Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls.

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

Trends and factors associated with the nutritional status of adolescent girls in Ghana: a secondary analysis of the 2003-2014 Ghana demographic and health survey (GDHS) data.

OBJECTIVE: We examined the trends over time and the factors associated with malnutrition among adolescent girls in Ghana. DESIGN: Cross-sectional analysis from 3 nationwide Ghana Demographic and Health Surveys conducted in 2003 (n 983), 2008 (n 955) and 2014 (n 857). We used Cox proportional hazard models with sample weighting to model the prevalence ratio (PR) of malnutrition. SETTING: Countrywide, covering rural and urban areas in Ghana. PARTICIPANTS: Non-pregnant adolescent girls aged 15-19 years. RESULTS: Compared with 2003, thinness declined marginally (PR 0·88 (95 % CI 0·45, 1·73)) in 2008 and in 2014 (PR 0·71 (95 % CI 0·38, 1·56)). Stunting declined marginally by 19 % in 2008 (PR 0·81 (95 % CI 0·59, 1·12)), flattening out in 2014 (PR 0·81 (95 % CI 0·57, 1·17)). We found an increasing trend of overweight/obesity with the PR peaking in 2014 (PR 1·39 (95 % CI 1·02, 1·88)) compared to 2003. The anaemia prevalence remained severe without a clear trend. A low level of education of the adolescent girl was positively associated with stunting. Increasing age was positively associated with stunting but inversely associated with thinness and anaemia. Girls who ever bore a child were more likely to be anaemic compared to those who never did. A lower level of household wealth and a unit increase in household size was negatively associated with overweight/obesity. Urban dwelling girls were less likely to be stunted. CONCLUSIONS: The stagnant burden of under-nutrition and rising over-nutrition emphasise the need for double-duty actions to tackle malnutrition in all its forms in Ghanaian adolescent girls.

Household factors and gestational age predict diet quality of pregnant women.

Adequate diet during pregnancy has positive effects on the mother and pregnancy outcome. Assessment of diet quality during pregnancy is particularly important in areas where household food security is suboptimal, to enable appropriate targeting and intervention. This study assessed diet quality and identified predicting factors among pregnant women in northern Ghana. A cross-sectional study involving 403 pregnant women was conducted in May 2018. Pregnant women attending antenatal care clinics (ANC) were selected using simple random sampling technique. We assessed socio-demographic characteristics, 24-h recall and household food security. The minimum dietary diversity for women (MDD-W) was used as a proxy measure for diet quality based on Food and Agricultural Organization (FAO) guidelines. Logistic regression models were fitted to determine the predictors of diet quality. The mean dietary diversity score (DDS) of 10 food groups was 4.4 ± 1.1 (95% CI: 4.3-4.5). Logistic regression showed that women of high educational level (adjusted odds ratio [AOR] = 2.42; 95% confidence interval [CI] [1.21-4.84]; P = 0.01), women of high household wealth index (AOR = 1.78; 95% CI [1.14-2.77]; P = 0.01], none/mild household hunger (AOR = 2.71; 95% CI [1.26-5.82]; P = 0.01), medium household size (6-15 members) (AOR = 1.66; 95% CI [1.04-2.66]; P = 0.03) and women of gestational age 20-35 weeks (AOR = 1.89; 95% CI [1.05-3.40]; P = 0.03) were more likely to have quality diets after adjusting for potential confounding variables. Diet quality among pregnant women was low and was predicted by educational level, household wealth, gestational age and food security. Women education and improvements in household food security could impact diets of pregnant women in northern Ghana.

Ten2Twenty-Ghana: Study Design and Methods for an Innovative Randomized Controlled Trial with Multiple-Micronutrient-Fortified Biscuits among Adolescent Girls in Northeastern Ghana.

Investing in adolescent girls' nutrition is vital for health and for breaking the intergenerational cycle of malnutrition and deprivation, but limited knowledge on the type, timing, and efficacy of interventions delays progress. We describe the design of a 26-wk randomized placebo-controlled trial with multiple-micronutrient-fortified biscuits (MMBs) among adolescent girls in northeastern Ghana. Apparently healthy, premenarche (n = 312) and postmenarche (n = 309) girls (10-17 y) were randomly assigned to receive the following for 5 d/wk: 1) MMBs (fortified with 11 vitamins and 7 minerals) or 2) unfortified biscuits. Data included plasma micronutrient status, anthropometry, body composition, cognitive function, psychosocial health, fertility, dietary intake, and sociodemographic and socioeconomic covariates, complemented with in-depth interviews (n = 30) and 4 focus group discussions. We hypothesized an increase in plasma ferritin and retinol-binding protein with a resultant increase in hemoglobin, cognition, vertical height, and psychosocial health. Our study seeks to investigate the efficacy and optimal timing of a multiple-micronutrient food intervention program for adolescent girls. The RCT was registered prospectively with the Netherlands Clinical Trials Register (NL7487).

