to 36% (Control), 30% (LD), 23% (MD) and 26% (HD). No dose-response effect was observed in Hb in this population. Most likely, this resulted from better than expected micronutrient status and lower than expected severity of anemia and micronutrient deficiencies in this cohort. It is unlikely that the addition of a fortified beverage to school feeding programs in this population would have a positive impact. Whether such an intervention would be cost-effective as a preventative approach needs to be assessed. This study demonstrates the importance of targeting such interventions to appropriate populations.

Iron Fortified Complementary Foods Containing a Mixture of Sodium Iron EDTA with Either Ferrous Fumarate or Ferric Pyrophosphate Reduce Iron Deficiency Anemia in 12- to 36-Month-Old Children in a Malaria Endemic Setting: A Secondary Analysis of a Cluster-Randomized Controlled Trial

Iron deficiency anemia (IDA) is a major public health problem in sub-Saharan Africa. The efficacy of iron fortification against IDA is uncertain in malaria-endemic settings. The objective of this study was to evaluate the efficacy of a complementary food (CF) fortified with sodium iron EDTA (NaFeEDTA) plus either ferrous fumarate (FeFum) or ferric pyrophosphate (FePP) to combat IDA in preschool-age children in a highly malaria endemic region. This is a secondary analysis of a nine-month cluster-randomized controlled trial conducted in south-central Côte d'Ivoire. 378 children aged 12-36 months were randomly assigned to no food intervention (n = 125; control group), CF fortified with 2 mg NaFeEDTA plus 3.8 mg FeFum for six days/week (n = 126; FeFum group), and CF fortified with 2 mg NaFeEDTA and 3.8 mg FePP for six days/week (n = 127; FePP group). The outcome measures were hemoglobin (Hb), plasma ferritin (PF), iron deficiency (PF < 30 μg/L), and anemia (Hb < 11.0 g/dL). Data were analyzed with random-effect models and PF was adjusted for inflammation. The prevalence of Plasmodium falciparum infection and inflammation during the study were 44-66%, and 57-76%, respectively. There was a significant time by treatment interaction on IDA (p = 0.028) and a borderline significant time by treatment interaction on iron deficiency with or without anemia (p = 0.068). IDA prevalence sharply decreased in the FeFum (32.8% to 1.2%, p < 0.001) and FePP group (23.6% to 3.4%, p < 0.001). However, there was no significant time by treatment interaction on Hb or total anemia. These data indicate that, despite the high endemicity of malaria and elevated inflammation biomarkers (C-reactive protein or α-1-acid-glycoprotein), IDA was markedly reduced by provision of iron fortified CF to preschool-age children for 9 months, with no significant differences between a combination of NaFeEDTA with FeFum or NaFeEDTA with FePP. However, there was no overall effect on anemia, suggesting most of the anemia in this setting is not due to ID. This trial is registered at clinicaltrials.gov (NCT01634945).

Methodologic approach for the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: The Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project is a multiagency and multicountry collaboration that was formed to improve micronutrient assessment and to better characterize anemia.Objectives: The aims of the project were to 1) identify factors associated with inflammation, 2) assess the relations between inflammation, malaria infection, and biomarkers of iron and vitamin A status and compare adjustment approaches, and 3) assess risk factors for anemia in preschool children (PSC) and women of reproductive age (WRA).Design: The BRINDA database inclusion criteria included surveys that 1) were conducted after 2004, 2) had target groups of PSC, WRA, or both, and 3) used a similar laboratory methodology for the measurement of ≥1 biomarker of iron [ferritin or soluble transferrin receptor or vitamin A status (retinol-binding protein or retinol)] and ≥1 biomarker of inflammation (α-1-acid glycoprotein or C-reactive protein). Individual data sets were standardized and merged into a BRINDA database comprising 16 nationally and regionally representative surveys from 14 countries. Collectively, the database covered all 6 WHO geographic regions and contained ∼30,000 PSC and 27,000 WRA. Data were analyzed individually and combined with the use of a meta-analysis.Results: The methods that were used to standardize the BRINDA database and the analytic approaches used to address the project's research questions are presented in this article. Three approaches to adjust micronutrient biomarker concentrations in the presence of inflammation and malaria infection are presented, along with an anemia conceptual framework that guided the BRINDA project's anemia analyses.Conclusions: The BRINDA project refines approaches to interpret iron and vitamin A biomarker values in settings of inflammation and malaria infection and suggests the use of a new regression approach as well as proposes an anemia framework to which real-world data can be applied. Findings can inform guidelines and strategies to prevent and control micronutrient deficiencies and anemia globally.

