Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017).

OBJECTIVE: The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar. DESIGN: Repeated cross-sectional surveys in three states of Myanmar. SETTING: Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta). PARTICIPANTS: From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations. RESULTS: Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting. CONCLUSIONS: Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Stunting: an overlooked problem in Myanmar - an economic evaluation.

OBJECTIVES: Stunting increases a child's susceptibility to diseases, increases mortality, and is associated over long term with reduced cognitive abilities, educational achievement, and productivity. We aimed to assess the most effective public health nutritional intervention to reduce stunting in Myanmar. METHODS: We searched the literature and developed a conceptual framework for interventions known to reduce stunting. We focused on the highest impact and most feasible interventions to reduce stunting in Myanmar, described policies to implement them, and compared their costs and projected effect on stunting using data-based decision trees. We estimated costs from the government perspective and calculated total projected cases of stunting prevented and cost per case prevented (cost-effectiveness). All interventions were compared to projected cases of stunting resulting from the current situation (e.g., no additional interventions). RESULTS: Three new policy options were identified. Operational feasibility for all three options ranged from medium to high. Compared to the current situation, two were similarly cost-effective, at an additional USD 598 and USD 667 per case of stunting averted. The third option was much less cost-effective, at an additional USD 27,741 per case averted. However, if donor agencies were to expand their support in option three to the entire country, the prevalence of 22.5 percent would be reached by 2025 at an additional USD 667 per case averted. CONCLUSIONS: A policy option involving immediate expansion of the current implementation of proven nutrition-specific interventions is feasible. It would have the highest impact on stunting and would approach the WHO 2025 target.

Local food-based complementary feeding recommendations developed by the linear programming approach to improve the intake of problem nutrients among 12-23-month-old Myanmar children.

Poor feeding practices result in inadequate nutrient intakes in young children in developing countries. To improve practices, local food-based complementary feeding recommendations (CFR) are needed. This cross-sectional survey aimed to describe current food consumption patterns of 12-23-month-old Myanmar children (n 106) from Ayeyarwady region in order to identify nutrient requirements that are difficult to achieve using local foods and to formulate affordable and realistic CFR to improve dietary adequacy. Weekly food consumption patterns were assessed using a 12-h weighed dietary record, single 24-h recall and a 5-d food record. Food costs were estimated by market surveys. CFR were formulated by linear programming analysis using WHO Optifood software and evaluated among mothers (n 20) using trial of improved practices (TIP). Findings showed that Ca, Zn, niacin, folate and Fe were 'problem nutrients': nutrients that did not achieve 100 % recommended nutrient intake even when the diet was optimised. Chicken liver, anchovy and roselle leaves were locally available nutrient-dense foods that would fill these nutrient gaps. The final set of six CFR would ensure dietary adequacy for five of twelve nutrients at a minimal cost of 271 kyats/d (based on the exchange rate of 900 kyats/USD at the time of data collection: 3rd quarter of 2012), but inadequacies remained for niacin, folate, thiamin, Fe, Zn, Ca and vitamin B6. TIP showed that mothers believed liver and vegetables would cause worms and diarrhoea, but these beliefs could be overcome to successfully promote liver consumption. Therefore, an acceptable set of CFR were developed to improve the dietary practices of 12-23-month-old Myanmar children using locally available foods. Alternative interventions such as fortification, however, are still needed to ensure dietary adequacy of all nutrients.

Folate and vitamin B12 status and dietary intake of anaemic adolescent schoolgirls in the delta region of Myanmar.

The aim of the present study was to assess the prevalence of deficiency of folate and vitamin B12 and, simultaneously, the nutrient intake adequacy of folate, vitamin B12, iron, vitamin A, vitamin C, vitamin B6 and calcium in 391 adolescent anaemic (Hb<120 g/l) schoolgirls living in the delta region of Myanmar (Burma). Dietary intakes were assessed using a 3 d estimated food record. The distribution of observed intakes calculated from the food records were adjusted for usual intakes, and the prevalence of inadequacy was estimated using the estimated average requirement cut-point method. Median (first, third quartile) serum folate and vitamin B12 concentrations were 6·5 (4·6, 8·5) nmol/l and 612·8 (443·2, 795·2) pmol/l, respectively. The prevalence of folate deficiency defined as <6·8 nmol/l was 54 %; however, vitamin B12 deficiency defined as <148 pmol/l was negligible (<1 %). The prevalence of inadequate intake of folate was high (100 %) as was the prevalence of inadequate intakes of vitamin A, vitamin C, vitamin B6 and calcium, ranging from 60 to 100 %. Red meat or poultry was rarely consumed, but fish was consumed on a daily basis. Green leafy vegetables were also consumed frequently but consumption of dairy products was uncommon. Folate deficiency was high, and the prevalence of inadequate intake of folate among other key micronutrients was relatively common in this sample of anaemic adolescent schoolgirls. Appropriate strategies such as food fortification and dietary diversification are needed to improve the micronutrient status of these young women to ensure optimal health and future reproductive success.

Development of a standardized consensus lexicon for terms related to micronutrient programs.

