Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose.

OBJECTIVE: Antenatal multiple micronutrient supplements (MMS) are a cost-effective intervention to reduce adverse pregnancy and birth outcomes. However, the current WHO recommendation on the use of antenatal MMS is conditional, partly due to concerns about the effect on neonatal mortality in a subgroup of studies comparing MMS with iron and folic acid supplements (IFA) containing 60 mg of iron. We aimed to assess the effect of MMS vs IFA on neonatal mortality stratified by iron dose in each supplement. METHODS: We updated the neonatal mortality analysis of the 2020 WHO guidelines using the generic inverse variance method and applied the random effects model to calculate the effect estimates of MMS vs. IFA on neonatal mortality in subgroups of trials (n=13) providing the same or different amounts of iron, i.e. MMS with 60 mg of iron vs IFA with 60 mg of iron; MMS with 30 mg of iron vs IFA with 30 mg of iron; MMS with 30 mg of iron vs IFA with 60 mg of iron; and MMS with 20 mg of iron vs IFA with 60 mg of iron. RESULTS: There were no statistically significant differences in neonatal mortality between MMS and IFA within any of the subgroups of trials. Analysis of MMS with 30 mg vs IFA with 60 mg of iron (7 trials, 14,114 participants), yielded a nonsignificant Risk Ratio (RR) of 1.12 (95% CI 0.83 to 1.50). CONCLUSION: Neonatal mortality did not differ between MMS and IFA regardless of iron dose in either supplement.

Inadequacy of nutrients and contaminants found in porridge-type complementary foods in Rwanda.

Child malnutrition remains persistently high in Rwanda. Complementary foods play a key role in young child nutrition. This study explores the quality and safety of complementary food products available in the Rwandan market. Ten of the most consumed porridge-type complementary food products in Rwanda have been analysed. Mean values of macronutrient and micronutrient contents were compared against three international standards and evaluated against label claims. Mean mycotoxin, microbiological, and pesticide contamination were compared with maximum tolerable limits. Mean energy density (385 kcal/100 g) and total fat content (7.9 g/100 g) were lower than all three international benchmarks. The mean fibre content of 8.5 g/100 g was above the maximum recommended amount of Codex Alimentarius and more than double the amount claimed on labels. Mean levels of vitamin A (retinyl palmitate, 0.54 mg/100 g) and vitamin E (α-tocopherol, 3.7 mg/100 g) fell significantly short of all three standards, whereas calcium and zinc requirements were only partially met. Average iron content was 12.1 mg/100 g. The analysis revealed a mean aflatoxin contamination of 61 µg/kg, and high mold and yeast infestation. Escherichia coli and pesticide residues were found, whereas no heavy metals could be quantitated. Overall, complementary food products in Rwanda show inadequate nutrient contents and high aflatoxin and microbial contamination levels. Improved regulation and monitoring of both local and imported products are needed to improve the quality and safety of complementary foods in Rwanda.

Including 60 mg Elemental Iron in a Multiple Micronutrient Supplement Blunts the Increase in Serum Zinc after 12 Weeks of Daily Supplementation in Predominantly Anemic, Nonpregnant Cambodian Women of Reproductive Age.