Predictors of anemia in preschool children: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: A lack of information on the etiology of anemia has hampered the design and monitoring of anemia-control efforts.Objective: We aimed to evaluate predictors of anemia in preschool children (PSC) (age range: 6-59 mo) by country and infection-burden category.Design: Cross-sectional data from 16 surveys (n = 29,293) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed separately and pooled by category of infection burden. We assessed relations between anemia (hemoglobin concentration <110 g/L) and severe anemia (hemoglobin concentration <70 g/L) and individual-level (age, anthropometric measures, micronutrient deficiencies, malaria, and inflammation) and household-level predictors; we also examined the proportion of anemia with concomitant iron deficiency (defined as an inflammation-adjusted ferritin concentration <12 μg/L). Countries were grouped into 4 categories on the basis of risk and burden of infectious disease, and a pooled multivariable logistic regression analysis was conducted for each group.Results: Iron deficiency, malaria, breastfeeding, stunting, underweight, inflammation, low socioeconomic status, and poor sanitation were each associated with anemia in >50% of surveys. Associations between breastfeeding and anemia were attenuated by controlling for child age, which was negatively associated with anemia. The most consistent predictors of severe anemia were malaria, poor sanitation, and underweight. In multivariable pooled models, child age, iron deficiency, and stunting independently predicted anemia and severe anemia. Inflammation was generally associated with anemia in the high- and very high-infection groups but not in the low- and medium-infection groups. In PSC with anemia, 50%, 30%, 55%, and 58% of children had concomitant iron deficiency in low-, medium-, high-, and very high-infection categories, respectively.Conclusions: Although causal inference is limited by cross-sectional survey data, results suggest anemia-control programs should address both iron deficiency and infections. The relative importance of factors that are associated with anemia varies by setting, and thus, country-specific data are needed to guide programs.

Predictors of anemia in women of reproductive age: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: Anemia in women of reproductive age (WRA) (age range: 15-49 y) remains a public health problem globally, and reducing anemia in women by 50% by 2025 is a goal of the World Health Assembly.Objective: We assessed the associations between anemia and multiple proximal risk factors (e.g., iron and vitamin A deficiencies, inflammation, malaria, and body mass index) and distal risk factors (e.g., education status, household sanitation and hygiene, and urban or rural residence) in nonpregnant WRA.Design: Cross-sectional, nationally representative data from 10 surveys (n = 27,018) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and pooled by the infection burden and risk in the country. We examined the severity of anemia and measured the bivariate associations between anemia and factors at the country level and by infection burden, which we classified with the use of the national prevalences of malaria, HIV, schistosomiasis, sanitation, and water-quality indicators. Pooled multivariate logistic regression models were constructed for each infection-burden category to identify independent determinants of anemia (hemoglobin concertation <120 g/L).Results: Anemia prevalence was ∼40% in countries with a high infection burden and 12% and 7% in countries with moderate and low infection burdens, respectively. Iron deficiency was consistently associated with anemia in multivariate models, but the proportion of anemic women who were iron deficient was considerably lower in the high-infection group (35%) than in the moderate- and low-infection groups (65% and 71%, respectively). In the multivariate analysis, inflammation, vitamin A insufficiency, socioeconomic status, and age were also significantly associated with anemia, but malaria and vitamin B-12 and folate deficiencies were not.Conclusions: The contribution of iron deficiency to anemia varies according to a country's infection burden. Anemia-reduction programs for WRA can be improved by considering the underlying infection burden of the population and by assessing the overlap of micronutrient deficiencies and anemia.

Coverage of Nutrition Interventions Intended for Infants and Young Children Varies Greatly across Programs: Results from Coverage Surveys in 5 Countries

Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d'Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage (message: awareness of the product; contact: use of the product ≥1 time; and effective: regular use aligned with program-specific goals), as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap.

Coverage of Large-Scale Food Fortification of Edible Oil, Wheat Flour, and Maize Flour Varies Greatly by Vehicle and Country but Is Consistently Lower among the Most Vulnerable: Results from Coverage Surveys in 8 Countries

Background: Large-scale food fortification (LSFF) of commonly consumed food vehicles is widely implemented in low- and middle-income countries. Many programs have monitoring information gaps and most countries fail to assess program coverage.

Objective: The aim of this work was to present LSFF coverage survey findings (overall and in vulnerable populations) from 18 programs (7 wheat flour, 4 maize flour, and 7 edible oil programs) conducted in 8 countries between 2013 and 2015.

Methods: A Fortification Assessment Coverage Toolkit (FACT) was developed to standardize the assessments. Three indicators were used to assess the relations between coverage and vulnerability: 1) poverty, 2) poor dietary diversity, and 3) rural residence. Three measures of coverage were assessed: 1) consumption of the vehicle, 2) consumption of a fortifiable vehicle, and 3) consumption of a fortified vehicle. Individual program performance was assessed based on the following: 1) achieving overall coverage ≥50%, 2) achieving coverage of ≥75% in ≥1 vulnerable group, and 3) achieving equity in coverage for ≥1 vulnerable group.

Results: Coverage varied widely by food vehicle and country. Only 2 of the 18 LSFF programs assessed met all 3 program performance criteria. The 2 main program bottlenecks were a poor choice of vehicle and failure to fortify a fortifiable vehicle (i.e., absence of fortification).

Conclusions: The results highlight the importance of sound program design and routine monitoring and evaluation. There is strong evidence of the impact and cost-effectiveness of LSFF; however, impact can only be achieved when the necessary activities and processes during program design and implementation are followed. The FACT approach fills an important gap in the availability of standardized tools. The LSFF programs assessed here need to be re-evaluated to determine whether to further invest in the programs, whether other vehicles are appropriate, and whether other approaches are needed.

