Analysis of data from a national micronutrient survey with a linear mixed model: estimates, predictions and lessons for future surveys.

Background: Because micronutrient deficiencies affect public health, countries monitor population status by national-scale, multi-stage, micronutrient surveys (MNS). In design-based surveys, inclusion probabilities are specified for sample units and the corresponding sample weights allow design-unbiased estimates to be made of population parameters. Corrections may be possible on departures from the design; an alternative is to use linear mixed models (LMM), with an estimated covariance structure reflecting the sampling design, to obtain model-based estimates. Design: The Ethiopia National Micronutrient Survey (2016) specified inclusion probabilities at enumeration area (EA) and household (HH) levels, and sample weights are provided. However, the design was not followed as it would have resulted in insufficient sampling from women of reproductive age. Results: Having found no evidence that sample weights were informative for target serum micronutrient concentrations (Zn), we estimated LMM parameters, with Regions as fixed effects, and the variation of individuals nested within households, households within EA, and EA within regions, random effects. We obtained LMM standard errors, Best Linear Unbiased Estimates (BLUEs) of regional means, and empirical Best Linear Unbiased Predictions for sampled/unsampled EA and HH. The probability that each true regional mean exceeded the sufficiency threshold ( 65 µ g dL - 1 ) was evaluated. The variances of BLUEs of regional means, under alternative sampling designs, were bootstrapped from LMM variance components. Conclusions: We demonstrate use of LMM to obtain model-unbiased estimates and predictions when surveys deviate from the original design; and the use of LMM variance components to evaluate alternative designs for further sampling, or for sampling comparable populations.

Current or recent malaria infection is associated with elevated inflammation-adjusted ferritin concentrations in pre-school children: a secondary analysis of the BRINDA database.

Inflammation and infections such as malaria affect micronutrient biomarker concentrations and hence estimates of nutritional status. It is unknown whether correction for C-reactive protein (CRP) and α1-acid glycoprotein (AGP) fully captures the modification in ferritin concentrations during a malaria infection, or whether environmental and sociodemographic factors modify this association. Cross-sectional data from eight surveys in children aged 6-59 months (Cameroon, Cote d'Ivoire, Kenya, Liberia, Malawi, Nigeria and Zambia; n 6653) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anaemia (BRINDA) project were pooled. Ferritin was adjusted using the BRINDA adjustment method, with values < 12 µg/l indicating iron deficiency. The association between current or recent malaria infection, detected by microscopy or rapid test kit, and inflammation-adjusted ferritin was estimated using pooled multivariable linear regression. Age, sex, malaria endemicity profile (defined by the Plasmodium falciparum infection prevalence) and malaria diagnostic methods were examined as effect modifiers. Unweighted pooled malaria prevalence was 26·0 % (95 % CI 25·0, 27·1) and unweighted pooled iron deficiency was 41·9 % (95 % CI 40·7, 43·1). Current or recent malaria infection was associated with a 44 % (95 % CI 39·0, 52·0; P < 0·001) increase in inflammation-adjusted ferritin after adjusting for age and study identifier. In children, ferritin increased less with malaria infection as age and malaria endemicity increased. Adjustment for malaria increased the prevalence of iron deficiency, but the effect was small. Additional information would help elucidate the underlying mechanisms of the role of endemicity and age in the association between malaria and ferritin.

Burden of selenium deficiency and cost-effectiveness of selenium agronomic biofortification of staple cereals in Ethiopia.

