Toward healthy and sustainable diets for the 21st century: Importance of sociocultural and economic considerations.

Four years after the EAT-Lancet landmark report, worldwide movements call for action to reorient food systems to healthy diets that respect planetary boundaries. Since dietary habits are inherently local and personal, any shift toward healthy and sustainable diets going against this identity will have an uphill road. Therefore, research should address the tension between the local and global nature of the biophysical (health, environment) and social dimensions (culture, economy). Advancing the food system transformation to healthy, sustainable diets transcends the personal control of engaging consumers. The challenge for science is to scale-up, to become more interdisciplinary, and to engage with policymakers and food system actors. This will provide the evidential basis to shift from the current narrative of price, convenience, and taste to one of health, sustainability, and equity. The breaches of planetary boundaries and the environmental and health costs of the food system can no longer be considered externalities. However, conflicting interests and traditions frustrate effective changes in the human-made food system. Public and private stakeholders must embrace social inclusiveness and include the role and accountability of all food system actors from the microlevel to the macrolevel. To achieve this food transformation, a new "social contract," led by governments, is needed to redefine the economic and regulatory power balance between consumers and (inter)national food system actors.

Retail Purchases of Red and Processed Meat by State in the United States.

The specific aim was to characterize retail purchases of red and processed meat and other major protein-rich foods in the U.S. and by state. Supermarket scanner data from grocery stores, supermarkets, and big box stores collected from 2017-2019 (NielsenIQ, New York, NY) was used to characterize retail purchases of red meat, processed meat, and other protein-rich foods in thirty-one states representative of US retail food sales. Red meat, processed meat, poultry, seafood, eggs, other meats, and non-meat foods (beans, nuts, seeds, meat alternatives) by weight accounted for 25.9%, 20.4%, 25.8%, 5.9%, 12.6%, 1.3%, and 10.1%, respectively of total sales in 2017-2019. Mean per capita purchases of red meat by weight was 30.1 g/d, ranging from 45.4 g/d in Mississippi to 21.9 g/d in New York. Mean per capita purchases of processed meat by weight was 23.8 g/d, ranging from 36.6 g/d in Mississippi to 15.2 g/d in California. We observed statistically significant correlations between red and processed meat purchases with cardiovascular mortality and colorectal cancer by state. Per capita retail purchases of red and processed meat appear to reflect a dietary pattern that is not consistent with current national and international dietary recommendations.

Relationship of cash transfers with risk of overweight and obesity in children and adults: a systematic review.

BACKGROUND: Cash transfer (CT) programs are an important type of social protection meant to reduce poverty. Whether CT programs increase the risk of overweight and obesity is unclear. The objective was to characterize the relationship between CT programs and the risk of overweight and obesity in children and adults. METHODS: We searched articles in PubMed, Embase, Cochrane, EconLit, Global Health, CINAHL Plus, IBSS, Health & Medical Collection, Scopus, Web of Science, and WHO Global Index Medicus in August 2021. Studies involving CT as the intervention, a control group, body mass index, overweight, or obesity as an outcome, and sample size > 300 were included. The Newcastle-Ottawa Scale was used for quality assessment. RESULTS: Of 2355 articles identified, 20 met the inclusion criteria. Because of marked heterogeneity in methodology, a narrative synthesis was used to present results. Thirteen of the studies reported that CT programs were associated with a significantly lower risk of overweight and obesity, eight studies showed no significant association, and one study reported a significantly increased risk of obesity in women. Quality assessment showed that most studies lacked sample size and power calculations, validation of exposure, descriptions of non-respondents or those lost to follow-up, and blinded outcome assessment. CONCLUSIONS: Overall, the studies were suggestive that CT programs either have no impact or decrease the risk of overweight and/or obesity in children, adolescents, and adults, but no firm conclusions can be drawn from the available evidence. This review demonstrated limitations in the available studies of CT programs and overweight/obesity.

Adherence to HIV and TB care and treatment, the role of food security and nutrition.