Assessing Coverage of Population-Based and Targeted Fortification Programs with the Use of the Fortification Assessment Coverage Toolkit (FACT): Background, Toolkit Development, and Supplement Overview

Food fortification is a widely used approach to increase micronutrient intake in the diet. High coverage is essential for achieving impact. Data on coverage is limited in many countries, and tools to assess coverage of fortification programs have not been standardized. In 2013, the Global Alliance for Improved Nutrition developed the Fortification Assessment Coverage Toolkit (FACT) to carry out coverage assessments in both population-based (i.e., staple foods and/or condiments) and targeted (e.g., infant and young child) fortification programs. The toolkit was designed to generate evidence on program coverage and the use of fortified foods to provide timely and programmatically relevant information for decision making. This supplement presents results from FACT surveys that assessed the coverage of population-based and targeted food fortification programs across 14 countries. It then discusses the policy and program implications of the findings for the potential for impact and program improvement.

Household Coverage with Adequately Iodized Salt Varies Greatly between Countries and by Residence Type and Socioeconomic Status within Countries: Results from 10 National Coverage Surveys

Background: Household coverage with iodized salt was assessed in 10 countries that implemented Universal Salt Iodization (USI).

Objective: The objective of this paper was to summarize household coverage data for iodized salt, including the relation between coverage and residence type and socioeconomic status (SES).

Methods: A review was conducted of results from cross-sectional multistage household cluster surveys with the use of stratified probability proportional to size design in Bangladesh, Ethiopia, Ghana, India, Indonesia, Niger, the Philippines, Senegal, Tanzania, and Uganda. Salt iodine content was assessed with quantitative methods in all cases. The primary indicator of coverage was percentage of households that used adequately iodized salt, with an additional indicator for salt with some added iodine. Indicators of risk were SES and residence type. We used 95% CIs to determine significant differences in coverage.

Results: National household coverage of adequately iodized salt varied from 6.2% in Niger to 97.0% in Uganda. For salt with some added iodine, coverage varied from 52.4% in the Philippines to 99.5% in Uganda. Coverage with adequately iodized salt was significantly higher in urban than in rural households in Bangladesh (68.9% compared with 44.3%, respectively), India (86.4% compared with 69.8%, respectively), Indonesia (59.3% compared with 51.4%, respectively), the Philippines (31.5% compared with 20.2%, respectively), Senegal (53.3% compared with 19.0%, respectively), and Tanzania (89.2% compared with 57.6%, respectively). In 7 of 8 countries with data, household coverage of adequately iodized salt was significantly higher in high- than in low-SES households in Bangladesh (58.8% compared with 39.7%, respectively), Ghana (36.2% compared with 21.5%, respectively), India (80.6% compared with 70.5%, respectively), Indonesia (59.9% compared with 45.6%, respectively), the Philippines (39.4% compared with 17.3%, respectively), Senegal (50.7% compared with 27.6%, respectively) and Tanzania (80.9% compared with 51.3%, respectively).

Conclusions: Uganda has achieved USI. In other countries, access to iodized salt is inequitable. Quality control and regulatory enforcement of salt iodization remain challenging. Notable progress toward USI has been made in Ethiopia and India. Assessing progress toward USI only through household salt does not account for potentially iodized salt consumed through processed foods.

High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan, Côte d'Ivoire: Findings from a Cross-Sectional Survey

Poor complementary feeding practices among infants and young children in Côte d’Ivoire are major contributing factors to the country’s high burden of malnutrition. As part of a broad effort to address this issue, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d’Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d’Ivoire. Four measures of coverage were assessed: “message coverage” (i.e., has the caregiver ever heard of the product?), “contact coverage” (i.e., has the caregiver ever fed the child the product?), “partial coverage” (i.e., has the caregiver fed the child the product in the previous month?), and “effective coverage” (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. In conclusion, the results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand. Moreover, given the high prevalence of malnutrition and poor IYCF practices, additional modes of delivering IYCF interventions and improving IYCF practices should be considered.

Assessing Program Coverage of Two Approaches to Distributing a Complementary Feeding Supplement to Infants and Young Children in Ghana

The work reported here assesses the coverage achieved by two sales-based approaches to distributing a complementary food supplement (KOKO Plus^™) to infants and young children in Ghana. Delivery Model 1 was conducted in the Northern Region of Ghana and used a mixture of health extension workers (delivering behavior change communications and demand creation activities at primary healthcare centers and in the community) and petty traders recruited from among beneficiaries of a local microfinance initiative (responsible for the sale of the complementary food supplement at market stalls and house to house). Delivery Model 2 was conducted in the Eastern Region of Ghana and used a market-based approach, with the product being sold through micro-retail routes (i.e., small shops and roadside stalls) in three districts supported by behavior change communications and demand creation activities led by a local social marketing company. Both delivery models were implemented sub-nationally as 1-year pilot programs, with the aim of informing the design of a scaled-up program. A series of cross-sectional coverage surveys was implemented in each program area. Results from these surveys show that Delivery Model 1 was successful in achieving and sustaining high (i.e., 86%) effective coverage (i.e., the child had been given the product at least once in the previous 7 days) during implementation. Effective coverage fell to 62% within 3 months of the behavior change communications and demand creation activities stopping. Delivery Model 2 was successful in raising awareness of the product (i.e., 90% message coverage), but effective coverage was low (i.e., 9.4%). Future programming efforts should use the health extension / microfinance / petty trader approach in rural settings and consider adapting this approach for use in urban and peri-urban settings. Ongoing behavior change communications and demand creation activities is likely to be essential to the continued success of such programming.