Selenium (Se) deficiency among populations in Ethiopia is consistent with low concentrations of Se in soil and crops that could be addressed partly by Se-enriched fertilisers. This study examines the disease burden of Se deficiency in Ethiopia and evaluates the cost-effectiveness of Se agronomic biofortification. A disability-adjusted life years (DALY) framework was used, considering goiter, anaemia, and cognitive dysfunction among children and women. The potential efficiency of Se agronomic biofortification was calculated from baseline crop composition and response to Se fertilisers based on an application of 10 g/ha Se fertiliser under optimistic and pessimistic scenarios. The calculated cost per DALY was compared against gross domestic product (GDP; below 1-3 times national GDP) to consider as a cost-effective intervention. The existing national food basket supplies a total of 28·2 µg of Se for adults and 11·3 µg of Se for children, where the risk of inadequate dietary Se reaches 99·1 %-100 %. Cereals account for 61 % of the dietary Se supply. Human Se deficiency contributes to 0·164 million DALYs among children and women. Hence, 52 %, 43 %, and 5 % of the DALYs lost are attributed to anaemia, goiter, and cognitive dysfunction, respectively. Application of Se fertilisers to soils could avert an estimated 21·2-67·1 %, 26·6-67·5 % and 19·9-66·1 % of DALY via maize, teff and wheat at a cost of US$129·6-226·0, US$149·6-209·1 and US$99·3-181·6, respectively. Soil Se fertilisation of cereals could therefore be a cost-effective strategy to help alleviate Se deficiency in Ethiopia, with precedents in Finland.

Food-based dietary guidelines for optimizing calcium intakes for reproductive-aged women in Ethiopia using local foods.

Increasing dietary calcium intakes of Ethiopian women of reproductive age (WRA) is a public health priority for reducing pre-eclampsia in pregnancy. Using linear programming, we determined whether locally available foods consumed by WRA in nine regions (urban and rural) and two administrative cities of Ethiopia could provide 1000 mg/day of dietary calcium, and we identified food-based recommendations (FBRs) to improve dietary calcium adequacy in each region. Results showed that diets providing 1000 mg/day of calcium were feasible in eight regions (40%) of the target populations examined. It would, however, require marked changes for most populations (90%), increasing the number of servings per week of several food groups to levels close to those of high consumers in each population. The selected calcium-specific FBRs integrate well into the 2022 Ethiopian Dietary Guidelines, requiring additional messages to consume green leafy vegetables, milk, root crops, or teff (Eragrostis tef) or to consume a higher number of servings of vegetables than currently recommended, depending on the population. In conclusion, these analyses show that a food-based approach can be used to achieve dietary calcium adequacy among WRA in 40% of the populations examined. For the other populations, food-based interventions alone may be inadequate and other interventions are likely needed.

Modeling the Contribution of Multiple Micronutrient Fortification of Salt to Daily Nutrient Intake Among the Ethiopian Population.

Background: Salt is an affordable commodity and has wide coverage regardless of economic and social status and, hence, could be suitable vehicle for multiple micronutrient fortification. Objectives: This study aimed to simulate the contribution folic acid and zinc fortification of iodized salt to nutrient intake among the Ethiopian population. Methods: The 2013 Ethiopian National Food Consumption Survey and various food composition tables were used to estimate baseline individual-level micronutrient intake. Usual intake was estimated using the Simulating Intake of Micronutrients for Policy Learning and Engagement macro tool. Discretionary salt consumption was calculated from total salt intake estimated using urinary sodium excretion. Fortificant addition rates were set to obtain maximum nutrient intake while simultaneously constraining that population with intake above the tolerable upper intake level to <5%. Addis Ababa and Somali (N = 2271), the regions with relatively the lowest and highest micronutrient deficiency prevalence in Ethiopia, were selected. Result: Baseline median intake of Zn was below the estimated average requirement for all demographic groups. Inadequate Zn intake ranged from 73% to 99%, the highest prevalence being observed among women in lower class of wealth quintiles from Somali region. Dietary folate inadequacy was as low as 2% among men in Addis Ababa but almost all (99%) women from Somali region had inadequate folate intake. Calculated discretionary salt intake was 7.5 g/d for adult men and women and 3.4 g/d for children. With addition 0.8 mg Zn and 30 µg of folic acid per gram of salt, multiple salt fortification is estimated to reduce Zn inadequacy by 38 percentage points in urban areas and19 percentage points in rural areas. Modeled reduction in folate inadequacy were 18% in urban areas and 22% in rural areas. Conclusions: Multiple salt fortification could be an effective approach to address micronutrient adequacy in Ethiopia given efficacious, technological, and economical feasibility.