Free Senior High School Lunch Contributes to Dietary Quality of Nonresidential Students in Ghana.

BACKGROUND: School feeding offers an excellent opportunity for targeted intervention to students not only as means for improving educational outcomes but also enhancing nutritional outcomes. The Government of Ghana introduced the free lunch feeding policy for nonresidential students in senior high schools (SHS) in 2018. OBJECTIVE: We assessed unintended benefits of the free lunch program to dietary improvement. METHODS: This was an analytical cross-sectional study among 403 (202 beneficiary and 201 non-beneficiary) students in SHS. The Food and Agriculture Organization's standard procedure for measuring dietary diversity score (DDS) was followed. A 3-day dietary recall was used to assess school day DDS, while a 24-hour recall was used to assess weekend DDS of students. Differences in DDS and food group consumption were determined using student t test and χ2 test, respectively. RESULTS: Nearly all (98.5%) beneficiary students consumed the free school lunch and 7 (70%) in 10 of them consumed it on all school days. While the students did not differ in their weekend meal DDS (6.3 ± 1.4 vs 6.5 ± 1.4, P = .39), beneficiaries of the school lunch had higher lunch DDS (7.5 ± 0.5 vs 6.5 ± 1.4, P < .001) and whole day DDS (11.5 ± 1 vs 9.3 ± 2.0, P < .001) compared to non-beneficiary students on school days. Even though the school lunch increased food group intake, vitamin-A rich vegetables and tubers, fruits, flesh and organ meats, and dairy products were hardly provided as components of school lunch. CONCLUSION: Provision of free school lunch meal to nonresidential students in SHSs in Ghana could contribute to improved diet quality.

Special foods and local herbs used to enhance breastmilk production in Ghana: rate of use and beliefs of efficacy.

BACKGROUND: Inadequate breastmilk production is one of the key factors associated with suboptimal breastfeeding. In most local African homes, special herbs and some food items are commonly used to promote breastmilk production (known as lactogogue/galactogogue). We describe the use and characterize the herbs and food items used to promote breastmilk production in two regions of Ghana. METHODS: We conducted a cross-sectional study in 2018 involving 402 lactating mothers. The range of foods used as lactogogues was obtained from 20 participants through focus group discussions. Quantitative data on demographics, lactogogue use and feeding practices were obtained through questionnaire administration. RESULTS: The mean age of women was 29.2 years and children were 10 months. Breastmilk production problems were low (22.4%) and the majority of lactating mothers felt they had adequate breastmilk (70.4%) but awareness about lactogogues was widespread in both regions (88.8%) and highest in the Brong-Ahafo region (90.0%). Information about lactogogues was mainly from grandparents (24.6%), parents (31.6), health facilities (16.5%) and friends (12.8%), while the media had little influence (< 1%). The majority of the mothers used lactogogues to enhance breastmilk production (67.7%), and a quarter of them used lactogogues because of their tradition (25.2%). Prevalence of lactogogue use was 83.8%, lactogogues were prepared separate from household meals (59.4%) and consumed one to three times a day (89.6%). Users felt the effectiveness within 24 h of use (98.5%). The most common lactogogues included; groundnut/peanut soup prepared with Bra leaves (Hibiscus sabdariffa), hot black tea, Werewere/Agushi (Citrulus colocynthis) prepared with Bra leaves, and Abemudro (a polyherbal formulation). Only 13.2% of lactating mothers also used lactogogues during pregnancy. CONCLUSIONS: Special foods and selected herbs are widely used to enhance breastmilk production in Ghana and constitute an important part of the diet of lactating mothers. These results could contribute to understanding breastfeeding behaviours and stimulate further research into evaluating the safety and scientific efficacy of these products in Ghana.

Malnutrition, Hypertension Risk, and Correlates: An Analysis of the 2014 Ghana Demographic and Health Survey Data for 15-19 Years Adolescent Boys and Girls.

