Maximizing the benefits and minimizing the risks of intervention programs to address micronutrient malnutrition: symposium report.

Interventions to address micronutrient deficiencies have large potential to reduce the related disease and economic burden. However, the potential risks of excessive micronutrient intakes are often not well determined. During the Global Summit on Food Fortification, 9-11 September 2015, in Arusha, a symposium was organized on micronutrient risk-benefit assessments. Using case studies on folic acid, iodine and vitamin A, the presenters discussed how to maximize the benefits and minimize the risks of intervention programs to address micronutrient malnutrition. Pre-implementation assessment of dietary intake, and/or biomarkers of micronutrient exposure, status and morbidity/mortality is critical in identifying the population segments at risk of inadequate and excessive intake. Dietary intake models allow to predict the effect of micronutrient interventions and their combinations, e.g. fortified food and supplements, on the proportion of the population with intakes below adequate and above safe thresholds. Continuous monitoring of micronutrient intake and biomarkers is critical to identify whether the target population is actually reached, whether subgroups receive excessive amounts, and inform program adjustments. However, the relation between regular high intake and adverse health consequences is neither well understood for many micronutrients, nor do biomarkers exist that can detect them. More accurate and reliable biomarkers predictive of micronutrient exposure, status and function are needed to ensure effective and safe intake ranges for vulnerable population groups such as young children and pregnant women. Modelling tools that integrate information on program coverage, dietary intake distribution and biomarkers will further enable program makers to design effective, efficient and safe programs

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali.

IntroductionModerate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6-35 months of age in Mali.MethodsWe conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn-soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal-legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy.ResultsCompared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment.ConclusionMAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds.Trial registrationNCT01015950

Predictors and Consequences of Anaemia Among Antiretroviral-Naïve HIV-Infected and HIV-Uninfected Children in Tanzania.

Predictors and consequences of childhood anaemia in settings with high HIV prevalence are not well known. The aims of the present study were to identify maternal and child predictors of anaemia among children born to HIV-infected women and to study the association between childhood anaemia and mortality. Prospective cohort study. Maternal characteristics during pregnancy and Hb measurements at 3-month intervals from birth were available for children. Information was also collected on malaria and HIV infection in the children, who were followed up for survival status until 24 months after birth. Dar es Salaam, Tanzania. The study sample consisted of 829 children born to HIV-positive women. Advanced maternal clinical HIV disease (relative risk (RR) for stage > or =2 v. stage 1: 1.31, 95 % CI 1.14, 1.51) and low CD4 cell counts during pregnancy (RR for <350 cells/mm3 v. > or =350 cells/mm3: 1.58, 95 % CI 1.05, 2.37) were associated with increased risk of anaemia among children. Birth weight <2500 g, preterm birth (<34 weeks), malaria parasitaemia and HIV infection in the children also increased the risk of anaemia. Fe-deficiency anaemia in children was an independent predictor of mortality in the first two years of life (hazard ratio 1.99, 95 % CI 1.06, 3.72). Comprehensive care including highly active antiretroviral therapy to eligible HIV-infected women during pregnancy could reduce the burden of anaemia in children. Programmes for the prevention of mother-to-child transmission of HIV and antimalarial treatment to children could improve child survival in settings with high HIV prevalence

Nutrition training in medical and other health professional schools in West Africa: the need to improve current approaches and enhance training effectiveness

Background: Health professionals play a key role in the delivery of nutrition interventions. Improving the quality of nutrition training in health professional schools is vital for building the necessary human resource capacity to implement effective interventions for reducing malnutrition in West Africa. This study was undertaken to assess the current status of nutrition training in medical, nursing and midwifery schools in West Africa. Design: Data were collected from 127 training programs organized by 52 medical, nursing, and midwifery schools. Using a semi-structured questionnaire, we collected information on the content and distribution of nutrition instruction throughout the curriculum, the number of hours devoted to nutrition, the years of the curriculum in which nutrition was taught, and the prevailing teaching methods. Simple descriptive and bivariate analyses were performed. Results: Nutrition instruction occurred mostly during the first 2 years for the nursing (84%), midwifery (87%), and nursing assistant (77%) programs and clinical years in medical schools (64%). The total amount of time devoted to nutrition was on average 57, 56, 48, and 28 hours in the medical, nursing, midwifery, and nursing assistant programs, respectively. Nutrition instruction was mostly provided within the framework of a dedicated nutrition course in nursing (78%), midwifery (87%), and nursing assistant programs (100%), whereas it was mainly embedded in other courses in medical schools (46%). Training content was heavily weighted to basic nutrition in the nursing (69%), midwifery (77%), and nursing assistant (100%) programs, while it was oriented toward clinical practice in the medical programs (64%). For all the programs, there was little focus (<6 hours contact time) on public health nutrition. The teaching methods on nutrition training were mostly didactic in all the surveyed schools; however, we found an integrated model in some medical schools (12%). None of the surveyed institutions had a dedicated nutrition faculty. The majority (55%) of the respondents rated nutrition instruction in their institutions as insufficient. Conclusions: The results of our study reveal important gaps in current approaches to nutrition training in health professional schools in West Africa. Addressing these gaps is critical for the development of a skilled nutrition workforce in the region. Nutrition curricula that provide opportunities to obtain more insights about the basic principles of human nutrition and their application to public health and clinical practice are recommended