High Coverage and Utilization of Fortified Take-Home Rations among Children 6-35 Months of Age Provided through the Integrated Child Development Services Program: Findings from a Cross-Sectional Survey in Telangana, India

The Integrated Child Development Services (ICDS) in the State of Telangana, India, freely provides a fortified complementary food product, Bal Amrutham, as a take-home ration to children 6–35 months of age. In order to understand the potential for impact of any intervention, it is essential to assess coverage and utilization of the program and to address the barriers to its coverage and utilization. A two-stage, stratified cross-sectional cluster survey was conducted to estimate the coverage and utilization of Bal Amrutham and to identify their barriers and drivers. In randomly selected catchment areas of ICDS centers, children under 36 months of age were randomly selected. A questionnaire, constructed from different validated and standard modules and designed to collect coverage data on nutrition programs, was administered to caregivers. A total of 1,077 children were enrolled in the survey. The coverage of the fortified take-home ration was found to be high among the target population. Nearly all caregivers (93.7%) had heard of Bal Amrutham and 86.8% had already received the product for the target child. Among the children surveyed, 57.2% consumed the product regularly. The ICDS program’s services were not found to be a barrier to product coverage. In fact, the ICDS program was found to be widely available, accessible, accepted, and utilized by the population in both urban and rural catchment areas, as well as among poor and non-poor households. However, two barriers to optimal coverage were found: the irregular supply of the product to the beneficiaries and the intra-household sharing of the product. Although sharing was common, the product was estimated to provide the target children with significant proportions of the daily requirements of macro- and micronutrients. Bal Amrutham is widely available, accepted, and consumed among the target population in the catchment areas of ICDS centers. The coverage of the product could be further increased by improving the supply chain.

Coverage of Adequately Iodized Salt Is Suboptimal and Rice Fortification Using Public Distribution Channels Could Reach Low-Income Households: Findings from a Cross-Sectional Survey of Anganwadi Center Catchment Areas in Telangana, India

Food fortification is a cost-effective approach to prevent and control of micronutrient deficiencies in India. A cross-sectional survey of children 0-35 months of age residing in the catchment areas of anganwadi centers in the state of Telangana was conducted to assess the coverage of adequately iodized salt and the potential for rice fortification. Salt samples were collected and tested for iodine concentration using iodometric titration. Information on demographics, household rice consumption, and Telangana's rice sector was collected and interpreted. In households of selected children, 79% of salt samples were found to be adequately iodized. Salt brand and district were significant predictors of inadequately iodized salt. Daily rice consumption among children and women averaged 122 grams and 321 grams per day, respectively. Approximately 28% of households reported consuming rice produced themselves or purchased from a local farmer, 65% purchased rice from a market or shop, 6% got rice from a public distribution system site, and 2% obtained it from a rice mill. In the catchment areas of Telangana's anganwadi centers, there is significant variation in the coverage of adequately iodized salt by district. Future surveys in Telangana should measure the coverage of salt iodization in the general population using quantitative methods. Nonetheless, increasing the adequacy of iodization of smaller salt manufacturers would help achieve universal salt iodization in Telangana. Despite high consumption of rice, our findings suggest that large-scale market-based rice fortification is not feasible in Telangana due to a large proportion of households producing their own rice and highly fragmented rice distribution. Distributing fortified rice via Telangana's public distribution system may be a viable approach to target low-income households, but would only reach a small proportion of the population in Telangana.

The Potential of Food Fortification to Add Micronutrients in Young Children and Women of Reproductive Age - Findings from a Cross-Sectional Survey in Abidjan, Côte d'Ivoire

Poor micronutrient intakes are a major contributing factor to the high burden of micronutrient deficiencies in Côte d'Ivoire. Large-scale food fortification is considered a cost-effective approach to deliver micronutrients, and fortification of salt (iodine), wheat flour (iron and folic acid), and vegetable oil (vitamin A) is mandatory in Côte d'Ivoire. A cross-sectional survey on households with at least one child 6-23 months was conducted to update coverage figures with adequately fortified food vehicles in Abidjan, the capital of and largest urban community in Côte d'Ivoire, and to evaluate whether additional iron and vitamin A intake is sufficient to bear the potential to reduce micronutrient malnutrition. Information on demographics and food consumption was collected, along with samples of salt and oil. Wheat flour was sampled from bakeries and retailers residing in the selected clusters. In Abidjan, 86% and 97% of salt and vegetable oil samples, respectively, were adequately fortified, while only 32% of wheat flour samples were adequately fortified, but all samples contained some added iron. There were no major differences in additional vitamin A and iron intake between poor and non-poor households. For vitamin A in oil, the additional percentage of the recommended nutrient intake was 27% and 40% for children 6-23 months and women of reproductive age, respectively, while for iron from wheat flour, only 13% and 19% could be covered. Compared to previous estimates, coverage has remained stable for salt and wheat flour, but improved for vegetable oil. Fortification of vegetable oil clearly provides a meaningful additional amount of vitamin A. This is not currently the case for iron, due to the low fortification levels. Iron levels in wheat flour should be increased and monitored, and additional vehicles should be explored to add iron to the Ivorian diet.

