Nutritional Status, Dietary Intake, and Relevant Knowledge of Adolescent Girls in Rural Bangladesh

This study estimated the levels and differentials in nutritional status and dietary intake and relevant knowledge of adolescent girls in rural Bangladesh using data from the Baseline Survey 2004 of the National Nutrition Programme. A stratified two-stage random cluster-sampling was used for selecting 4,993 unmarried adolescent girls aged 13-18 years in 708 rural clusters. Female interviewers visited girls at home to record their education, occupation, dietary knowledge, seven-day food-frequency, intake of iron and folic acid, morbidity, weight, and height. They inquired mothers about age of their daughters and possessions of durable assets to divide households into asset quintiles. Results revealed that 26% of the girls were thin, with body mass index (BMI)-for-age <15th percentile), 0.3% obese (BMI-for-age >95th percentile), and 32% stunted (height-for-age 642SD). Risks of being thin and stunted were higher if girls had general morbidity in the last fortnight and foul-smelling vaginal discharge than their peers. Consumptions of non-staple good-quality food items in the last week were less frequent and correlated well positively with the household asset quintile. Girls of the highest asset quintile ate fish/meat 2.1 (55%) days more and egg/milk two (91%) days more than the girls in the lowest asset quintile. The overall dietary knowledge was low. More than half could not name the main food sources of energy and protein, and 36% were not aware of the importance of taking extra nutrients during adolescence for growth spurt. The use of iron supplement was 21% in nutrition-intervention areas compared to 8% in non-intervention areas. Factors associated with the increased use of iron supplements were related to awareness of the girls about extra nutrients and their access to mass media and education. Community-based adolescent-friendly health and nutrition education and services and economic development may improve the overall health and nutritional knowledge and status of adolescents

Nutrition: Basis for Healthy Children and Mothers in Bangladesh

Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR, B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984–2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR, B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR, B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peer-counselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR, B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR, B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place

Nutrition: Basis for Healthy Children and Mothers in Bangladesh

Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR,B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984-2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR,B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR,B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peercounselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR,B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR,B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place

Nutrition of Children and Women in Bangladesh: Trends and Directions for the Future

Although child and maternal malnutrition has been reduced in Bangladesh, the prevalence of underweight (weight-for-age z-score <-2) among children aged less than five years is still high (41%). Nearly one-third of women are undernourished with body mass index of <18.5 kg/m2. The prevalence of anaemia among young infants, adolescent girls, and pregnant women is still at unacceptable levels. Despite the successes in specific programmes, such as the Expanded Programme on Immunization and vitamin A supplementation, programmes for nutrition interventions are yet to be implemented at scale for reaching the entire population. Given the low annual rate of reduction in child undernutrition of 1.27 percentage points per year, it is unlikely that Bangladesh would be able to achieve the United Nations’ Millennium Development Goal to address undernutrition. This warrants that the policy-makers and programme managers think urgently about the ways to accelerate the progress. The Government, development partners, non-government organizations, and the academia have to work in concert to improve the coverage of basic and effective nutrition interventions, including exclusive breastfeeding, appropriate complementary feeding, supplementation of micronutrients to children, adolescent girls, pregnant and lactating women, management of severe acute malnutrition and deworming, and hygiene interventions, coupled with those that address more structural causes and indirectly improve nutrition. The entire health system needs to be revitalized to overcome the constraints that exist at the levels of policy, governance, and service-delivery, and also for the creation of demand for the services at the household level. In addition, management of nutrition in the aftermath of natural disasters and stabilization of prices of foods should also be prioritized

Measuring socioeconomic status in multicountry studies: Results from the eight-country MAL-ED study

Background: There is no standardized approach to comparing socioeconomic status (SES) across multiple sites in epidemiological studies. This is particularly problematic when cross-country comparisons are of interest. We sought to develop a simple measure of SES that would perform well across diverse, resource-limited settings. Methods: A cross-sectional study was conducted with 800 children aged 24 to 60 months across eight resource-limited settings. Parents were asked to respond to a household SES questionnaire, and the height of each child was measured. A statistical analysis was done in two phases. First, the best approach for selecting and weighting household assets as a proxy for wealth was identified. We compared four approaches to measuring wealth: maternal education, principal components analysis, Multidimensional Poverty Index, and a novel variable selection approach based on the use of random forests. Second, the selected wealth measure was combined with other relevant variables to form a more complete measure of household SES. We used child height-for-age Z-score (HAZ) as the outcome of interest. Results: Mean age of study children was 41 months, 52% were boys, and 42% were stunted. Using cross-validation, we found that random forests yielded the lowest prediction error when selecting assets as a measure of household wealth. The final SES index included access to improved water and sanitation, eight selected assets, maternal education, and household income (the WAMI index). A 25% difference in the WAMI index was positively associated with a difference of 0.38 standard deviations in HAZ (95% CI 0.22 to 0.55). Conclusions: Statistical learning methods such as random forests provide an alternative to principal components analysis in the development of SES scores. Results from this multicountry study demonstrate the validity of a simplified SES index. With further validation, this simplified index may provide a standard approach for SES adjustment across resource-limited settings.publishedVersio

Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study

We report the infant feeding experiences in the first month of life for 2,053 infants participating in \u201cMalnutrition and Enteric Infections: Consequences for Child Health and Development\u201d (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were &lt; 60% in 6 of 8 sites, and of partial breastfeeding (or no) were &gt; 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids

Nutritional Status, Dietary Intake, and Relevant Knowledge of Adolescent Girls in Rural Bangladesh

