Are low tolerable upper intake levels for vitamin a undermining effective food fortification efforts?

Vitamin A deficiency (VAD) is a major health problem, particularly in low-resource countries, putting an estimated 125-130 million preschool-aged children at increased risk of morbidity and mortality from infectious diseases. Vitamin A supplementation reduces VAD and increases child survival; it is complemented by fortifying foods with vitamin A. Concern over increased risk of bone fracture associated with vitamin A intakes below the tolerable upper intake level (UL) among populations in affluent countries conflicts with the need to increase intakes in less developed countries, where populations are at greater risk of VAD and intakes are unlikely to reach the UL as diets include fewer foods containing retinol while vitamin A from carotenoids poses no risk of overdose. With the implementation of recently developed risk management tools, vitamin A can be used safely in food fortification, including point-of-use fortification in the context of supplementation among specific target groups in low-resource countrie

Diarrhea and fever as risk factors for anemia among children under age five living in urban slum areas of Indonesia

SummaryObjectivesTo characterize diarrhea and fever as risk factors for anemia among children in developing countries.MethodsWe characterized risk factors for anemia in a sample of 32873 children, aged 6–59 months, from poor families in urban slum areas of Indonesia from 2000 to 2003.ResultsThe prevalence of anemia was 58.7%. In separate multivariate models, after adjusting for age, sex, stunting, maternal age and education, and weekly per capita household expenditure, current diarrhea (OR 1.20, 95% CI 1.07–1.35, p=0.002), current fever (OR 1.44, 95% CI 1.18–1.75, p<0.0001), and a history of diarrhea in the previous seven days (OR 1.12, 95% CI 1.03–1.23, p=0.024) were associated with an increased risk of anemia.ConclusionsDiarrhea and fever are important risk factors for anemia among young children living in urban slum communities in Indonesia

Value Chain Focus on Food and Nutrition Security

Value chains are not a new concept and many working in agriculture and business have been utilizing not only the concept, but have put value chains into practical use. Yet very little has been done to ensure nutrition is included and linked into the chain. This is likely a reflection of the cross-disciplinary nature of food value chains (FVCs). The analysis of FVC requires an understanding of nutrition, agriculture, food technology, economics, marketing, etc. However, the training received by nutritionists in these other areas is often insufficient. Because of this, there are still many unanswered questions that require research, more operational understanding and collaborative investigation. Nevertheless, FVCs for nutrition have a role to play in terms of identifying innovative ways to improve the availability, affordability and acceptability of nutritious foods both in the context of under- and overnutrition, and there is currently a push for conducting FVC analyses in an integrated manner with various stakeholders. This will require buy-in from various actors in the value chain and will need to target both supply and demand-side dynamics. There is likely a role for policy in terms of supporting actions along the FVC that can contribute to healthier consumption patterns; however, there is also a role for the private sector. Applying a business-lens to nutrition may help to identify opportunities for integrating nutrition into FVCs with the goal of increasing the availability, affordability and acceptability of nutritious foods for the population

Acceptability of 12 fortified balanced energy protein supplements : insights from Burkina Faso

Poor maternal nutrition contributes to poor birth outcomes, including low birth weight and small for gestational age births. Fortified balanced energy protein (BEP) supplements may be beneficial, although evidence is limited. This mixed method study, conducted among pregnant women in Burkina Faso, is part of a larger clinical trial that seeks to understand the impact of fortified BEP supplements on pregnancy outcomes and child growth. The formative research reported here, a single‐meal rapid assessment of 12 product formulations, sought to understand product preferences for provision of BEP supplements and contextual factors that might affect product acceptability and use. Results indicate a preference for products perceived as sweet rather than salty/savoury and for products perceived as familiar, as well as a sensitivity to product odours. Women expressed a willingness and intention to use the products even if they did not like them, because of the health benefits for their babies. Data also indicate that household food sharing practices may impact supplement use, although most women denied any intention to share the products. Sharing behaviour should therefore be monitored, and strategies to avoid sharing should be developed during the succeeding parts of the research

Effect of lipid-based nutrient supplement-Medium quantity on reduction of stunting in children 6-23 months of age in Sindh, Pakistan: A cluster randomized controlled trial

Background: Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan.Objective: The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement-medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group.Design: A cluster randomized controlled trial was conducted in Thatta and Sujawal districts of Sindh province, Pakistan. A total of 870 (419 in intervention; 451 in control) children between 6-18 months old were enrolled in the study. The unit of randomization was union council and considered as a cluster. A total of 12 clusters, 6 in each study group were randomly assigned to intervention and control group. All children received standard government health services, while children in the intervention group also received 50 grams/day of Wawamum.Results: Children who received Wawamum were found to have a significantly reduced risk of stunting (RR = 0.91, 95% CI; 0.88-0.94, p\u3c0.001) and wasting (RR = 0.78, 95% CI; 0.67-0.92, p = 0.004) as compared to children who received the standard government health services. There was no evidence of a reduction in the risk of underweight (RR = 0.94, 95% CI; 0.85-1.04, p = 0.235) in the intervention group compared to the control group. Statistically significant reduction in anaemia in the intervention group was also found as compared to the control group (RR = 0.97, 95% CI; 0.94-0.99, p = 0.042). The subgroup analysis by age, showed intervention effect is significant in reduction of risk of stunting in younger children of aged 6-12 month (RR = 0.83, 95% CI; 0.81-0.86, p = \u3c0.001) and their older peers aged 13-18 month- (RR = 0.90, 95% CI; 0.83-0.97, p = 0.008). The mean compliance of Wawamum was 60% among children.Conclusions: The study confirmed that the provision of Wawamum to children 6-23 months of age is effective in reducing the risk of stunting, wasting and anaemia. This approach should be scaled up among the most food insecure areas/households with a high prevalence of stunting to achieve positive outcomes for nutrition and health. This study was registered at clinicaltrials.gov as NCT02422953. Clinical Trial Registration Number: NCT02422953