The sex differences in malnutrition and hypertension during adolescence is largely inconclusive. There is also a paucity of data on the sex-specific correlates of malnutrition and hypertension for adolescents. Hence, this study aimed to assess the association between malnutrition, pre-hypertension/hypertension (PHH) and sex among adolescents. The study also aimed to determine and contrast the factors associated with these risks in Ghana. We analysed data of non-pregnant adolescent girls (n = 857) and adolescent boys (n = 870) aged 15-19 years from the 2014 Ghana Demographic and Health Survey (DHS). We modelled the prevalence risk ratio (PRR) of malnutrition and PHH using Cox proportional hazard models. Compared to adolescent girls, boys were more than twice likely to be stunted (PRR = 2.58, 95% C.I (1.77, 3.76)) and underweight (PRR = 2.67, 95% C.I (1.41, 5.09)) but less likely to be overweight/obese (PRR = 0.85, 95% C.I (0.08, 0.29)). Boys were also about twice likely to have PHH (PRR = 1.96, 95% C.I (1.47, 2.59)) compared to their female peers. Girls were more at risk of the detrimental effects of poor education on stunting and PHH. Empowerment index while protective of stunting for girls (PRR = 0.82, 95% C.I (0.67, 0.99)) also increased their risk of overweight/obesity (PRR = 1.31, 95% C.I (1.02, 1.68)). A higher household wealth index (HWI) increased the risk of overweight/obesity for adolescent girls but was protective of stunting and PHH for adolescent boys. Improvement in household water, hygiene, and sanitation (WASH) reduced the risk of stunting by 15% for adolescent boys. Overall, our findings suggest a double-burden of malnutrition with an up-coming non-communicable disease burden for adolescents in Ghana. Our findings may also be highlighting the need to target adolescent boys alongside girls in nutrition and health intervention programmes.

Effect of maternal growth monitoring knowledge on stunting, wasting and underweight among children 0-18 months in Tamale metropolis of Ghana.

OBJECTIVE: This study sought to assess maternal growth monitoring knowledge and its effect on stunting, wasting and underweight among children 0-18 months in the Tamale Metropolis. An analytical cross-sectional study design, involving 340 mother-child pairs randomly selected from 4 health facilities in the Tamale Metropolis was used. A structured questionnaire was used to collect information on socio-demographic characteristics and maternal growth monitoring knowledge. Weight and length of children were taken to assess nutritional status (stunting, underweight and wasting). Chi square/Fisher's exact test was used to determine the association between maternal growth monitoring knowledge level and child nutritional status. RESULTS: The study revealed that 87.6% of mothers had good knowledge on growth monitoring. The prevalence of stunting, underweight and wasting were 9.4%, 25.9% and 17.9% respectively. Bivariate analysis revealed that there is no association between maternal growth monitoring knowledge and stunting (p = 0.781), wasting (p = 0.743) and underweight (p = 0.529) among children 0-18 months in the Tamale Metropolis.

Iodine status of reproductive age women and their toddlers in northern Ghana improved through household supply of iodized salt and weekly indigenous meal consumption.

Iodine deficiency (ID) during pregnancy results in pregnancy losses, intrauterine growth retardation, and lower IQ in the offspring. Even after two decades of universal salt iodization (USI) implementation, the efficacy of USI has not been reported in high risk groups in vulnerable regions in Ghana. We aimed to assess and improve ID status in childbearing age women (all lactating women) and their toddlers in northern Ghana, a geographically and socioeconomically vulnerable region. We provided weekly supply of household iodized salt and community-based feeding of native Hibiscus Sabdariffaa leaves meal (HSM) prepared with iodized salt to women and their toddlers in intervention (n = 60) vs. control group (n = 60). At baseline, ID was prevalent in women (36%) and their toddlers (29%). For women, both median UIC values for intervention (57.4 ug/l) and control group (65.1 ug/l) were below the recommended UIC value of 100 ug/l with no significant differences between the two groups (p = 0.2778). At the endpoint, median UIC for the intervention group (123.6 ug/l) was significantly higher (p = 0.008) than the control group (59.7 ug/l). Our results suggest that weekly supply of iodized salt along with the feeding HSM is an effective channel for improving iodine status of economically disadvantaged groups in communities remote from coastal lands. Furthermore, our results suggest that decreased median UIC among lactating mothers does not necessarily imply lower iodine status for their breastfed toddlers. And finally, the observed median UIC<100 ug/l may point to a non-improvement in iodine status for the past decade for Ghana. There is a need to revisit, assess, and ascertain the challenges in preventing populations from attaining the intended benefits of the USI policy in Ghana.