Projecting the Contribution of Provitamin A Maize Biofortification and Other Nutrition Interventions to the Nutritional Adequacy and Cost of Diets in Rural Zimbabwe.

BACKGROUND: Evidence of the effectiveness of biofortified maize with higher provitamin A (PVA) to address vitamin A deficiency in rural Africa remains scant. OBJECTIVES: This study projects the impact of adopting PVA maize for a diversity of households in an area typical of rural Zimbabwe and models the cost and composition of diets adequate in vitamin A. METHODS: Household-level weighed food records were generated from 30 rural households during a week in April and November 2021. Weekly household intakes were calculated, as well as indicative costs of diets using data from market surveys. The impact of PVA maize adoption was modeled assuming all maize products contained observed vitamin A concentrations. The composition and cost of the least expensive indicative diets adequate in vitamin A were calculated using linear programming. RESULTS: Very few households would reach adequate intake of vitamin A with the consumption of PVA maize. However, from a current situation of 33%, 50%-70% of households were projected to reach ≥50% of their requirements (the target of PVA), even with the modest vitamin A concentrations achieved on-farm (mean of 28.3 µg RAE per 100 g). This proportion would increase if higher concentrations recorded on-station were achieved. The estimated daily costs of current diets (mean ± standard deviation) were USD 1.43 ± 0.59 in the wet season and USD 0.96 ± 0.40 in the dry season. By comparison, optimization models suggest that diets adequate in vitamin A could be achieved at daily costs of USD 0.97 and USD 0.79 in the wet and dry seasons, respectively. CONCLUSIONS: The adoption of PVA maize would bring a substantial improvement in vitamin A intake in rural Zimbabwe but should be combined with other interventions (e.g., diet diversification) to fully address vitamin A deficiency.

Urine Se concentration poorly predicts plasma Se concentration at sub-district scales in Zimbabwe, limiting its value as a biomarker of population Se status.

Introduction: The current study investigated the value of urine selenium (Se) concentration as a biomarker of population Se status in rural sub-Saharan Africa. Method: Urine and plasma Se concentrations were measured among children aged 6-59 months (n = 608) and women of reproductive age (WRA, n = 781) living in rural Zimbabwe (Murehwa, Shamva, and Mutasa districts) and participating in a pilot national micronutrient survey. Selenium concentrations were measured by inductively coupled plasma-mass spectrometry (ICP-MS), and urine concentrations were corrected for hydration status. Results: The median (Q1, Q3) urine Se concentrations were 8.4 µg/L (5.3, 13.5) and 10.5 µg/L (6.5, 15.2) in children and WRA, respectively. There was moderate evidence for a relationship between urine Se concentration and plasma Se concentration in children (p = 0.0236) and WRA (p = < 0.0001), but the relationship had poor predictive value. Using previously defined thresholds for optimal activity of iodothyronine deiodinase (IDI), there was an association between deficiency when indicated by plasma Se concentrations and urine Se concentrations among WRA, but not among children. Discussion: Urine Se concentration poorly predicted plasma Se concentration at sub-district scales in Zimbabwe, limiting its value as a biomarker of population Se status in this context. Further research is warranted at wider spatial scales to determine the value of urine Se as a biomarker when there is greater heterogeneity in Se exposure.

Differences in the nutritional quality of improved finger millet genotypes in Ethiopia.