Food security and nutrition play an important role in HIV and TB care and treatment, including for improving treatment outcomes, adherence and uptake of HIV and TB care. This AIDS and behaviour supplement on "Adherence to HIV and TB care and treatment, the role of food security and nutrition" provides an overview of the current evidence and knowledge about the barriers to uptake and retention in HIV and TB treatment and care and on whether and how food and nutrition assistance can help overcome these barriers. It contains nine papers on three topic areas discussing: (a) adherence and food and nutrition security in context of HIV and TB, their definitions, measurement tools and the current situation; (b) food and nutrition insecurity as barriers to uptake and retention; and (c) food and nutrition assistance to increase uptake and retention in care and treatment. Future interventions in the areas of food security, nutrition and social protection for increasing access and adherence should be from an HIV sensitive lens, linking the continuum of care with health systems, food systems and the community, complementing existing platforms through partnerships and integrated services.

The enabling effect of food assistance in improving adherence and/or treatment completion for antiretroviral therapy and tuberculosis treatment: a literature review.

Socioeconomic costs of HIV and TB and the difficulty of maintaining optimal treatment are well documented. Social protection measures such as food assistance may be required to offset some of the treatment related costs as well as to ensure food security and maintain good health of the affected individual and household. Programmes have started placing greater emphasis on treatment adherence and are looking for proven interventions that can optimize it. This paper looks at the effect of food assistance for enabling treatment adherence and reviews studies that used food assistance to promote adherence. Eight of ten studies found that provision of food can improve adherence and/or treatment completion for HIV care and treatment, ART and TB-DOTS. This indicates that food provision is not only a biological, but also a behavioural intervention, and underscores that unresolved food insecurity can be an impediment to treatment adherence and consequently to good treatment outcomes.

Retention in care and adherence to ART are critical elements of HIV care interventions.

Retention in care and adherence to antiretroviral treatment (ART) are critical elements of HIV care interventions and are closely associated with optimal individual and public health outcomes and cost effectiveness. This literature review was conducted to analyse how the roles of clients in HIV care and treatment are discussed, from terminology used to measurement methods to consequences of a wide range of patient-related factors impacting client adherence to ART and retention in care. Unfortunately, data suggests that clients find it hard to follow recommended behaviour. For HIV, the greatest loss to follow-up occurs before starting treatment, though each step of the continuum of care is affected. Measurement approaches can be divided into 'direct' and 'indirect' methods; in practice, a combination is often considered the best strategy. Inadequate retention and adherence lead to decreased health outcomes (morbidity, mortality, drug resistances, risk of transmission) and cost effectiveness (increased costs and lower productivity).

What Is the Likely Impact of Alternative Proteins on Diet Quality, Health, and the Environment in Low- and Middle-Income Countries.

Alternative protein (AP) foods are proposed to support a global protein transition. Whereas AP food innovation has been a strategy to promote consumption of protein sources with low environmental impact in high-income countries (HICs) diets, their relation to sustainable, high-quality diets in low- and middle-income countries (LMICs) remains to be established. AP foods vary in nutrient profile, processing requirements, costs, and environmental impact. Current literature regarding AP suitability in LMIC contexts is limited. This perspective examined environmental and nutritional metrics that can assess the sustainability of AP in LMICs. Current research areas needed to accurately assess environmental impacts while considering nutritional density were identified. An overview of the usability of relevant AP in both high- and low-resource settings was also explored. Metrics addressing diverse contextual synergies in LMICs, unifying nutritional, environmental, and socioeconomic considerations, were found necessary to guide the integration of AP into LMIC diets.

Key strategies to further reduce stunting in Southeast Asia: lessons from the ASEAN countries workshop.

BACKGROUND: To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified. OBJECTIVE: Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia. METHODS: Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries. RESULTS: Between 1990-2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation. CONCLUSIONS: In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.

Cost of the Diet (CoD) tool: first results from Indonesia and applications for policy discussion on food and nutrition security.