Growth monitoring and promotion practices among health workers may be suboptimal despite high knowledge scores.

BACKGROUND: The child health record booklet (CHRB) is a powerful tool for screening children under five and for education of caregivers by health workers. The objective of the present study was to assess the knowledge and utilization of CHRB by mothers and health workers in child growth monitoring and promotion (GMP) in the East Mamprusi Municipal, Northern region, Ghana. METHODS: A descriptive cross-sectional study was conducted among mothers attending child welfare clinics (CWC) and health workers providing GMP at CWC. Observational checklists were used to assess 73 CHRB on the completeness and correctness of growth charts. Mothers and health workers' knowledge on essential components of CHRB were assessed with a questionnaire. RESULTS: Weight measurements were correctly recorded in all booklets analyzed. Even though a greater proportion (70.7%) of health workers exhibited high knowledge scores on the interpretation of the essential components of the CHRB,most of the charts analyzed were not completely filled (72.6%) but rather correctly filled (74.0%). Mean knowedge score (3.4 ± 1.3) on growth charting was low among mothers who attend GMP. Work overload (26.1%), inadequate supply of CHRB (26.1%) and vaccine shortages (18.7%) were concerns raised by health workers on the effective usage of the CHRB. CONCLUSION: Knowledge scores on the child health record booklets among health workers and mothers in this part of northern Ghana were high but charting of growth of children was sub-optimal among health workers.

Dietary patterns and associated factors of schooling Ghanaian adolescents.

BACKGROUND: Assessment of single nutrients or foods does not normally reflect the diet of population groups. Dietary pattern analyses are useful in understanding the overall diet and its relationship with disease conditions. The objective of the present study was to determine the dietary patterns and associated factors among schooling adolescents in Northern Ghana. METHODS: A cross-sectional study involving 366 pupils in 10 junior high schools in the Tamale metropolis was conducted. A Food Frequency Questionnaire (FFQ) which consisted of 60 commonly consumed foods was used to assess pupils' 7-day intake. Foods grouped (14) from FFQ data based on shared nutritional value were used to identify dietary patterns using principal component analysis (PCA). Bivariate and multivariate logistic regression analyses were used to determine the association between identified patterns and sociodemographic, anthropometric status, and household characteristics of pupils. RESULTS: Half of the pupils were female (50.3%) and average age was 15.6 ± 2.0 years. PCA identified two dietary patterns which in total explained 49.7% of the variability of the diet of pupils. The patterns were sweet tooth pattern (STP) with high factor loadings for sugar sweetened snacks, energy and soft drinks, sweets, tea and coffee, and milk and milk products, and a traditional pattern (TP) which showed high factor loadings for cereals and grains, local beverages, nuts, seeds and legumes, vegetables, and fish and seafood. Logistic regression showed that pupils who lived with their parents [AOR = 1.95; 95% CI (1.1-3.4); p = 0.019], those who went to school with pocket money [AOR = 4.73; 95% CI (1.5-15.0); p = 0.008], and those who lived in the wealthiest homes [AOR = 3.4; 95% CI (1.6-7.5); p = 0.002)] had higher odds of following the STP. The TP was associated with high dietary diversity (p = 0.035) and household wealth [AOR = 3.518; 95% CI (1.763-7.017); p < 0.001)]. None of the patterns was associated with anthropometric status of pupils. CONCLUSION: Adolescents in the present study followed a sweet tooth or a traditional diet pattern which associated more with household- and individual-level factors but not anthropometric status.

Ramadan fasting alters food patterns, dietary diversity and body weight among Ghanaian adolescents.