Overview of the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) Project

Anemia remains a widespread public health problem. Although iron deficiency is considered the leading cause of anemia globally, the cause of anemia varies considerably by country. To achieve global targets to reduce anemia, reliable estimates of the contribution of nutritional and non-nutritional causes of anemia are needed to guide interventions. Inflammation is known to affect many biomarkers used to assess micronutrient status and can thus lead to incorrect diagnosis of individuals and to overestimation or underestimation of the prevalence of deficiency in a population. Reliable assessment of iron status is particularly needed in settings with high infectious disease burden, given the call to screen for iron deficiency to mitigate potential adverse effects of iron supplementation. To address these information gaps, in 2012 the CDC, National Institute for Child Health and Human Development, and Global Alliance for Improved Nutrition formed a collaborative research group called Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA). Data from nationally and regionally representative nutrition surveys conducted in the past 10 y that included preschool children and/or women of childbearing age were pooled. Of 25 data sets considered for inclusion, 17 were included, representing ∼30,000 preschool children, 26,000 women of reproductive age, and 21,000 school-aged children from all 6 WHO geographic regions. This article provides an overview of the BRINDA project and describes key research questions and programmatic and research implications. Findings from this project will inform global guidelines on the assessment of anemia and micronutrient status and will guide the development of a research agenda for future longitudinal studies.

Multiple-Micronutrient Fortified Non-Dairy Beverage Interventions Reduce the Risk of Anemia and Iron Deficiency in School-Aged Children in Low-Middle Income Countries: A Systematic Review and Meta-Analysis (i-iv)

Multiple-micronutrient (MMN) fortification of beverages may be an effective option to deliver micronutrients to vulnerable populations. The aim of the present systematic review and meta-analysis is to evaluate the nutritional impacts of MMN fortified beverages in the context of low-middle income countries. A systematic search of published literature yielded 1022 citations, of which 10 randomized controlled trials (nine in school-aged children and one in pregnant women) met inclusion criteria. Results of school-aged children were included in the meta-analysis. Compared to iso-caloric controls, children who received MMN fortified beverages for 8 weeks to 6 months showed significant improvements in hemoglobin (+2.76 g/L, 95% CI [1.19, 4.33], p = 0.004; 8 studies) and serum ferritin (+15.42 pmol/L, [5.73, 25.12], p = 0.007; 8 studies); and reduced risk of anemia (RR 0.58 [0.29, 0.88], p = 0.005; 6 studies), iron deficiency (RR 0.34 [0.21, 0.55], p = 0.002; 7 studies), and iron deficiency anemia (RR 0.17 [0.06, 0.53], p = 0.02; 3 studies). MMN fortified beverage interventions could have major programmatic implications for reducing the burden of anemia and iron deficiency in school-aged children in low-middle income countries. Additional research is needed to investigate effects on other biochemical outcomes and population subgroups.

Improving complementary feeding in Ghana: reaching the vulnerable through innovative business--the case of KOKO Plus

Reaching vulnerable populations in low-resource settings with effective business solutions is critical, given the global nature of food and nutrition security. Over a third of deaths of children under 5 years of age are directly or indirectly caused by undernutrition. The Lancet series on malnutrition (2013) estimates that over 220,000 lives of children under 5 years of age can be saved through the implementation of an infant and young child feeding and care package. A unique project being undertaken in Ghana aims to bring in two elements of innovation in infant and young child feeding. The first involves a public-private partnership (PPP) to develop and test the efficacy and effectiveness of the delivery of a low-cost complementary food supplement in Ghana called KOKO Plus™. The second involves the testing of the concepts of social entrepreneurship and social business models in the distribution and delivery of the product. This paper shares information on the ongoing activities in the testing of concepts of PPPs, social business, social marketing, and demand creation using different delivery platforms to achieve optimal nutrition in Ghanaian infants and young children in the first 2 years of life. It also focuses on outlining the concept of using PPP and base-of-the-pyramid approaches toward achieving nutrition objectives.

Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A

BACKGROUND

The prevalence of stunting, underweight, and micronutrient deficiencies are persistently high in young children in the Philippines, and among other factors, suboptimal infant and young child feeding behavior may contribute to these forms of malnutrition.

OBJECTIVE

To improve the understanding of contributors associated with the nutritional status of children 6 to 23 months of age living in urban areas of the Philippines.

METHODS

A cross-sectional survey was conducted covering five urban centers in the Philippines. Data on infant and young child feeding and nutritional status (including wasting, stunting, underweight, anemia, iron deficiency, and vitamin A deficiency) were collected for 1,784 children.

RESULTS

Among children from urban and predominantly poor and very poor households, 26% were stunted, 18% were underweight, and 5% were wasted. Forty-two percent were anemic, 28% were iron deficient, and 3% were vitamin A deficient. About half of the children were breastfed within an hour after birth, were breastfed at the time of the survey, and had been continuously breastfed up to 1 year of age. Of the factors investigated, low socioeconomic status, use of cheaper cooking fuel, and nonuse of multivitamins were all independently associated with stunting. The prevalence of anemia, iron deficiency, and vitamin A deficiency were independently associated with the same factors and poorer sanitation facilities, lower maternal education, current unemployment, and inflammation.