BACKGROUND: Multiple micronutrient (MMN) supplementation may result in interaction effects due to competing absorptive pathways of trace elements. OBJECTIVES: The aim of this study was to investigate the effect of MMN supplementation with or without iron on serum zinc, selenium, and copper concentrations in Cambodian women. METHODS: In a 2 × 2 factorial double-blind randomized 12-wk trial, predominantly anemic, nonpregnant women (aged 18-45 y) received daily 60 mg of iron (Fe; n = 201); 14 other micronutrients including zinc (15 mg), selenium (65 µg), and copper (2 mg), but no iron (MMN; n = 202); 60 mg iron plus MMN (Fe + MMN; n = 206); or a placebo (n = 200). Fasting morning blood was collected at baseline and 12 wk from women in 26 villages in Kampong Chhnang province. Serum zinc, selenium, and copper concentrations (secondary outcomes of the randomized controlled trial) were measured using inductively coupled plasma mass spectrometry. Generalized linear regression was used to estimate intervention effects [ß coefficient (95% CI)] for Fe (with or without MMN) and MMN (with or without Fe) after testing for the presence of an Fe × MMN interaction. RESULTS: A total of 760 women completed the trial. Zinc deficiency prevalence at baseline was 45% (inflammation-adjusted serum zinc <10.7 µmol/L). A significant Fe × MMN interaction (P = 0.02) was detected in the 2 × 2 analysis with serum zinc concentration as the outcome: the MMN group had a higher mean serum zinc concentration at 12 wk (12.3 µmol/L; 95% CI: 12.2, 12.4 µmol/L) compared with all other groups, and the Fe + MMN group had a higher mean serum zinc concentration (11.6 µmol/L; 95% CI: 11.5, 11.7 µmol/L) compared with the Fe group (11.0 µmol/L; 95% CI: 10.9, 11.0 µmol/L) and the placebo group (11.2 µmol/L; 95% CI: 11.1, 11.4 µmol/L). CONCLUSIONS: The inclusion of 60 mg iron in the daily MMN formulation may be interfering with the absorption and/or metabolism of supplemental zinc in Cambodian women. This is of particular concern when MMN supplementation is implemented in populations with risk of zinc deficiency. This trial was registered at clinicaltrials.gov as NCT-02481375.

Translational and Implementation Research to Bridge Evidence and Implementation.

BACKGROUND: The role of science in guiding interventions and programs and contributing to progress in achieving global targets is undeniable. In public health nutrition, biological research in the past century focused largely on single nutrients and provided the basis for addressing nutritional deficiencies. This focus has now expanded to consider evidence including, but not limited, to knowledge about food, diet, behavior, context, and culture. The complex double burden of malnutrition will need to be addressed through a wider lens that appreciates the multiple and interrelated facets that underpin it. SUMMARY: Despite the acknowledged importance of translational research in improving nutritional outcomes, significant gaps remain in the process leading from science to practice. This article sheds light on 2 examples that demonstrate this, namely, anemia and stunting. Further, much work is still required to translate the current evidence base into effective actions that result in impact at scale, pointing toward the need for more implementation research in nutrition. Key Messages: While discoveries may take time to surface and implementers are impatient to address the challenge at hand, it is essential to identify and deploy the best available evidence while continuously advancing the evidence base, and to seek the right balance between action and inaction.

The association between active tobacco use during pregnancy and growth outcomes of children under five years of age: a systematic review and meta-analysis.

BACKGROUND: Despite considerable global efforts to reduce growth faltering in early childhood, rates of stunting remain high in many regions of the world. Current interventions primarily target nutrition-specific risk factors, but these have proven insufficient. The objective of this study was to synthesize the evidence on the relationship between active tobacco use during pregnancy and growth outcomes in children under five years of age. METHODS: In this systematic review and meta-analysis, six online databases were searched to identify studies published from January 1, 1980, through October 31, 2016, examining the association between active tobacco use during pregnancy and small-for-gestational age (SGA), length/height, and/or head circumference. Ecological studies were not included. A meta-analysis was conducted, and subgroup analyses were carried out to explore the effect of tobacco dosage. RESULTS: Among 13,189 studies identified, 210 were eligible for inclusion in the systematic review, and 124 in the meta-analysis. Active tobacco use during pregnancy was associated with significantly higher rates of SGA (pooled adjusted odds ratio [AORs] = 1.95; 95% confidence interval [CI]: 1.76, 2.16), shorter length (pooled weighted mean difference [WMD] = 0.43; 95% CI: 0.41, 0.44), and smaller head circumference (pooled WMD = 0.27; 95% CI: 0.25, 0.29) at birth. In addition, a dose-response effect was evident for all growth outcomes. CONCLUSION: Tobacco use during pregnancy may represent a major preventable cause of impaired child growth and development.

Increasing egg availability through smallholder business models in East Africa and India.