BACKGROUND: The Minimum Cost of a Nutritious Diet (MCNut) is the cost of a theoretical diet satisfying all nutrient requirements of a family at the lowest possible cost, based on availability, price, and nutrient content of local foods. A comparison with household expenditure shows the proportion of households that would be able to afford a nutritious diet. OBJECTIVE: To explore using the Cost of Diet (CoD) tool for policy dialogue on food and nutrition security in Indonesia. METHODS: From October 2011 to June 2012, market surveys collected data on food commodity availability and pricing in four provinces. Household composition and expenditure data were obtained from secondary data (SUSENAS 2010). Focus group discussions were conducted to better understand food consumption practices. Different types of fortified foods and distribution mechanisms were also modeled. RESULTS: Stark differences were found among the four areas: in Timor Tengah Selatan, only 25% of households could afford to meet the nutrient requirements, whereas in urban Surabaya, 80% could. The prevalence rates of underweight and stunting among children under 5 years of age in the four areas were inversely correlated with the proportion of households that could afford a nutritious diet. The highest reduction in the cost of the child's diet was achieved by modeling provision of fortified blended food through Social Safety Nets. Rice fortification, subsidized or at commercial price, can greatly improve nutrient affordability for households. CONCLUSIONS: The CoD analysis is a useful entry point for discussions on constraints on achieving adequate nutrition in different areas and on possible ways to improve nutrition, including the use of special foods and different distribution strategies.

Program experience with micronutrient powders and current evidence.

The efficacy of micronutrient powders (MNP) in the treatment of anemia in moderately anemic children aged 6-24 mo has been clearly demonstrated. The evidence of the effectiveness of MNP in large-scale programs, however, is scarce. This article describes the program experience and findings of large-scale MNP distribution in refugee camps and in an emergency context in Bangladesh, Nepal, and Kenya. The MNP contained 15-16 micronutrients as per the WHO/World Food Programme/UNICEF joint statement, whereas the iron content was reduced to 2.5 mg from NaFeEDTA in a malaria-endemic area in Kenya. Hundreds of thousands of children aged 6-59 mo and pregnant and lactating women were targeted to consume MNP either daily or every other day over an extended period of time. Extensive social marketing campaigns were undertaken to promote regular use of the product. A number of studies were embedded in the programs to assess the impact of MNP on the nutritional status of target beneficiaries. Some improvements in anemia prevalence estimates were observed in particular subgroups, but other results did not show significant improvements. A significant decrease in the prevalence of stunting was observed in Nepal and Kenya but not in Bangladesh. Diarrhea episodes decreased significantly among children receiving MNP in Nepal. A key challenge is to ensure high MNP acceptance and adherence among beneficiaries. Investigation of non-nutritional causes of anemia is warranted in settings with high compliance but no improvement in hemoglobin status. Further investigation into the most appropriate manner to use MNP in malaria endemic settings is warranted.

Relationship of maternal knowledge of anemia with maternal and child anemia and health-related behaviors targeted at anemia among families in Indonesia.

Our specific aim was to characterize maternal knowledge of anemia and its relationship to maternal and child anemia and to behaviors related to anemia reduction. We examined the relationship between maternal knowledge of anemia and anemia in the mother and the youngest child, aged 6-59 months, in 7,913 families from urban slums and 37,874 families from rural areas of Indonesia. Knowledge of anemia was defined based upon the mother's ability to correctly name at least one symptom of anemia and at least one treatment or strategy for reducing anemia. Hemoglobin was measured in both the mother and the child. In urban and rural areas, respectively, 35.8 and 36.9% of mothers had knowledge of anemia, 28.7 and 25.1% of mothers were anemic (hemoglobin <12 g/dL), and 62.3 and 54.0% of children were anemic (hemoglobin <11 g/dL). Maternal knowledge of anemia was associated with child anemia in urban and rural areas, respectively (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.79, 1.02, P = 0.10; OR 0.93, 95% CI 0.87, 0.98, P = 0.01) in multivariate logistic regression models adjusting for potential confounders. There was no significant association between maternal knowledge of anemia and maternal anemia. Maternal knowledge of anemia was significantly associated with iron supplementation during pregnancy and child consumption of fortified milk. There was no association of maternal knowledge of anemia with child deworming. Maternal knowledge of anemia is associated with lower odds of anemia in children and with some health behaviors related to reducing anemia.

Determinants of anemia clustering among mothers and children in Indonesia.

OBJECTIVES: To describe risk factors for clustering of anemia among mothers and children in Indonesia. METHODS: An anemia cluster was defined as hemoglobin <12 g/dl in the mother and <11 g/dl in the youngest child, aged 6-59 months. RESULTS: Anemia clustering occurred in 4907 (18.3%) of 26 809 urban families and 12 756 (15.5%) of 82 291 rural families. Maternal overweight/obesity, older child age, consumption of fortified milk by the child, use of iodized salt, vitamin A supplementation, paternal smoking and greater expenditure on animal and plant source foods were associated with lower odds of anemia clustering. Older maternal age, maternal underweight, ≥2 children in the family and >4 individuals eating from the same kitchen were associated with greater odds of anemia clustering. CONCLUSION: Fortified milk, iodized salt, vitamin A supplementation and greater expenditure on plant and animal foods are among modifiable risk factors associated with lower risk of anemia clustering in Indonesia.