Multivitamin Supplementation Improves Haematologic Status in Children Born to HIV-positive women in Tanzania.

Anaemia is prevalent among children born to HIV-positive women, and it is associated with adverse effects on cognitive and motor development, growth, and increased risks of morbidity and mortality. To examine the effect of daily multivitamin supplementation on haematologic status and mother-to-child transmission (MTCT) of HIV through breastfeeding. A total of 2387 infants born to HIV-positive women from Dar es Salaam, Tanzania were enrolled in a randomized, double-blind, placebo-controlled trial, and provided a daily oral supplement of multivitamins (vitamin B complex, C and E) or placebo at age 6 weeks for 24 months. Among them, 2008 infants provided blood samples and had haemoglobin concentrations measured at baseline and during a follow-up period. Anaemia was defined as haemoglobin concentrations <11 g/dL and severe anaemia <8.5 g/dL. Haemoglobin concentrations among children in the treatment group were significantly higher than those in the placebo group at 12 (9.77 vs. 9.64 g/dL, p=0.03), 18 (9.76 vs. 9.57 g/dL, p=0.004), and 24 months (9.93 vs. 9.75 g/dL, p=0.02) of follow-up. Compared to those in the placebo group, children in the treatment group had a 12% lower risk of anaemia (hazard ratio (HR): 0.88; 95% CI: 0.79-0.99; p=0.03). The treatment was associated with a 28% reduced risk of severe anaemia among children born to women without anaemia (HR: 0.72; 95% CI: 0.56-0.92; p=0.008), but not among those born to women with anaemia (HR: 1.10; 95% CI: 0.79-1.54; p=0.57; p for interaction=0.007). One thousand seven hundred fifty three infants who tested HIV-negative at baseline and had HIV testing during follow-up were included in the analysis for MTCT of HIV. No association was found between multivitamin supplements and MTCT of HIV. Multivitamin supplements improve haematologic status among children born to HIV-positive women. Further trials focusing on anaemia among HIV-exposed children are warranted in the context of antiretroviral therapy

Effect of selenium supplementation on HIV-1 RNA detection in breast milk of Tanzanian women

Objective Selenium supplementation for HIV-infected women may increase genital shedding of HIV-1, but no studies have examined the effect on viral shedding in breast milk. Research Methods and Procedures HIV-infected pregnant women enrolled at 12–27 weeks gestation in a randomized, double-blind, placebo-controlled trial of daily selenium (200 μg as selenomethionine) had cell-free HIV-1 RNA quantified in breast milk at 4–9 weeks postpartum. All participants received high dose multivitamins containing vitamin B-complex, C, and E as standard of care. Results The proportion of women with detectable (>50 copies/mL) HIV-1 RNA in breast milk appeared to be increased in the selenium group (36.4%) as compared to the placebo (27.5%) among the total cohort (n=420), but results were borderline statistically significant (RR: 1.32; 95% CI: 1.00–1.76; p=0.05). In secondary analyses, the proportion of women with detectable HIV-1 RNA in breast milk was significantly greater in the selenium group (37.8%) as compared to placebo (27.5%) among women who did not receive HAART (RR: 1.37; 95% CI: 1.03–1.82; p=0.03). This relationship was primarily due to a significant effect of selenium among primiparous women (RR: 2.24; 95% CI: 1.30–3.86; p<0.01), but not multiparous women (RR: 1.14; 95% CI: 0.81–1.59; p=0.54) (p-value for interaction=0.02). Too few women received HAART in this study (n=12) to establish the effect of selenium supplementation. Conclusions Selenium supplementation appears to increase HIV-1 RNA detection in breast milk among primiparous women not receiving HAART. Safety studies among pregnant women on HAART need to be conducted before providing selenium containing supplements