Inconsistent use of terminology among diverse stakeholders hinders effective communication in micronutrient programs, especially large-scale food fortification (LSFF) which involves stakeholders from different sectors. To align the terminology use, the Micronutrient Data Innovation Alliance (DInA) of the Micronutrient Forum (MNF) created a lexicon of terms related to LSFF and other micronutrient programs. The purpose of this lexicon is to establish a central repository of consensus definitions of key terms to facilitate communication among diverse stakeholders involved in micronutrient programs including public and private sectors, donor agencies, food industries, academic institutions, etc. This paper describes the methodology of lexicon development. Important terms related to micronutrient programs were compiled from multiple sources, including United Nations agencies, program implementation and technical support agencies, relevant websites, and scientific literature. The selection of terms was guided by key micronutrient interventions (fortification, supplementation, dietary diversification) and the program cycle (assessment, planning, implementation, monitoring and evaluation). Definitions of terms were identified from these references and checked for consistency across different sources. For terms with multiple definitions, a modified Delphi method was applied to harmonize the definitions. The first draft lexicon (n = 113 terms) was reviewed by six experts from the University of California, Davis (UCD) and MNF, and second draft (n = 115 terms) was shared with 24 global micronutrient experts for feedback. Fifty-four terms were found to have multiple definitions. Of which, minor modification was made for 12-terms with nominal difference and remaining 42-terms were shared with over 140 micronutrient-experts disseminated via an online survey through newsletters and emails to solicit experts' opinions on the most appropriate definition or a modified one. Nineteen legal terms and 83 micronutrient terms (n = 102 terms) were subsequently added. Overall, 39 experts from diverse areas of expertise (LSFF, micronutrient program planning and implementation, surveys and research, policy development, food industry regulations, food safety, and public health nutrition) participated in the online survey. The terms with >75% agreement among experts were considered as final, while the remaining were reviewed again by experts from UCD and MNF until consensus was reached on harmonized definitions. The current lexicon is available online at the DInA-website. and contains 217 terms and will be maintained as a "living document". The lexicon will facilitate the ability of key stakeholders of micronutrient programs to evaluate and compare program performance in order to make informed decisions on how to ensure future progress in reducing micronutrient deficiencies.

Exploring food security and nutrition among young women in the formally regulated garment sector of Myanmar.

Malnutrition can adversely influence women's overall health and development and that of their children. In the Yangon region of Myanmar, young women aged 15-19 years can be excessively thin, overweight, or anemic. A significant proportion of these young women working within the formal sector are employed in the garment industry. This study used a mixed-method approach to generate robust evidence on food security and nutrition in young female garment workers. The research revealed that women have poor quality of nutrition, restricted their food intake, and ate less preferred food. The risk factors for not meeting the minimum dietary diversity were related to migration patterns, employment, food security level, and living conditions. This study offers recommendations and identifies areas for interventions that are either wanted by consulted stakeholders and/or for which there is an evidence basis for their recommendation: (1) promote food- and nutrition-specific programming, (2) increase healthy food access, and (3) improve employment conditions. These future interventions should generate comprehensive research, data, and benefits to fill in the evidence gaps identified and provide guidance on how to promote nutrition in the workplace for this vulnerable group of workers.

Scaling Up Breastfeeding in Myanmar through the Becoming Breastfeeding Friendly Initiative.

BACKGROUND: Optimal breastfeeding practices in Myanmar are above global averages, and the Ministry of Health and Sports (MoHS) has demonstrated its commitment to support nutrition and breastfeeding through continued policy and program actions. In 2017, the MoHS, in partnership with Save the Children, led the piloting of the Becoming Breastfeeding Friendly (BBF) Initiative. BBF provides a guide for countries to assess the enabling environment for breastfeeding and a country's readiness to scale up breastfeeding policies and programs. OBJECTIVE: The aim of this study was to document the BBF process and outcomes in Myanmar. METHODS: A Working Group (WG) of 14 members, led by a chair and 2 cochairs, conducted the BBF assessment using the BBF Index (BBFI), generated and prioritized recommendations, and disseminated the findings over the course of 5 meetings. Additional meetings were held to gain stakeholder endorsement and approval of the BBF process and WG before commencement and MoHS endorsement of the findings. RESULTS: The BBFI score for Myanmar was 1.2 out of 3.0, which indicates a moderate environment for scaling up breastfeeding policies and programs. The Funding and Resources gear earned the lowest score (0.5), whereas Political Will earned the highest score (2.0). Overall, 4 gears were weak and 4 were moderate in strength. Nine recommendation themes were generated and prioritized. The top priority recommendation was to form a National Infant and Young Child Feeding Alliance. The MoHS endorsed the 9 recommendations in December 2018 and has provided leadership for the formation of the alliance. CONCLUSIONS: The BBF Initiative was successfully conducted in Myanmar, resulting in 9 prioritized recommendations for strengthening the breastfeeding enabling environment and substantial interagency collaborations. Adaptations to the BBF process were made for the context, and we note numerous lessons learned that should be considered by other countries that plan to commit to the BBF Initiative.

Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs.

Thiamine is an essential micronutrient that plays a key role in energy metabolism. Many populations worldwide may be at risk of clinical or subclinical thiamine deficiencies, due to famine, reliance on staple crops with low thiamine content, or food preparation practices, such as milling grains and washing milled rice. Clinical manifestations of thiamine deficiency are variable; this, along with the lack of a readily accessible and widely agreed upon biomarker of thiamine status, complicates efforts to diagnose thiamine deficiency and assess its global prevalence. Strategies to identify regions at risk of thiamine deficiency through proxy measures, such as analysis of food balance sheet data and month-specific infant mortality rates, may be valuable for understanding the scope of thiamine deficiency. Urgent public health responses are warranted in high-risk regions, considering the contribution of thiamine deficiency to infant mortality and research suggesting that even subclinical thiamine deficiency in childhood may have lifelong neurodevelopmental consequences. Food fortification and maternal and/or infant thiamine supplementation have proven effective in raising thiamine status and reducing the incidence of infantile beriberi in regions where thiamine deficiency is prevalent, but trial data are limited. Efforts to determine culturally and environmentally appropriate food vehicles for thiamine fortification are ongoing.