Improved crop genotypes are constantly introduced. However, information on their nutritional quality is generally limited. The present study reports the proximate composition and the concentration and relative bioavailability of minerals of improved finger millets of different genotypes. Grains of finger millet genotypes (n = 15) grown in research station during 2019 and 2020 in Ethiopia, and replicated three times in a randomized complete block design, were analysed for proximate composition, mineral concentration (iron, zinc, calcium, selenium), and antinutritional factors (phytate, tannin and oxalate). Moreover, the antinutritional factors to mineral molar ratio method was used to estimate mineral bioavailability. The result shows a significant genotypic variation in protein, fat and fibre level, ranging from 10% to 14.6%, 1.0 to 3.8%, and 1.4 to 4.6%, respectively. Similarly, different finger millets genotypes had significantly different mineral concentrations ranging from 3762 ± 332 to 5893 ± 353 mg kg-1 for Ca, 19.9 ± 1.6 to 26.2 ± 2.7 mg kg-1 for Zn, 36.3 ± 4.6 to 52.9 ± 9.1 mg kg-1 for Fe and 36.6 ± 11 to 60.9 ± 22 µg kg-1 for Se. Phytate (308-360 µg g-1), tannin (0.15-0.51 mg g-1) and oxalate (1.26-4.41 mg g-1) concentrations were also influenced by genotype. Antinutritional factors to minerals molar ratio were also significantly different by genotypes but were below the threshold for low mineral bioavailability. Genotype significantly influenced mineral and antinutritional concentrations of finger millet grains. In addition, all finger millet genotypes possess good mineral bioavailability. Especially, the high Ca concentration in finger millet, compared to in other cereals, could play a vital role to combating Ca deficiency. The result suggests the different finger millet genotypes possess good nutrient content and may contribute to the nutrition security of the local people.

Dietary selenium intake among Ethiopian children in areas known for selenium spatial variability.

Introduction: There is spatial variability of selenium (Se) in soil and crops in Ethiopia. We assessed the Se content of food items, breast milk, and urine among infants in Ethiopia from two areas with contrasting Se concentrations in soils. Methods: Dietary Se intakes among children (6-23 months) were evaluated using a weighed food record on two non-consecutive days. Also, spot urine samples from children and breast milk samples from their mothers were collected to determine Se concentration. Selenium concentrations in the samples were analyzed using an inductively coupled plasma mass spectrometer (ICP-MS). Results: Injera (prepared from teff and mixtures of other cereals) with a legume-based stew were the most frequently consumed foods by the children in both areas, followed by pasta. Overall, the Se concentration (mean ± SD) of food items, breast milk (12.2 ± 3.9 µg/L vs. 3.39 ± 1.5 µg/L), and urine samples (22.5 ± 11.5 µg/L vs. 3.0 ± 1.9 µg/L) from East Amhara were significantly higher than the corresponding samples from West Amhara (p < 0.001). The total Se intakes by the study children from East Amhara and West Amhara were 30.2 [IQ 25%, 14.2; IQ 75%, 54.1] and 7.4 [IQR 25%, 4.2; IQ 75%, 10.6] µg day-1, respectively; 31.5% of children from East Amhara and 92% of children from West Amhara were at risk of inadequate Se intakes. Urinary Se excretion accounted for 53 and 39% of daily dietary Se intake in East Amhara and West Amhara, respectively. Dietary Se intake was positively correlated with urinary Se excretion in East Amhara (r = 0.56; p < 0.001) but not among samples from West Amhara (r = 0.16; p ≥ 0.05), suggesting greater physiological Se conservation in a state of deficiency. Conclusion: There is spatial variability of Se in foods, breast milk, and urine in Ethiopia, suggesting the need for implementation of targeted agronomic interventions that enhance Se concentrations in the edible portion of plant foods.

Farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan: a mixed methods study.