Rice fortification: its potential for improving micronutrient intake and steps required for implementation at scale.

BACKGROUND: Micronutrient deficiencies affect over 2 billion people worldwide, with profound implications for health, cognitive development, education, economic development, and productivity. Fortification of staple foods is a cost-effective strategy to increase vitamin and mineral intake among the general population. Rice is consumed by billions of people (> 440 million MT/year) but is as yet rarely fortified. OBJECTIVE: To discuss the untapped opportunity of rice fortification. METHODS: Review literature and experience with rice fortification and compare to fortification of other staple foods. RESULTS: Most technologies used to fortify rice first produce the fortified kernels and then blend them with regular, polished rice. Technologies differ with regard to how nutrients are added to the rice kernels, required investment, production cost, and degree of resemblance to unfortified rice. There are, so far, limited success stories for rice fortification. Some of the main roadblocks appear to be high initial investment and associated cost; lack of government leadership; and consumer hesitation to accept variations in the characteristics of rice, or a higher price, without good understanding of the benefits. CONCLUSIONS: In countries with a large centralized rice milling industry, starting rice fortification is easier than in countries with many small mills. Countries with large safety nets that supply rice to the poorest, for free or subsidized, have a good channel to reach those most in need. Furthermore, key players from the public and private sectors should establish a coalition to support the use of fortified rice and address some of the barriers to its implementation.

The Potential Impact of Climate Change on the Micronutrient-Rich Food Supply.

Micronutrient deficiencies are a major cause of morbidity and mortality in low- and middle-income countries worldwide. Climate change, characterized by increasing global surface temperatures and alterations in rainfall, has the capacity to affect the quality and accessibility of micronutrient-rich foods. The goals of this review are to summarize the potential effects of climate change and its consequences on agricultural yield and micronutrient quality, primarily zinc, iron, and vitamin A, of plant foods and upon the availability of animal foods, to discuss the implications for micronutrient deficiencies in the future, and to present possible mitigation and adaptive strategies. In general, the combination of increasing atmospheric carbon dioxide and rising temperature is predicted to reduce the overall yield of major staple crops, fruits, vegetables, and nuts, more than altering their micronutrient content. Crop yield is also reduced by elevated ground-level ozone and increased extreme weather events. Pollinator loss is expected to reduce the yield of many pollinator-dependent crops such as fruits, vegetables, and nuts. Sea-level rise resulting from melting of ice sheets and glaciers is predicted to result in coastal inundation, salt intrusion, and loss of coral reefs and mangrove forests, with an adverse impact upon coastal rice production and coastal fisheries. Global ocean fisheries catch is predicted to decline because of ocean warming and declining oxygen. Freshwater warming is also expected to alter ecosystems and reduce inland fisheries catch. In addition to limiting greenhouse gas production, adaptive strategies include postharvest fortification of foods; micronutrient supplementation; biofortification of staple crops with zinc and iron; plant breeding or genetic approaches to increase zinc, iron, and provitamin A carotenoid content of plant foods; and developing staple crops that are tolerant of abiotic stressors such as elevated carbon dioxide, elevated temperature, and increased soil salinity.

Affordability influences nutritional quality of seafood consumption among income and race/ethnicity groups in the United States.