BACKGROUND: Ramadan is a monthlong fast for healthy adolescents and adult Muslims. The quality of foods eaten and eating patterns in Ramadan may be different from other months of the year. Food intake of adolescents is a concern as energy and nutrient requirements are higher and needed to support the growth spurt of this stage. The objective of the present study was to describe the food patterns, dietary diversity and body weight changes among adolescents during Ramadan. METHODS: A prospective cohort study design with four measurement points (baseline, midline, endline and post endline) was conducted among 366 adolescents in Junior High Schools. Food pattern was assessed with a food frequency questionnaire, a 24-h dietary recall was used to assess dietary diversity and body weight was measured using an electronic scale. A repeated measures ANOVA was used to compare changes in dietary diversity scores (DDS) and weight of pupils. RESULTS: Half of the pupils (50.3%) were female and average age was 15.9 ± 1.8 years. Pupils fasted for an average of 28.3 ± 4.0 days and 14.3 ± 0.5 h a day (dawn to dusk) during Ramadan. The number and types of dishes taken at meal times differed substantially between Ramadan periods and outside Ramadan. Consumption of vitamin A-rich fruits, other fruits, and milk and milk products increased markedly during Ramadan. However, fasting came with a reduction in consumption of foods from roots and tubers, legumes and nuts, and dark green leafy vegetables while other food groups remained unchanged. Mean DDS increased significantly during Ramadan (F (2.933, 1070.573) = 7.152, p < 0.001) while mean daily meal frequency decreased (F (2.936, 1071.623) = 51.653, p < 0.001). There was significant body weight loss (-1.5 kg (95% CI: -1.1 kg to -1.6 kg)) among adolescents (F (2.656, 958.95) = 304.90, p < 0.001). Weight loss was short-lived; regained one month after Ramadan. CONCLUSION: In this prospective cohort study among schooling Ghanaian adolescents who fast during Ramadan, fasting was characterised by marked changes in usual food patterns, increased dietary diversity and significant body weight loss.

Nutritional status and dietary diversity of orphan and non - orphan children under five years: a comparative study in the Brong Ahafo region of Ghana.

BACKGROUND: Undernutrition in children under 5 years is a major risk factor to child deaths and is related to impaired cognitive development and lower school performance. Underprivileged children such as orphans are at particularly high risk of undernutrition. Little is however known about the nutritional status and dietary diversity of orphan children in Ghana. This study therefore compared the nutritional status and dietary diversity of orphan and non- orphan children. METHODS: An analytical cross - sectional study design was used. Two hundred and forty-six children (123 non- orphan and 123 orphans) were sampled from households (non - orphans) and four orphanages (orphans). Maternal / caregiver and child socio-demographic characteristics and dietary diversity of children was assessed with a semi - structured questionnaire. We measured anthropometric characteristics of children. Stunting, wasting and underweight in children was classified using Height - for - age Z - scores (HAZ), Weight - for - height Z - scores (WHZ) and Weight - for - age Z - scores (WAZ) respectively. Bivariate and multivariate analyses were used to compare the nutritional status and dietary diversity of orphan and non- orphan children. RESULTS: Majority of the children were male (52.4%). The prevalence of stunting, wasting and underweight was 17.9, 5.3 and 7.7% respectively for all children. There was no difference in the prevalence of stunting (17.1% vs 18.7%) (p = 0. 74), wasting (4.9% vs 5.7%) (p = 0.78) and underweight (7.3% vs 8.1%) (p = 0.81) among non - orphans and orphans. There was also no difference in mean HAZ (p = 0.52), WHZ (p = 0.27) and WAZ (p = 0.12) of non- orphan and orphan children. However, orphans had higher mean dietary diversity score (p <  0.001) and minimum dietary diversity (p <  0.001) than non - orphans. After controlling for potential confounders, non - orphans were 7.491 times more likely to have a low dietary diversity [AOR = 7.491; 95% CI (1.851-30.320); p = 0.005] compared to orphans. CONCLUSION: Present study data show no significant difference in the anthropometric status of orphan and non - orphan children. Orphans were more likely to receive a diversified diet than non - orphans.

Seasonality affects dietary diversity of school-age children in northern Ghana.