Background: Zinc biofortified wheat may be a sustainable strategy to increase zinc intake in areas where fortification and dietary diversification are not feasible or are limited by household purchasing power. This convergent mixed methods study aimed to explore the farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan. Methods: A telephone survey was conducted with farmers (n = 418) who were provided with Zincol-2016 biofortified wheat seed for the 2019-2020 growing season, as part of a wheat grain micronutrient mapping study across Punjab Province. The survey explored the farmers' experiences of growing Zincol-2016 and whether they opted to grow it again in the subsequent season. Semi-structured focus group discussions were undertaken in a separate group of farmers in Khyber Pakhtunkhwa (KP) province (n = 12) who grew Zincol-2016 for the BiZiFED2 RCT. Millers were also interviewed in KP, both those who had processed Zincol-2016 for the trial (n = 12) and those who had no experience of processing biofortified wheat (n = 12). Survey data were analyzed using descriptive statistics and transcripts of focus groups were analyzed using thematic analysis. Results: Nearly half of farmers who responded to the survey (47%) re-cultivated Zincol-2016 in the following season. The drivers for Zincol-2016 re-cultivation were seed availability (100%), grain yield and growth resistance (98%), quality of the flour from the previous harvest (97%) and nutritional benefit (94.5%). Discussions with farmers suggested that the main motivators for potential scale-up of biofortified wheat were the perceived quality of the grain, wheat, and flour. Millers saw it as an opportunity to expand their business. Farmers and millers valued the health benefits of the wheat. Challenges for scale-up include the need of additional support to produce it, unfamiliarity with the biofortification process, production costs, and external threats to the supply chain. Conclusion: Farmers and millers showed a strong implicit preference for Zincol-2016 over alternative varieties. Crop performance and product yield were the most cited motivators for growing Zincol-2016. Farmers and millers are willing to produce and process biofortified wheat if financial and educational support is provided.

Increasing fibre in white flour and bread: Implications for health and processing.

Dietary fibre is beneficial for human health, but dietary intakes are below recommended levels in most countries. Cereals are the major source of dietary fibre in Western diets, with bread providing about 20% of the daily intake in the United Kingdom. Despite the promotion of fibre-rich wholegrain products, white bread (which has a lower fibre content) remains dominant in many countries due to cultural preferences. Increasing the fibre content of white bread and other products made from white flour is therefore an attractive strategy for increasing fibre intake. This can be achieved by exploiting genetic variation in wheat without major effects on the processing quality or the consumer acceptability of products. Modelling data for food consumption in the United Kingdom shows that increasing the fibre content of white flour by 50% (from about 4% to 6% dry weight) and in wholegrain by 20% will increase total fibre intake by 1.04 g/day and 1.41 g/day in adult females and males, respectively. Furthermore, in vitro studies indicate that the increased fibre content of white bread should reduce the rate of starch digestion and glucose release in the human gastrointestinal tract.

Do agronomic approaches aligned to regenerative agriculture improve the micronutrient concentrations of edible portions of crops? A scoping review of evidence.

Regenerative Agriculture (RA) is used to describe nature-based agronomic approaches that aim to build soil health and crop resilience, minimize negative environmental outcomes, and improve farmer livelihoods. A benefit that is increasingly attributed to crops grown under RA practices is improved nutritional content. However, we do not know the extent to which RA influences crop nutritional quality and under what management approaches and context, can such effects be realized. A scoping review of recent literature (Web of Science, 2000-2021) was carried out to assess the evidence that RA approaches improve crop micronutrient quality. Papers included combinations of agronomic approaches that could be defined as Regenerative: "Organic Inputs" including composts and manures, cover crops, crop rotations, crop residues and biochars; "Reduced Tillage", "Intercropping", "Biostimulants" e.g. arbuscular mycorrhizal fungi; plant growth promoting bacteria, and "Irrigation", typically deficit-irrigation and alternate wetting and drying. The crop types reviewed were predetermined covering common sources of food and included: Tomato (Solanum lycopersicum L.), Wheat (Triticum aestivum L.), Rice (Oryza sativa L.), Maize (Zea mays L.), Pulses (Fabaceae), Alliums (Allium spp.), and "other" crop types (30 types). This scoping review supports a potential role for RA approaches in increasing the concentrations of micronutrients in the edible portions of several crop types under specific practices, although this was context specific. For example, rice grown under increased organic inputs showed significant increases in grain zinc (Zn) concentration in 15 out of 16 studies. The vitamin C concentration of tomato fruit increased in ~50% of studies when plants were grown under increased organic inputs, and in 76% of studies when plants were grown under deficit irrigation. Overall, the magnitude and reproducibility of the effects of RA practices on most crop nutritional profiles were difficult to assess due to the diversity of RA approaches, geographical conditions, and the limited number of studies for most crops in each of these categories. Future research with appropriate designs, improved on-farm surveillance and nutritional diagnostics are needed for better understanding the potential role of RA in improving the quality of food, human nutrition, and health.