Effect of Selenium Supplements on Hemoglobin Concentration and Morbidity among HIV‐1–Infected Tanzanian Women

Selenium deficiency may increase risks of anemia and morbidity among people with human immunodeficiency virus infection. We therefore investigated the effect of selenium supplements (200 µg of selenomethionine) on these end points among 915 pregnant Tanzanian women. Hemoglobin concentration was measured at baseline (at 12–27 weeks of gestation) and at 6 weeks and 6 months postpartum, and morbidity data were collected during monthly visits to the clinic. Selenium supplements had no effect on hemoglobin concentrations during follow-up (mean difference, 0.05 g/dL; 95% confidence interval, −0.07 to 0.16 g/dL) but reduced diarrheal morbidity risk by 40% (relative risk, 0.60; 95% confidence interval, 0.42–0.84). There was no effect on the other morbidity end points

Predictors of stillbirth among HIV-infected Tanzanian women

Objective: To determine maternal risk factors for stillbirth among pregnant HIV-infected women in sub-Saharan Africa. Design: Prospective cohort study nested within a micronutrient trial. At enrollment, maternal sociodemographic, obstetric, immunologic, clinical, and nutritional variables were measured. Women were followed through monthly clinic visits until delivery. Multivariate predictors of stillbirth were identified in Poisson regression models. Setting: Antenatal clinic in a tertiary care hospital in urban Dar es Salaam, Tanzania. Population: N = 1,078 women enrolled between 12 and 27 weeks of gestation. Main outcome measures: Stillbirth (delivery of dead baby ≥ 28 weeks’ gestation), fresh stillbirth, and macerated stillbirth. Results: Among 1,017 singleton pregnancies, there were 49 stillbirths, yielding a stillbirth risk of 50.0 per 1,000 deliveries (95% Confidence Interval(CI) = 37.2, 65.6). Of stillbirths with known type, 53.7% were fresh and 46.3% macerated. In multivariate analyses, baseline measures of late ( ≥ 21 weeks’ gestation) study entry (Relative Risk (RR) = 2.13, 95% CI = 1.17, 3.87), CD3 count ≥ 1,179 cells/ml (RR = 2.15, 95% CI = 1.16, 4.01), stillbirth history (RR = 3.53, 95% CI = 1.30, 9.59), primiparity (RR = 3.65, 95% CI = 1.83, 7.29), and syphilis infection (RR = 2.06, 95% CI = 1.09, 3.88) predicted increased stillbirth risk. Late study entry, illiteracy, stillbirth history, primiparity, CD3 count ≥ 1,179 cells/ml, gonorrhea infection, and previous hospitalization predicted increased risk of fresh stillbirth, while living alone and syphilis infection predicted increased risk of macerated stillbirth. Conclusions: Applying antenatal screening and preventive tools for the socioeconomic, obstetric, immunologic, and clinical risk factors identified may assist in reducing the high incidence of stillbirth among HIV-infected women in urban sub-Saharan Africa

Conceptual framework of food systems for children and adolescents

Transforming food systems is essential to ensuring nutritious, safe, affordable, and sustainable diets for all, including children and adolescents. This paper proposes a new conceptual framework (the ‘Innocenti Frame­ work’) to better articulate how the diets of children and adolescents are shaped by food systems. The framework is comprised of a set of food system drivers, determinants (namely, food supply chains, external food environ­ ments, personal food environments, and behaviors of caregivers, children and adolescents), influencers, and interactions, which together determine children’s and adolescents’ diets. The conceptual framework conceptu­ alizes the dynamic linkages between the elements of food systems, and highlights the importance of continuously shaping food systems to deliver nutritious, safe, affordable, and sustainable diets to children and adolescents

Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition.

BackgroundModerate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone.ObjectiveThe aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period.MethodsBC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status.ResultsMean&nbsp;±&nbsp;SD %FM at baseline was 28.6%&nbsp;±&nbsp;5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P&nbsp;=&nbsp;0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P&nbsp;=&nbsp;0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P&nbsp;=&nbsp;0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover.ConclusionsIn this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950