Relationship of homestead food production with night blindness among children below 5 years of age in Bangladesh

Abstract Objective To examine the relationship between homestead food production and night blindness among pre-school children in rural Bangladesh in the presence of a national vitamin A supplementation programme. Design A cross-sectional study. Setting A population-based sample of six rural divisions of Bangladesh assessed in the Bangladesh Nutrition Surveillance Project 2001-2005. Subjects A total of 158 898 children aged 12-59 months. Results The prevalence rates of night blindness in children among those who did and did not receive vitamin A capsules in the last 6 months were 0·07 % and 0·13 %, respectively. Given the known effect of vitamin A supplementation on night blindness, the analysis was stratified by children's receipt of vitamin A capsules in the last 6 months. Among children who did not receive vitamin A capsules in the last 6 months, the lack of a home garden was associated with increased odds of night blindness (OR = 3·16, 95 % CI 1·76, 5·68; P = 0·0001). Among children who received vitamin A capsules in the last 6 months, the lack of a home garden was not associated with night blindness (OR = 1·28, 95 % CI 0·71, 2·31; P = 0·4). Conclusions Homestead food production confers a protective effect against night blindness among pre-school children who missed vitamin A supplementation in rural Banglades

Child malnutrition and mortality among families not utilizing adequately iodized salt

ABSTRACT Background: Salt iodization is the main strategy for reducing iodine deficiency disorders worldwide. Characteristics of families not using iodized salt need to be known to expand coverage. Objective: The objective was to determine whether families who do not use iodized salt have a higher prevalence of child malnutrition and mortality and to identify factors associated with not using iodized salt. Design: Use of adequately iodized salt (ͧ30 ppm), measured by rapid test kits, was assessed between January 1999 and September 2003 in 145 522 and 445 546 families in urban slums and rural areas, respectively, in Indonesia. Results: Adequately iodized salt was used by 66.6% and 67.2% of families from urban slums and rural areas, respectively. Among families who used adequately iodized salt, mortality in neonates, infants, and children aged 5 y was 3.3% compared with 4.2%, 5.5% compared with 7.1%, and 6.9% compared with 9.1%, respectively (P 0.0001 for all), in urban slums; among families who did not use adequately iodized salt, the respective values were 4.2% compared with 6.3%, 7.1% compared with 11.2%, and 8.5% compared with 13.3% (P 0.0001 for all) in rural areas. Families not using adequately iodized salt were more likely to have children who were stunted, underweight, and wasted. In multivariate analyses that controlled for potential confounders, low maternal education was the strongest factor associated with not using adequately iodized salt. Conclusion: In Indonesia, nonuse of adequately iodized salt is associated with a higher prevalence of child malnutrition and mortality in neonates, infants, and children aged 5 y. Stronger efforts are needed to expand salt iodization in Indonesia. Am J Clin Nutr 2008;87:438 -44

Preventive Effects of Long-Term Supplementation with 2 Nutritious Food Supplements in Young Children in Niger

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Ready-to-use therapeutic foods (RUTFs) are solid foods that were developed by changing the formulation of the existing liquid diet, F-100, recommended by the World Health Organization (WHO) for the rapid catch-up phase of the treatment of children suffering from severe acute malnutrition (SAM). The resulting products proved highly effective in promoting weight gain in both severely and moderately wasted children and adults, including those infected with HIV. The formulation of the existing RUTFs, however, has never been optimized to maximize linear growth, vitamin and mineral status, and functional outcomes. The high milk content of RUTFs makes it an expensive product, and using lower quantities of milk seems desirable. However, the formulation of alternative, less expensive but more effective versions of RUTF faces difficult challenges, as there are uncertainties regarding the effect in terms of protein quality, antinutrient content, and flatulence factors that will result from the replacement of current dairy ingredients by less expensive protein-rich ingredients. The formulation of alternative RUTFs will require further research on these aspects, followed by efficacy studies comparing the future RUTFs to the existing formulations

Specialized nutritious food combined with cash transfers and social and behavior change communication to prevent stunting among children aged 6 to 23 months in Pakistan: Protocol for a cluster randomized controlled trial

Background: In Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country-43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households.Objective: The primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months.Methods: A 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package.Results: The study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020.Conclusions: The findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months