CONCLUSIONS

These factors merit attention in future programming and interventions may include promotion of the timely introduction of appropriate fortified complementary foods, the use of affordable multiple micronutrient preparations, and measures to reduce infections.

Vegetable variety is a key to improved diet quality in low-income women in California

Primary prevention education interventions, including those sponsored by the US Department of Agriculture for low-income families, encourage and support increases in vegetable intake. Promoting vegetable variety as a focal point for behavior change may be a useful strategy to increase vegetable consumption. A simple vegetable variety evaluation tool might be useful to replace the time-intensive 24-hour dietary recall. The purpose of our study was to determine whether vegetable variety is associated with vegetable consumption and diet quality among US Department of Agriculture program participants. Variety of vegetable intake and measures of total vegetable intake, diet quality, and diet cost were evaluated. Low-income, female participants (N=112) aged 20 to 55 years with body mass index 17.7 to 68.5 who were the primary food purchasers/preparers for their households were recruited from four California counties representing rural, urban, and suburban areas. Energy density and Healthy Eating Index-2005 were used to assess diet quality. Vegetable variety was based on number of different vegetables consumed per week using a food frequency questionnaire, and three groups were identified as: low variety, ≤5 different vegetables per week; moderate variety, 6 to 9 vegetables per week; and high variety, ≥10 vegetables per week. Compared with the low-variety group, participants in the high-variety group ate a greater quantity of vegetables per day (P<0.001); their diets had a higher Healthy Eating Index score (P<0.001) and lower energy density (P<0.001); and costs of their daily diet and vegetable use were higher (P<0.001). Thus, greater vegetable variety was related to better overall diet quality, a larger quantity of vegetables consumed, and increased diet cost.

Fortification of staple cereal flours with iron and other micronutrients: cost implications of following World Health Organization-endorsed recommendations

BACKGROUND

Wheat and maize flours are widely used delivery vehicles for mass fortification. In lower-income countries, most, if not all, national-level cereal flour fortification programs routinely fortify with iron; however, cofortification with other micronutrients is common. Little information is available on the cost implications programs face when considering current fortification practices versus what the World Health Organization (WHO) interim consensus statement recommends.

OBJECTIVE

The objectives of the present paper are to provide information on the costs of adding different chemical forms of iron and/or other micronutrients to premix formulations, and to discuss some of the issues that should be considered regarding which micronutrients to include in the premix.

METHODS

Nine countries in Latin America, Africa, and Asia (three countries per region) that currently cofortify with multiple micronutrients including iron were selected based on low (< 75 g/day), medium (75 to 149 g/day), and high (> or = 150 g/day) mean population flour consumption levels. Premix costs per metric ton of flour produced were estimated for improving iron formulations and for following WHO recommendations for other micronutrients.

RESULTS

For the selected programs to maintain current premix formulations and improve iron compounds, premix costs would increase by between 155% and 343% when the iron compound was switched from electrolytic iron to sodium iron ethylenediaminetetraacetate (NaFeEDTA), by 6% to 50% when it was switched from electrolytic iron to ferrous sulfate, and by 4% to 13 when iron addition rates were adjusted without switching the compound. To meet WHO recommendations for other micronutrients, premix costs would increase the most when the amounts of vitamins B12 and A were increased.

CONCLUSIONS

For programs that currently cofortify with iron and additional micronutrients, the quality of the iron fortificant should not be overlooked simply to be able to afford to add more micronutrients to the premix. Micronutrients should be selected according to population needs, costs, and potential beneficial synergistic reactions the added micronutrients may have.

Estimating dietary costs of low-income women in California: a comparison of 2 approaches

BACKGROUND

Currently, no simplified approach to estimating food costs exists for a large, nationally representative sample.

OBJECTIVE

The objective was to compare 2 approaches for estimating individual daily diet costs in a population of low-income women in California.

DESIGN

Cost estimates based on time-intensive method 1 (three 24-h recalls and associated food prices on receipts) were compared with estimates made by using less intensive method 2 [a food-frequency questionnaire (FFQ) and store prices]. Low-income participants (n = 121) of USDA nutrition programs were recruited. Mean daily diet costs, both unadjusted and adjusted for energy, were compared by using Pearson correlation coefficients and the Bland-Altman 95% limits of agreement between methods.

RESULTS

Energy and nutrient intakes derived by the 2 methods were comparable; where differences occurred, the FFQ (method 2) provided higher nutrient values than did the 24-h recall (method 1). The crude daily diet cost was $6.32 by the 24-h recall method and $5.93 by the FFQ method (P = 0.221). The energy-adjusted diet cost was $6.65 by the 24-h recall method and $5.98 by the FFQ method (P < 0.001).

CONCLUSIONS

Although the agreement between methods was weaker than expected, both approaches may be useful. Additional research is needed to further refine a large national survey approach (method 2) to estimate daily dietary costs with the use of this minimal time-intensive method for the participant and moderate time-intensive method for the researcher.

Results of Fortification Rapid Assessment Tool (FRAT) Surveys in Sub-Saharan Africa and Suggestions for Future Modifications of the Survey Instrument

Background

Food fortification has been increasingly recognized as a promising approach to prevent micronutrient deficiencies. The Fortification Rapid Assessment Tool (FRAT) was developed to assist public health program managers to acquire the information needed to implement an effective mass food fortification program. Multiple countries have conducted FRAT surveys, but information on results and experiences with the FRAT tool has been available only at the national level.