This study estimated the levels and differentials in nutritional status and dietary intake and relevant knowledge of adolescent girls in rural Bangladesh using data from the Baseline Survey 2004 of the National Nutrition Programme. A stratified two-stage random cluster-sampling was used for selecting 4,993 unmarried adolescent girls aged 13-18 years in 708 rural clusters. Female interviewers visited girls at home to record their education, occupation, dietary knowledge, seven-day food-frequency, intake of iron and folic acid, morbidity, weight, and height. They inquired mothers about age of their daughters and possessions of durable assets to divide households into asset quintiles. Results revealed that 26% of the girls were thin, with body mass index (BMI)-for-age <15th percentile), 0.3% obese (BMI-for-age >95th percentile), and 32% stunted (height-for-age ≤2SD). Risks of being thin and stunted were higher if girls had general morbidity in the last fortnight and foul-smelling vaginal discharge than their peers. Consumptions of non-staple good-quality food items in the last week were less frequent and correlated well positively with the household asset quintile. Girls of the highest asset quintile ate fish/meat 2.1 (55%) days more and egg/milk two (91%) days more than the girls in the lowest asset quintile. The overall dietary knowledge was low. More than half could not name the main food sources of energy and protein, and 36% were not aware of the importance of taking extra nutrients during adolescence for growth spurt. The use of iron supplement was 21% in nutrition-intervention areas compared to 8% in non-intervention areas. Factors associated with the increased use of iron supplements were related to awareness of the girls about extra nutrients and their access to mass media and education. Community-based adolescent-friendly health and nutrition education and services and economic development may improve the overall health and nutritional knowledge and status of adolescents

Diarrhoea and smoking: An analysis of decades of observational data from Bangladesh Health behavior, health promotion and society

Background: Although cigarette smoking affects all biological systems of the human body including the gastrointestinal tract, there is a lack of evidence regarding its effect on the severity of diarrhoeal disease and whether a dose-response relationship exists. We therefore tested for the presence of specific causative pathogens for infectious diarrhoea, assessed the independent effect of smoking on its severity and tested whether any dose-response relationship existed while controlling for subjects' age, sociodemographic characteristics and presence of causative pathogens in an urban setting in Bangladesh. Methods: A total of 20,757 patients aged 15 years and above with diarrhoea were enrolled into the Diarrhoeal Disease Surveillance System, managed by the International Centre for Diarrhoeal Disease Research, Bangladesh, from 1993 to 2012. We collected data on individuals' current daily consumption of cigarettes and bidis (traditional hand-rolled cigarettes) and conducted an ordered logistic regression to determine the effect of smoking on diarrhoeal disease severity and whether a dose-response relationship exists. Results: We identified 19 % of patients with diarrhoea as smokers, of whom 52 % smoked 1-9 cigarettes per day. While 97 % of smokers were Male, 41 % were aged 15-30 years of age. Smokers were found to have a significantly lower severity of diarrhoeal disease (OR: 0.92, 95 % CI: 0.85-0.99, p∈=∈0.025) after adjusting for age, wealth quintile, illiteracy and the presence of specific causative pathogens (Vibrio cholerae and Shigella). We observed no dose-response relationship between the number of cigarettes smoked per day and disease severity when adjusting for the same covariates. Smokers were more frequently infected with Shigella (7 vs. 6 %, p

Causal Pathways from Enteropathogens to Environmental Enteropathy: Findings from the MAL-ED Birth Cohort Study

Background: Environmental enteropathy (EE), the adverse impact of frequent and numerous enteric infections on the gut resulting in a state of persistent immune activation and altered permeability, has been proposed as a key determinant of growth failure in children in low- and middle-income populations. A theory-driven systems model to critically evaluate pathways through which enteropathogens, gut permeability, and intestinal and systemic inflammation affect child growth was conducted within the framework of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) birth cohort study that included children from eight countries. Methods: Non-diarrheal stool samples (N = 22,846) from 1253 children from multiple sites were evaluated for a panel of 40 enteropathogens and fecal concentrations of myeloperoxidase, alpha-1-antitrypsin, and neopterin. Among these same children, urinary lactulose:mannitol (L:M) (N = 6363) and plasma alpha-1-acid glycoprotein (AGP) (N = 2797) were also measured. The temporal sampling design was used to create a directed acyclic graph of proposed mechanistic pathways between enteropathogen detection in non-diarrheal stools, biomarkers of intestinal permeability and inflammation, systemic inflammation and change in length- and weight- for age in children 0–2 years of age. Findings: Children in these populations had frequent enteric infections and high levels of both intestinal and systemic inflammation. Higher burdens of enteropathogens, especially those categorized as being enteroinvasive or causing mucosal disruption, were associated with elevated biomarker concentrations of gut and systemic inflammation and, via these associations, indirectly associated with both reduced linear and ponderal growth. Evidence for the association with reduced linear growth was stronger for systemic inflammation than for gut inflammation; the opposite was true of reduced ponderal growth. Although Giardia was associated with reduced growth, the association was not mediated by any of the biomarkers evaluated. Interpretation: The large quantity of empirical evidence contributing to this analysis supports the conceptual model of EE. The effects of EE on growth faltering in young children were small, but multiple mechanistic pathways underlying the attribution of growth failure to asymptomatic enteric infections had statistical support in the analysis. The strongest evidence for EE was the association between enteropathogens and linear growth mediated through systemic inflammation. Funding: Bill & Melinda Gates Foundation