BACKGROUND AND OBJECTIVES: Dietary diversity score (DDS) is relatively easy to measure and is shown to be a very useful indicator of the probability of adequate micronutrient intake. Dietary diversity, however, is usually assessed during a single period and little is known about the effect of seasonality on it. This study investigates whether dietary diversity is influenced by seasonality. METHODS: Two cross-sectional surveys were conducted in two different seasons-dry season (October 2010) and rainy season (May 2011) among the same school-age children (SAC) in two rural schools in northern Ghana. The study population consisted of 228 school-age children. A qualitative 24-hour dietary recall was conducted in both seasons. Based on 13 food groups, a score of 1 was given if a child consumed a food item belonging to a particular food group, else 0. Individual scores were aggregated into DDS for each child. Differences in mean DDS between seasons were compared using linear mixed model analysis. RESULTS: The dietary pattern of the SAC was commonly plant foods with poor consumption of animal source foods. The mean DDS was significantly higher (P < 0.001) in the rainy season (6.95 ± 0.55) compared to the dry season (6.44 ± 0.55) after adjusting for potential confounders such as age, sex, occupation (household head and mother) and education of household head. The difference in mean DDS between dry and rainy seasons was mainly due to the difference in the consumption of Vitamin A-rich fruits and vegetables between the seasons. While vitamin A-rich fruits (64.0% vs. 0.9%; P < 0.0001) and vitamin A rich dark green leafy vegetables (52.6% vs. 23.3%, P < .0001) were consumed more during the rainy season than the dry season, more children consumed vitamin A-rich deep yellow, orange and red vegetables during the dry season than during the rainy season (73.7% vs. 36.4%, P <0.001). CONCLUSION: Seasonality has an effect on DDS and may affect the quality of dietary intake of SAC; in such a context, it would be useful to measure DDS in different seasons. Since DDS is a proxy indicator of micronutrient intake, the difference in DDS may reflect in seasonal differences in dietary adequacy and further studies are needed to establish this.

Subclinical inflammation influences the association between vitamin A- and iron status among schoolchildren in Ghana.

BACKGROUND AND OBJECTIVE: In resource-poor settings, micronutrient deficiencies such as vitamin A deficiency may co-exist with iron-deficiency. In this study we assessed the iron and vitamin A status of schoolchildren and the association between vitamin A and iron status. METHODS: A cross-sectional design using the baseline data of a dietary intervention trial conducted among randomly selected 5-12 years old schoolchildren (n = 224) from 2 rural schools in northern Ghana. Hemoglobin (Hb), serum ferritin (SF) and serum transferrin receptor (sTfR) concentrations were used as measures of iron status. Retinol binding protein (RBP) was used as a measure of vitamin A status. Subclinical inflammation (SCI) was measured using C-reactive protein (CRP) and α1-acid glycoprotein (AGP) concentrations. We examined the cross-sectional association between vitamin A and iron status biomarkers with multiple linear regressions. RESULTS: The proportions of schoolchildren with anemia (WHO criteria), iron-deficiency (ID, SF <15µg/l and/or sTfR >8.5mg/l) and iron-deficiency anemia (IDA, concurrent anemia and ID) were 63.8%, 68.3% and 46.4% respectively. Low or marginal vitamin A status (0.70 µmol/l ≤ RBP < 1.05µmol/l) was present in 48.2% while 37.5% of the schoolchildren had vitamin A deficiency (VAD, RBP <0.70 µmol/l). The prevalence of SCI as well as concurrent VAD and ID were 48.7% and 25% respectively. RBP was associated with Hb (ß = 7.2, P = 0.05) but not SF (ß = 20.7, P = 0.33) and sTfR concentration (ß = 12.0, P = 0.63). In the presence of SCI, RBP was not associated with hemoglobin status but a significant positive association was observed among children without SCI. CONCLUSIONS: The study shows that RBP is significantly associated with Hb concentration but not with SF and sTfR. The observed relationship between RBP and Hb is only significant in the absence of SCI.

The effect of maternal and child factors on stunting, wasting and underweight among preschool children in Northern Ghana.

BACKGROUND: Undernutrition among preschool children in Northern region is the highest in Ghana. However, there is scarcity of data on the factors that determine undernutrition in these children. This study investigated the effect of maternal and child factors on undernutrition among preschool children in Northern Ghana. METHODS: This study was a community based analytical cross-sectional survey on a sample of 425 mother- child pairs drawn from 25 clusters. A semi- structured questionnaire was used to collect data on maternal and child socio-demographic characteristics, feeding practices and anthropometry. Anthropometric indices of Height-for-age Z-scores (HAZ), Weight-for-height Z-scores (WHZ) and Weight-for - age Z-scores (WAZ) were used to classify child stunting, wasting and underweight respectively. Bivariate and multivariate analyses were performed to determine associations between explanatory variables and undernutrition. RESULTS: The prevalence of stunting, wasting and underweight were 28.2, 9.9 and 19.3% respectively. Multiple logistic regression analysis showed that, the odds of stunting was higher among male children [AOR = 1.99; 95% CI (1.26-3.13); p = 0.003], children of mothers less than 150 cm in height [AOR = 3.87; 95% CI (1.34-11.20); p = 0.01], mothers 155-159 cm tall [AOR = 2.21; 95% CI (1.34-3.66); p = 0.002], and older children aged 12-23 months [AOR 9.81; 95% CI (2.85-33.76); p < 0.001]. Wasting was significantly higher among male children [AOR = 2.40; 95% CI (1.189-4.844); p = 0.015], consumption of less than four food groups [AOR = 3.733; 95% CI (1.889-7.376); p < 0.001] and among children of underweight mothers [AOR = 3.897; 95% CI (1.404-10.820); p = 0.009]. Male children [AOR = 2.685; 95% CI (1.205-5.98); p = 0.016] and having low birth weight [AOR = 3.778; 95% CI (1.440-9.911); p < 0.001] were associated with higher odds of underweight in children. CONCLUSION: Maternal height associated negatively with stunting but not wasting. Factors that affect low height -for-age z-score (HAZ) may not necessarily be the same as stunting. Infant and child feeding practices as measured by dietary diversity score associated positively with weight-for-height Z-scores than length-for-age Z-scores of young children. Surprisingly, consumption of some specific food groups including, animal source foods, legumes, staples and eggs were associated with lower HAZ but with increased likelihood of higher WHZ among children 6-59 months.