Objective

To summarize the findings of the FRAT surveys previously conducted in sub-Saharan Africa.

Methods

Surveys from 12 sub-Saharan African countries (Burkina Faso, Cameroon, Congo, Guinea, Malawi, Mali, Mauritania, Mozambique, Niger, Rwanda, Senegal, Uganda) were identified. Information on consumption patterns for wheat flour, vegetable oil, sugar, and bouillon cubes was reviewed and summarized.

Results

Most surveys found that a moderate to high proportion of women reported consuming wheat flour (48% to 93%), vegetable oil (44% to 98%), sugar (55% to 99%), and bouillon cubes (79% to 99%) in the past 7 days, although consumption was more common and more frequent in urban areas than in rural areas. Similarly, the reported amounts consumed during the previous 24 hours were generally higher in urban settings.

Conclusions

The FRAT instrument has been successfully used in multiple countries, and the results obtained have helped in planning national food fortification programs. However, the recommended sampling scheme may need to be reconsidered, and the guidelines should be revised to clarify important aspects of fieldworker training, implementation, data analysis and interpretation, and reporting of the results.

A multi-micronutrient beverage enhances the vitamin A and zinc status of Nigerian primary schoolchildren

Schoolchildren in Nigeria are rarely targeted by micronutrient interventions. We completed a 6-mo, double-blind, placebo-controlled trial to determine the effects of a multi-micronutrient beverage on biochemical and anthropometric indicators of nutritional status among schoolchildren participating in a pilot school feeding program in Nasarawa State, Nigeria. Children received 1 of 2 interventions 5 d/wk during school hours: 1) 250 mL/d of a multi-micronutrient beverage that included vitamin A, iron, and zinc (micronutrient); or 2) an isoenergetic control beverage (control). At baseline, 566 children 5-13 y old were randomized to groups (micronutrient: n = 288; control: n = 278). Height, weight, hemoglobin, and serum concentrations of C-reactive protein, ferritin, retinol, and zinc were measured at baseline and at the end of the study. A total of 270 children in the micronutrient group and 264 children in the control group completed the study. Self-reports of vomiting increased in both groups at 6 mo; however, the prevalence tended to be greater in the micronutrient group (21%) compared to the control group (14%) (P = 0.06). Biochemical changes were greater in the micronutrient group compared to control for serum retinol (0.10 ± 0.02 μmol/L vs. 0.02 ± 0.02 μmol/L; P = 0.016) and zinc (1.0 ± 0.2 μmol/L vs. 0.6 ± 0.2 μmol/L; P = 0.031). The intervention did not significantly affect hemoglobin or serum ferritin concentrations. The cost effectiveness of the intervention needs to be further evaluated, as does the efficacy of the beverage on anemia and indicators of iron status.

Plasma zinc concentration increases within 2 weeks in healthy Senegalese men given liquid supplemental zinc, but not zinc-fortified wheat bread

The responsiveness of plasma zinc concentration to zinc fortification is uncertain. Our objective in this study was to determine whether plasma zinc concentration changes in response to consuming zinc-fortified foods or liquid zinc supplements. We conducted a 4-wk double-blind, randomized trial among 132 healthy Senegalese men ≥ 18 y. Participants received 1 of 4 interventions: 1) (control) 200 g/d of wheat bread fortified with iron and folic acid, but not zinc, and a liquid multivitamin supplement without zinc between meals; 2) (zinc supplement) the same bread and the same multivitamin supplement with 15 mg zinc as ZnSO(4) added; 3) (moderate zinc fortification) the same bread cofortified with 7.5 mg zinc as ZnO and the same multivitamin supplement without zinc; or 4) (high zinc fortification) the same bread cofortified with 15 mg zinc as ZnO and the same multivitamin supplement without zinc. Fasting blood samples were collected twice at baseline and at d 15 and 29 of the intervention. There was no significant interaction between group and study day (P = 0.11). However, at d 15, the mean change in plasma zinc concentration in the zinc-supplemented group was greater than in the placebo and fortification groups ( 0.72 μmol/L vs. -0.09 to 0.03 μmol/L; P = 0.05). At d 29 there were no significant group-wise differences. Across all time points, the zinc-supplemented group was the only group where plasma zinc concentration increased from baseline (P = 0.006). These results suggest that plasma zinc concentration may not be a sufficiently sensitive indicator to evaluate short-term responses to zinc fortification.

Plasma zinc concentration responds to short-term zinc supplementation, but not zinc fortification, in young children in Senegal1,2

BACKGROUND

Simple, low-cost methods are needed to evaluate the effect of zinc-fortification programs. Plasma zinc concentration is a useful biomarker of zinc intake from supplementation, but responses to zinc fortification are inconsistent.

OBJECTIVE

The objective was to compare the change in plasma zinc concentrations in young children who received zinc from either a liquid supplement or a zinc-fortified complementary food.

DESIGN

A double-blind intervention trial was conducted in 137 young Senegalese children aged 9-17 mo who were randomly assigned to receive one of the following treatments for 15 d: 1) 30 g dry weight of an iron-fortified cereal porridge and a liquid multivitamin supplement without zinc (control group), 2) the same porridge and multivitamin supplement with 6 mg Zn added to the supplement dose (ZnSuppl group), or 3) the same porridge with added zinc to provide 6 mg Zn per 25 g dry weight of porridge and multivitamin without zinc (ZnFort group).