Micronutrients and socio-demographic factors were major predictors of anaemia among the Ethiopian population.

Anaemia is characterised by low hemoglobin (Hb) concentration. Despite being a public health concern in Ethiopia, the role of micronutrients and non-nutritional factors as a determinant of Hb concentrations has been inadequately explored. This study focused on the assessment of serum micronutrient and Hb concentrations and a range of non-nutritional factors, to evaluate their associations with the risk of anaemia among the Ethiopian population (n 2046). It also explored the mediation effect of Zn on the relation between se and Hb. Bivariate and multivariate regression analyses were performed to identify the relationship between serum micronutrients concentration, inflammation biomarkers, nutritional status, presence of parasitic infection and socio-demographic factors with Hb concentration (n 2046). Sobel-Goodman test was applied to investigate the mediation of Zn on relations between serum se and Hb. In total, 18·6 % of participants were anaemic, 5·8 % had iron deficiency (ID), 2·6 % had ID anaemia and 0·6 % had tissue ID. Younger age, household head illiteracy and low serum concentrations of ferritin, Co, Cu and folate were associated with anaemia. Serum se had an indirect effect that was mediated by Zn, with a significant effect of se on Zn (P < 0·001) and Zn on Hb (P < 0·001). The findings of this study suggest the need for designing a multi-sectorial intervention to address anaemia based on demographic group.

A pilot survey of selenium status and its geospatial variation among children and women in three rural districts of Zimbabwe.

Introduction: Selenium (Se) deficiency is increasingly recognized as a public health problem in sub-Saharan Africa. Methods: The current cross-sectional study assessed the prevalence and geospatial patterns of Se deficiency among children aged 6-59 months (n = 741) and women of 15-49 years old (n = 831) selected by simple random sampling in rural Zimbabwe (Murewa, Shamva, and Mutasa districts). Venous blood samples were collected and stored according to World Health Organization guidelines. Plasma Se concentration was determined by inductively coupled plasma-mass spectrometry. Results: Median, Q1, and Q3 plasma Se concentrations were 61.2, 48.7, and 73.3 µg/L for women and 40.5, 31.3, and 49.5 µg/L for children, respectively. Low plasma Se concentrations (9.41 µg/L in children and 10.20 µg/L in women) indicative of severe Se deficiency risk was observed. Overall, 94.6% of children and 69.8% of women had sub-optimal Se status defined by plasma Se concentrations of <64.8 µg/L and <70 µg/L, respectively. Discussion: High and widespread Se deficiency among women and children in the three districts is of public health concern and might be prevalent in other rural districts in Zimbabwe. Geostatistical analysis by conditional kriging showed a high risk of Se deficiency and that the Se status in women and children in Murewa, Shamva, and Mutasa districts was driven by short-range variations of up to ⁓12 km. Selenium status was homogenous within each district. However, there was substantial inter-district variation, indicative of marked spatial patterns if the sampling area is scaled up. A nationwide survey that explores the extent and spatial distribution of Se deficiency is warranted.

Impact of zinc and iron agronomic biofortification on grain mineral concentration of finger millet varieties as affected by location and slope.