Use of commercial infant cereals as complementary food in infants and young children in Ghana.

BACKGROUND: Typical complementary foods in developing countries are often inadequate in multiple micronutrients. One way of preventing micronutrient deficiency among infants and young children (IYC) is to feed them a variety of nutrient dense foods. The use of commercial infant cereals (CIC) as complementary food is increasing in Ghana. However, it is unknown whether giving CIC may discourage inclusion of other locally available and nutritious foods as mothers may hold the notion that CIC is superior. This study therefore examined the use of CIC as complementary food, the micronutrient intake from CIC and reasons for its use. METHODS: A cross-sectional study was conducted involving mothers with IYC aged 6-23 months who give CIC as complementary food. Questionnaires were administered to estimate the usual daily frequencies and quantities of CIC. Micronutrient intakes from CIC were calculated. We also calculated the proportion of the recommended nutrient intake (RNI) contributed by micronutrients from CIC. RESULTS: Of the 384 children sampled, 64.6% were aged 13-23 months and 50.3% were females. More than half of the mothers earned income through trading (55.2%) and nearly one quarter of them had senior high school education (24.7%). Majority of the children consumed 3-4 tablespoons (52.3%) of CIC in a feeding moment. Younger children (6-12 months) were served CIC more frequent than older children (13-23 months). The mean ± SD of micronutrients from CIC were 6.76 ± 2.67 mg, 4.79 ± 1.70 mg, 384.12 ± 139.69 mg, 266.70 ± 100.74 mg and 69.11 ± 24.65 µg for the minerals Fe, Zn, Ca, P and I respectively. The vitamin intakes were: 337.17 ± 119.70 µg, 42.88 ± 15.28 mg, 0.84 ± 0.31 µg, 34.24 ± 12.22 µg and 2.70 ± 1.03 mg for vitamin A, vitamin C, vitamin B12, folic acid and niacin respectively. Micronutrients from CIC consumption contributed to at least 70% of the RNIs for Fe, Zn, Ca, I, vitamin A, vitamin C and vitamin B12. Mothers believed that CIC alone could meet the nutritional needs of children and ensure optimal growth and health. CONCLUSION: The results of present study show that use of CIC as complementary food was high among mothers with IYC 6-12 months. Mothers believed that CIC was nutritionally adequate for their children and did not see the need to include or enrich other locally available complementary foods. Mothers should be educated on the need to include other foods with CIC to increase the dietary quality of IYC.

Grain legume cultivation and children's dietary diversity in smallholder farming households in rural Ghana and Kenya.

Boosting smallholder food production can potentially improve children's nutrition in rural Sub-Saharan Africa through a production-own consumption pathway and an income-food purchase pathway. Rigorously designed studies are needed to provide evidence for nutrition impact, but are often difficult to implement in agricultural projects.Within the framework of a large agricultural development project supporting legume production (N2Africa), we studied the potential to improve children's dietary diversity by comparing N2Africa and non-N2Africa households in a cross-sectional quasi-experimental design, followed by structural equation modelling (SEM) and focus group discussions in rural Ghana and Kenya. Comparing N2Africa and non-N2Africa households, we found that participating in N2Africa was not associated with improved dietary diversity of children. However, for soybean, SEM indicated a relatively good fit to the posteriori model in Kenya but not in Ghana, and in Kenya only the production-own consumption pathway was fully supported, with no effect through the income-food purchase pathway. Results are possibly related to differences in the food environment between the two countries, related to attribution of positive characteristics to soybean, the variety of local soybean-based dishes, being a new crop or not, women's involvement in soybean cultivation, the presence of markets, and being treated as a food or cash crop. These findings confirm the importance of the food environment for translation of enhanced crop production into improved human nutrition. This study also shows that in a situation where rigorous study designs cannot be implemented, SEM is a useful option to analyse whether agriculture projects have the potential to improve nutrition.