BACKGROUND: The 2020 US Dietary Guidelines for Americans recommend that the US population consume more seafood. Most analyses of seafood consumption ignore heterogeneity in consumption patterns by species, nutritional content, production methods, and price, which have implications for applying recommendations. OBJECTIVES: We assessed seafood intake among adults by socioeconomic and demographic groups, as well as the cost of seafood at retail to identify affordable and nutritious options. METHODS: NHANES 2011-2018 dietary data (n = 17,559 total, n = 3285 eating seafood) were used to assess adult (≥20 y) intake of seafood in relation to income and race/ethnicity. Multivariable linear regression assessed the association between seafood consumption and income, adjusted for age, sex, and race/ethnicity, and the association between nutrients and seafood price, using Nielsen 2017-2019 retail sales data, adjusted for sales volume. RESULTS: Low-income groups consume slightly less seafood than high-income groups [low income: mean 120.2 (95% CI: 103.5, 137.2) g/wk; high income: 141.8 (119.1, 164.1) g/wk] but substantially less seafood that is high in long-chain n-3 (ω-3) PUFAs [lower income: 21.3 (17.3, 25.5) g/wk; higher income: 46.8 (35.4, 57.8) g/wk]. Intake rates, species, and production method choices varied by race/ethnicity groups and within race/ethnicity groups by income. Retail seafood as a whole costs more than other protein foods (e.g., meat, poultry, eggs, beans), and fresh seafood high in n-3 PUFAs costs more (P < 0.002) than fresh seafood low in n-3 PUFAs. Retail seafood is available in a wide range of price points and product forms, and some lower-cost fish and shellfish were high in n-3 PUFAs, calcium, iron, selenium, and vitamins B-12 and D. CONCLUSIONS: New insights into the relation between seafood affordability and consumption patterns among income and ethnicity groups suggest that specific policies and interventions may be needed to enhance the consumption of seafood by different groups.

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

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

Provision of micronutrient powder in response to the Cyclone Sidr emergency in Bangladesh: cross-sectional assessment at the end of the intervention.

BACKGROUND: Micronutrient powder has been endorsed as an effective means to improve the micronutrient status of emergency-affected populations. OBJECTIVE: To document the experience and findings of a cross-sectional assessment of the micronutrient powder program implemented as part of the emergency response to Cyclone Sidr. METHODS: Micronutrient powder was distributed to 100,714 children under 5 years of age and 59,439 pregnant or lactating women severely affected by Cyclone Sidr in Bangladesh. A cross-sectional assessment, including hemoglobin and anthropometric measurements, was conducted after the completion of the micronutrient powder program among children under 5 years of age, lactating mothers, and postmenarcheal adolescent girls in the intervention area. Comparison groups for each, drawn from the control area, which had not received micronutrient powder, were assessed at the same time. RESULTS: The prevalence of anemia among children under 5 years of age was approximately 80% in both areas. Among children in the intervention area, those who consumed at least 75% of the micronutrient powder sachets had a lower prevalence of stunting than those who consumed less than 75% of the sachets (40% vs. 52%, p < .05). Among lactating mothers in the intervention area, the prevalence rates of thinness and anemia were lower among those who consumed at least 75% of the sachets than among those who consumed less than 75% of the sachets (thinness, 31% vs. 46%, p < .05; anemia, 50% vs. 61%, p = .07). For adolescent girls in the intervention and control areas, none of whom had received micronutrient powder, the prevalence rates of anemia were 52% and 45%, respectively (p = .05). CONCLUSIONS: Micronutrient powder may reduce anemia among lactating mothers, when the compliance rate is high. Anemia prevalence prior to micronutrient powder distribution had not been investigated and could have been higher among children and lactating mothers in the intervention than in the control area, resulting in the negation of the potential positive impact of micronutrient powder on anemia.

Assessing the impact of micronutrient intervention programs implemented under special circumstances--meeting report.

INTRODUCTION AND OBJECTIVE: The World Food Programme and the Office of the United Nations High Commissioner for Refugees organized a meeting of experts to discuss evaluation of micronutrient interventions under special circumstances, such as emergency and refugee situations. RESULTS: Multimicronutrient interventions for groups with higher needs may include home fortification products for young children or supplements for pregnant and lactating women. The choice of preparation should be guided by target group needs, evidence of efficacy of a product or its compounds, acceptability, and cost-effectiveness. Different designs can be used to assess whether an intervention has the desired impact. First, program implementation and adherence must be ascertained. Then, impact on micronutrient status can be assessed, but design options are often limited by logistic challenges, available budget, security issues, and ethical and practical issues regarding nonintervention or placebo groups. Under these conditions, a plausibility design using pre- and postintervention cross-sectional surveys, a prospective cohort study, or a step-wedge design, which enrolls groups as they start receiving the intervention, should be considered. Post hoc comparison of groups with different adherence levels may also be useful. Hemoglobin is often selected as an impact indicator because it is easily measured and tends to respond to change in micronutrient status, especially iron. However, it is not a very specific indicator of micronutrient status, because it is also influenced by inflammation, parasitic infestation, physiological status (age, pregnancy), altitude, and disorders such as thalassemia and sickle cell disease. CONCLUSION: Given the constraints described above, replicability of impact in different contexts is key to the validation of micronutrient interventions.