RESULTS

Mean (±SD) plasma zinc concentration (μg/dL) increased by 4.7 ± 1.6 (P = 0.004) in the ZnSuppl group, which was significantly greater (P = 0.009) than the mean change in the control group (-1.0 ± 1.6; P = 0.51) and in the ZnFort group (-1.8 ± 1.7; P = 0.29). The latter 2 groups did not differ from each other (P = 0.99).

CONCLUSIONS

Plasma zinc concentration increased in children who received daily zinc supplementation for 15 d but not in those who received a zinc-fortified complementary food containing a similar amount of zinc. Additional longer-term studies are needed to assess the effect of zinc-fortification programs on zinc-related functional outcomes and the usefulness of plasma zinc as a biomarker of program effect. This trial was registered at www.clinicaltrials.gov as study NCT0094398.

Bibliographic analysis of scientific research on selected topics in public health nutrition in West Africa: Review of articles published from 1998 to 2008

Few countries in West Africa have the capacity for carrying out advanced training in nutrition and public health. To provide additional information on current regional applied nutrition research capacity and productivity, we analysed peer-reviewed articles on key public health nutrition topics that were published from 1998 to 2008. Using MEDLINE/PubMed, the following terms were searched: 'breast feeding', 'infant nutrition physiology' (comprising complementary feeding and weaning), 'protein energy malnutrition', 'nutrition and infection', 'vitamin A', 'iodine', 'zinc' and 'overweight', each linked with the term 'Western Africa'. In total, 412 unique articles (37±6 articles per year) were identified. Most research focused on infant and young child feeding practices, selected micronutrient deficiencies, and the emerging problem of overweight and obesity. The primary author of nearly half (46%) the publications was located in an institution outside of West Africa. Most articles were published in English (90%), and nearly half of all articles (41%) were cross-sectional studies. Our findings indicate that few peer-reviewed research studies are being published on key public health topics in the West African region, considering the magnitude of nutrition problems in this region. New approaches are needed to encourage and support research capacity and output in West Africa.

Acceptability of zinc-fortified, lipid-based nutrient supplements (LNS) prepared for young children in Burkina Faso

Micronutrient deficiencies are a public health concern among young children in low-income countries, and novel strategies are needed to improve the nutritional status of children at risk. One promising approach is the use of lipid-based nutrient supplements (LNS), which can be added to complementary food at the time of consumption. The optimal amount of zinc to include in LNS is uncertain, and concerns have been expressed about possible adverse effects of zinc on sensory characteristics of LNS. We conducted a series of acceptability studies of LNS containing either 0 or 10 mg of zinc per daily 20 g LNS dose among Burkinabe children 9-15 months old and their mothers. These acceptability studies included observations of children's consumption, maternal and child sensory reaction to the products using a 5-unit hedonic scale, a triangle test for detection of differences and a review of maternal reports of their child-feeding experiences during a 2-week home-feeding trial. The LNS products were well appreciated by the mothers and children during the sensory trials and the 2-week home-feeding trial. The addition of 10 mg zinc to LNS did not affect the consumed proportion of the offered porridge-LNS-mixture (P = 0.43). Results of the triangle test with mothers confirmed that there was no detectable difference between products containing 0 or 10 mg zinc per 20 g LNS dose. Most importantly, interviews and focus groups following the 2-week home-feeding trial indicated good acceptability of the products by mothers and their children.

Less-energy-dense diets of low-income women in California are associated with higher energy-adjusted diet costs

BACKGROUND

US-based studies are needed to estimate the relation, if any, between diet quality and estimated diet costs.

OBJECTIVE

We hypothesized that lower cost diets among low-income women in California would be energy dense but nutrient poor.

DESIGN

Energy and nutrient intakes for 112 women aged 18-45 y living in California were obtained with a food-frequency instrument. Dietary energy density (in MJ/kg or kcal/g) and energy-adjusted diet costs (in $/10 MJ or $/2000 kcal) were calculated with local food prices. Tertile splits of energy density and energy cost were analyzed with one-factor analysis of variance.

RESULTS

Mean daily energy intake excluding all beverages was 7.1 MJ (1699 kcal), and mean dietary energy density was 6.5 kJ/kg (1.54 kcal/g). Lower dietary energy density was associated with significantly higher intakes of dietary fiber (P = 0.004), vitamin A (P < 0.001), and vitamin C (P < 0.001) and with significantly lower intakes of total fat (P = 0.003) and saturated fat (P < 0.001). Higher diet cost was associated with significantly lower dietary energy density (P < 0.001), total fat (P = 0.024), and saturated fat (P = 0.025) and with significantly higher intakes of vitamins A (P = 0.003) and C (P < 0.001). Each additional dollar in estimated diet costs was associated with a drop in energy density of 0.94 MJ/kg (0.225 kcal/g).

CONCLUSIONS

The finding that higher quality diets were more costly for these low-income women has implications for the food assistance and education programs of the US Department of Agriculture. Policy interventions may be required to allow low-income families in the United States to improve the quality of their diets given their food budget constraints.