Background: Food crop micronutrient concentrations can be enhanced through agronomic biofortification, with the potential to reduce micronutrient deficiencies among rural population if they have access to fertilizers. Here we reported the impact of agronomic biofortification on finger millet grain zinc (Zn) and iron (Fe) concentration. Methods: A field experiment was conducted in farmers' fields in Ethiopia in two locations; over two seasons in one district (2019 and 2020), and over a single season (2019) in a second district. The experimental design had 15 treatment combinations comprising 3 finger millet varieties and 5 soil-applied fertilizer treatments: (T1) 20 kg ha-1 FeSO4 + 25 kg ha-1 ZnSO4 + NPKS; (T2) 25 kg ha-1 ZnSO4 + NPKS; (T3) NPKS; (T4) 30% NPKS; (T5) 20 kg ha-1 FeSO4 + NPKS. The treatments were studied at two slope positions (foot and hill), replicated four times in a randomized complete block design. Results: Grain Zn concentration increased by 20% in response to Fe and Zn and by 18.9% due to Zn addition. Similarly, grain Fe concentration increased by 21.4% in T1 and 17.8% in T5 (Fe). Zinc fertilizer application (p < 0.001), finger millet variety (p < 0.001), and an interaction of Fe and Zn had significant effect on grain Zn concentration. Iron fertilizer (p < 0.001) and interactive effect of Fe fertilizer and finger millet variety (p < 0.01) had significant effects on grain Fe concentration. Location but not slope position was a source of variation for both grain Zn and Fe concentrations. Conclusion: Soil application of Zn and Fe could be a viable strategy to enhance grain Zn and Fe concentration to finger millet grain. If increased grain Zn and Fe is bioavailable, it could help to combat micronutrient deficiencies.

Anemia in children aged 6-59 months was significantly associated with maternal anemia status in rural Zimbabwe.

Globally, anemia is a public health problem affecting mostly women of reproductive age (WRA, n = 452) and children aged 6-59 months (n = 452) from low- and lower-middle-income countries. This cross-sectional study assessed the prevalence and determinants of anemia in WRA and children aged 6-59 months in rural Zimbabwe. The venous blood sample was measured for hemoglobin utilizing a HemoCue machine. Anthropometric indices were assessed and classified based on World Health Organization standards. Socioeconomic characteristics were assessed. The median (±inter quartile range (IQR)) age of WRA was 29 ± 12 years and that for children was 29 ± 14 months. The prevalence of anemia was 29.6% and 17.9% in children and WRA, respectively, while the median (±IQR) hemoglobin levels were 13.4 ± 1.8 and 11.7 ± 1.5 g/dl among women and children, respectively. Multiple logistic regression analysis was used to assess determinants of anemia. Anemia in children was significantly associated with maternal anemia (odds ratio (OR) = 2.02; 95% CI 1.21-3.37; p = .007) and being a boy (OR = 0.63; 95% CI 0.41-0.95; p = .029), while anemia in WRA was significantly associated with the use of unimproved dug wells as a source of drinking water (OR = 0.36; 95% CI 0.20-0.66; p = .001) and lack of agricultural land ownership (OR = 0.51; 95% CI 0.31-0.85; p = .009). Anemia is a public health problem in the study setting. The positive association between maternal and child anemia reflects the possibility of cross-generational anemia. Therefore, interventions that focus on improving preconceptual and maternal nutritional status may help to reduce anemia in low-income settings.

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries.

OBJECTIVES: Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage. METHODS: We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment. RESULTS: Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries. CONCLUSION: VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

Measuring the impact of malaria infection on indicators of iron and vitamin A status: a systematic literature review and meta-analysis.

Inflammation and infections such as malaria affect estimates of micronutrient status. Medline, Embase, Web of Science, Scopus and the Cochrane library were searched to identify studies reporting mean concentrations of ferritin, hepcidin, retinol or retinol binding protein in individuals with asymptomatic or clinical malaria and healthy controls. Study quality was assessed using the US National Institute of Health tool. Random effects meta-analyses were used to generate summary mean differences. In total, forty-four studies were included. Mean ferritin concentrations were elevated by: 28·2 µg/l (95 % CI 15·6, 40·9) in children with asymptomatic malaria; 28·5 µg/l (95 % CI 8·1, 48·8) in adults with asymptomatic malaria; and 366 µg/l (95 % CI 162, 570) in children with clinical malaria compared with individuals without malaria infection. Mean hepcidin concentrations were elevated by 1·52 nmol/l (95 % CI 0·92, 2·11) in children with asymptomatic malaria. Mean retinol concentrations were reduced by: 0·11 µmol/l (95 % CI -0·22, -0·01) in children with asymptomatic malaria; 0·43 µmol/l (95 % CI -0·71, -0·16) in children with clinical malaria and 0·73 µmol/l (95 % CI -1·11, -0·36) in adults with clinical malaria. Most of these results were stable in sensitivity analyses. In children with clinical malaria and pregnant women, difference in ferritin concentrations were greater in areas with higher transmission intensity. We conclude that biomarkers of iron and vitamin A status should be statistically adjusted for malaria and the severity of infection. Several studies analysing asymptomatic infections reported elevated ferritin concentrations without noticeable elevation of inflammation markers, indicating a need to adjust for malaria status in addition to inflammation adjustments.