Relationship of the availability of micronutrient powder with iron status and hemoglobin among women and children in the Kakuma Refugee Camp, Kenya.

BACKGROUND: Micronutrient powder is a potential strategy to improve iron status and reduce anemia in refugee populations. OBJECTIVE: To evaluate the effect of the availability of home fortification with a micronutrient powder containing 2.5 mg of sodium iron ethylenediaminetetraacetate (NaFeEDTA) on iron status and hemoglobin in women and children in the Kakuma Refugee Camp in northwest Kenya. METHODS: Hemoglobin and soluble transferrin receptor were measured in 410 children 6 to 59 months of age and 458 women of childbearing age at baseline (just before micronutrient powder was distributed, along with the regular food ration) and at midline (6 months) and endline (13 months)follow-up visits. RESULTS: At the baseline, midline, and endline visits, respectively, the mean (+/- SE) hemoglobin concentration in women was 121.4 +/- 0.8, 120.8 +/- 0.9, and 120.6 +/- 1.0 g/L (p = .42); the prevalence of anemia (hemoglobin < 120 g/L) was 42.6%, 41.3%, and 41.7% (p = .92); and the mean soluble transferrin receptor concentration was 24.1 +/- 0.5, 20.7 +/- 0.7, and 20.8 +/- 0.7 nmol/L (p = .0006). In children, the mean hemoglobin concentration was 105.7 +/- 0.6, 109.0 30322 1.5, and 105.5 +/- 0.3 g/L (p = .95), respectively; the prevalence of anemia (hemoglobin < 110 g/L) was 55.5%, 52.3%, and 59.8% (p = .26); and the mean soluble transferrin receptor concentration was 36.1 +/- 0.7, 29.5 +/- 1.9, and 28.4 +/- 3.2 nmol/L (p = .02), in models that were adjusted for age using least squares means regression. CONCLUSIONS: In children and in women of childbearing age, the availability of micronutrient powder was associated with a small improvement in iron status but no significant change in hemoglobin in this refugee camp setting.

Consumption of micronutrient-fortified milk and noodles is associated with lower risk of stunting in preschool-aged children in Indonesia.

BACKGROUND: Stunting is highly prevalent in developing countries and is associated with greater morbidity and mortality. Micronutrient deficiencies contribute to stunting, and micronutrient-fortified foods are a potential strategy to reduce child stunting. OBJECTIVE: To examine the relationship between the use of fortified powdered milk and noodles and child stunting in a large, population-based sample of Indonesian children. METHODS: Consumption of fortified milk and fortified noodles was assessed in children 6 to 59 months of age from 222,250 families living in rural areas and 79,940 families living in urban slum areas in Indonesia. RESULTS: The proportions of children who consumed fortified milk and fortified noodles were 34.0% and 22.0%, respectively, in rural families, and 42.4% and 48.5%, respectively, in urban families. The prevalence of stunting among children from rural and urban families was 51.8% and 48.8%, respectively. Children from rural and urban families were less likely to be stunted if they consumed fortified milk (in rural areas, OR = 0.87; 95% CI, 0.85 to 0.90; p < .0001; in urban areas, OR = 0.80; 95% CI, 0.76 to 0.85; p < .0001) or fortified noodles (in rural areas, OR = 0.95; 95% CI, 0.91 to 0.99;p = .02; in urban areas, OR = 0.95; 95% CI, 0.91 to 1.01; p = .08) in multiple logistic regression models adjusted for potential confounders. In both rural and urban families, the odds of stunting were lower when a child who consumed fortified milk also consumed fortified noodles, or when a child who consumed fortified noodles also consumed fortified milk. CONCLUSIONS: The consumption of fortified milk and noodles is associated with decreased odds of stunting among Indonesian children. These findings add to a growing body of evidence regarding the potential benefits of multiple micronutrient fortification on child growth.