More than two-thirds of dietary iodine in children in northern Ghana is obtained from bouillon cubes containing iodized salt.

OBJECTIVE: Bouillon cubes are widely consumed by poor households in sub-Saharan Africa. Because their main ingredient is salt, bouillon cubes could be a good source of iodine if iodized salt is used in their production and if their consumption by target groups is high. Our objective was to measure the iodine content of bouillon cubes, estimate their daily intake in school-aged children and evaluate their potential contribution to iodine intakes. DESIGN: In a cross-sectional study, we measured urinary iodine concentrations (UIC) and estimated total daily iodine intakes. We administered a questionnaire on usage of bouillon cubes. We measured the iodine content of bouillon cubes, household salt, drinking-water and milk products. SETTING: Primary schools in northern Ghana. SUBJECTS: Schoolchildren aged 6-13 years. RESULTS: Among school-aged children (n 250), median (interquartile range) UIC and estimated iodine intake were 242 (163-365) µg/l and 129 (85-221) µg/d, indicating adequate iodine status. Median household salt iodine concentration (n 100) was only 2·0 (0·83-7·4) µg/g; 72 % of samples contained <5 µg iodine/g. Iodine concentrations in drinking-water and milk-based drinks were negligible. Median iodine content of bouillon cubes was 31·8 (26·8-43·7) µg/g, with large differences between brands. Estimated median per capita consumption of bouillon cubes was 2·4 (1·5-3·3) g/d and median iodine intake from bouillon cubes was 88 (51-110) µg/d. CONCLUSIONS: Despite low household coverage with iodized salt, iodine nutrition in school-aged children is adequate and an estimated two-thirds of their dietary iodine is obtained from bouillon cubes.

How well do WHO complementary feeding indicators relate to nutritional status of children aged 6-23 months in rural Northern Ghana?

BACKGROUND: Though the World Health Organization (WHO) recommended Infant and Young Child Feeding (IYCF) indicators have been in use, little is known about their association with child nutritional status. The objective of this study was to explore the relationship between IYCF indicators (timing of complementary feeding, minimum dietary diversity, minimum meal frequency and minimum acceptable diet) and child growth indicators. METHODS: A community-based cross-sectional survey was carried out in November 2013. The study population comprised mothers/primary caregivers and their children selected using a two-stage cluster sampling procedure. RESULTS: Of the 1984 children aged 6-23 months; 58.2 % met the minimum meal frequency, 34.8 % received minimum dietary diversity (≥4 food groups), 27.8 % had received minimum acceptable diet and only 15.7 % received appropriate complementary feeding. With respect to nutritional status, 20.5 %, 11.5 % and 21.1 % of the study population were stunted, wasted and underweight respectively. Multiple logistic regression analysis revealed that compared to children who were introduced to complementary feeding either late or early, children who started complementary feeding at six months of age were 25 % protected from chronic malnutrition (AOR = 0.75, CI = 0.50 - 0.95, P = 0.02). It was found that children whose mothers attended antenatal care (ANC) at least 4 times were 34 % protected [AOR 0.66; 95 % CI (0.50 - 0.88)] against stunted growth compared to children born to mothers who attended ANC less than 4 times. Children from households with high household wealth index were 51 % protected [AOR 0.49; 95 % CI (0.26 - 0.94)] against chronic malnutrition compared to children from households with low household wealth index. After adjusting for potential confounders, there was a significant positive association between appropriate complementary feeding index and mean WLZ (ß = 0.10, p = 0.005) but was not associated with mean LAZ. CONCLUSIONS: The WHO IYCF indicators better explain weight-for-length Z-scores than length-for-age Z-scores of young children in rural Northern Ghana. Furthermore, a composite indicator comprising timely introduction of solid, semi-solid or soft foods at 6 months, minimum meal frequency, and minimum dietary diversity better explains weight-for-length Z-scores than each of the single indicators.