Bioaccessibility of iron in pearl millet flour contaminated with different soil types.

A controlled in-vitro experiment was conducted to determine the bioaccessibility of extrinsic soil iron in pearl millet contaminated with typical Malawian soils. Pearl millet was contaminated with soils at ratios typically encountered in real life. Iron concentrations of soil-contaminated flour increased such that soil-derived iron contributed 56, 83 and 91% of the total iron when the proportions of soil were 0.1, 0.5 and 1% (soil: grain w/w), respectively. When soils were digested alone, the concentration of bioaccessible iron differed depending on the type of soil. However, the concentration of bioaccessible iron in soil-contaminated flours did not exceed that of uncontaminated flour and there was no effect of soil type. This suggests that knowledge of the proportion of extrinsic soil iron in soil-contaminated grains would be useful for iron bioavailability estimations. Vanadium is a reliable indicator of the presence of extrinsic soil iron in grains and has potential applications in this regard.

Zinc agronomic biofortification of staple crops may be a cost-effective strategy to alleviate zinc deficiency in Ethiopia.

Background: Inadequate dietary zinc (Zn) supplies and Zn deficiency (ZnD) are prevalent in Ethiopia, where cereals are major dietary sources, yet low in bioavailable Zn. Zinc agronomic biofortification (ZAB) of staple crops through application of Zn fertilizers may contribute to alleviating ZnD. However, large-scale promotion and adoption of ZAB requires evidence of the feasibility and public health benefits. This paper aimed to quantify the potential cost-effectiveness of ZAB of staple crops for alleviating ZnD in Ethiopia. Methods: Current burden of ZnD among children in Ethiopia was quantified using a disability-adjusted life years (DALYs) framework. Evidence on baseline dietary Zn intake, cereal consumption, and fertilizer response ratio was compiled from existing literature and secondary data sources. Reduction in the burden of ZnD attributable to ZAB of three staple cereals (maize, teff, and wheat) via granular and foliar Zn fertilizer applications was calculated under optimistic and pessimistic scenarios. The associated costs for fertilizer, labor, and equipment were estimated in proportion to the cropping area and compared against DALYs saved and the national Gross Domestic Product capita-1. Results: An estimated 0.55 million DALYs are lost annually due to ZnD, mainly due to ZnD-related mortality (91%). The ZAB of staple cereals via granular Zn fertilizer could reduce the burden of ZnD by 29 and 38% under pessimistic and optimistic scenarios, respectively; the respective values for ZAB via foliar application were 32 and 40%. The ZAB of staple cereals via granular fertilizer costs US$502 and US$505 to avert each DALY lost under optimistic and pessimistic scenarios, respectively; the respective values for ZAB via foliar application were US$226 and US$ 496. Foliar Zn application in combination with existing pesticide use could reduce costs to US$260-353 for each DALY saved. Overall, ZAB of teff and wheat were found to be more cost-effective in addressing ZnD compared to maize, which is less responsive to Zn fertilizer. Conclusion: ZAB of staple crops via granular or foliar applications could be a cost-effective strategy to address ZnD, which can be integrated with the existing fertilizer scheme and pesticide use to minimize the associated costs.