Availability and consumption of eggs, especially in Sub-Saharan Africa and Asia, is low despite their apparent benefits. We investigated constraints in egg production in four countries; Kenya, Ethiopia, Malawi, and India and identified five business models that are viable and sustainable. They are (a) micro-franchising, (b) microfinancing, (c) co-operative farming, (d) enterprise development, and (e) out-grower model. All of them involve smallholder farmers to increase egg production. These farmers have access to soft loans and use improved inputs and extension services to varying degrees. Inputs include resilient breeds of day-old chicks or point-of-lay hens, feed, vaccines, medicines, and housing. Outgrower and enterprise development models have a significant potential of rapidly increasing egg yields, achieve self-sufficiency, operate at or near scale, and provide a high income for the farmers. This study shows how a range of actors in commercial, not-for-profit and microfinance sectors with specialized skills, can facilitate the transformation of the egg production sector. Specific skills include brooding (hatchery operations), feed milling, aggregation, and training of smallholder farmers or large-scale rearing. The five archetypes we describe here are promising ways to increase egg availability in rural areas.

Situation analysis of procurement and production of multiple micronutrient supplements in 12 lower and upper middle-income countries.

Globally, there are few vitamin and mineral ingredient manufacturers. To support local, in-country or regional procurement and production of multiple micronutrient supplements (MMS), the following production scenarios are possible: (a) straight ingredients of vitamins and minerals forms imported or locally produced that are mixed, tableted, or encapsulated and packaged by a local manufacturer; (b) import or local production of a vitamin and minerals premix that is tableted or encapsulated and packaged locally; (c) import of a bulk, finished product (tablets or capsules) that is packaged and branded; and (d) or import of a branded packaged product. This paper is a situation analysis of the market, manufacturing, and policy factors that are driving the production of MMS in 12 lower and upper middle-income countries. Key informants completed a self-administered structured questionnaire, which examined the local context of products available in the market and their cost, regulations and policies, in Brazil, Colombia, Guatemala, Mexico, Peru, Bangladesh, India, Vietnam, Ghana, Kenya, Nigeria, and South Africa. Our study found that although most countries have the capacity to produce locally MMS, the major barriers observed for sustainable and affordable production include (a) poor technical capacity and policies for ensuring quality along the value chain and (b) lack of policy coherence to incentivize local production and lower the manufacture and retail price of MMS. Also, better guidelines and government oversight will be required because not one country had an MMS formulation that matched the globally recommended formulation of the United Nations Multiple Micronutrient Preparation (UNIMMAP).

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

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

The Egg Hub Model: A Sustainable and Replicable Approach to Address Food Security and Improve Livelihoods.

Background: Despite progress in improving living standards and reduced poverty, food insecurity and malnutrition remain a significant issue worldwide. Childhood is a critical time for the intake of protein to support physical and cognitive growth, including animal-source foods like eggs which can effectively mitigate stunting in low- and middle-income countries. In Malawi, high malnutrition rates among women and children represent a significant public health challenge, but high-quality sources such as eggs remain costly, scarce, and rarely consumed by children in Malawi. The Egg Hub model, identified and piloted by local agri-food entrepreneurs and the Sight and Life Foundation in Malawi, tackles the obstacles faced by smallholder farmers, working to increase egg production, enhance availability, and improve consumption within rural communities by supporting small-scale farmers transition from unsustainable and unproductive backyard rearing to small-scale farm through access to high-quality inputs, training, loans, and a guaranteed market for their eggs. Objectives: This paper provides a detailed account of the implementation of the pilot of the Egg Hub Model in Malawi including the demand creation process, the impact of the model on producers, consumers, and operators, and the social, economic, and environmental sustainability aspects of the model. Methods: Qualitative and quantitative surveys (n = 217 consumers) were used for demand creation and qualitative surveys were used with 15 retailers to determine egg sales. With 16 farmers and the egg hub operator, business metrics, including profits and loss records, were analyzed. Results: The pilot of the Egg Hub model in Malawi supported 85 farmers to triple their egg production, allowing their communities to purchase eggs at prices reduced by 40%, benefiting an estimated number of 180,000 rural poor. Egg consumption among the target population increased from an average of 2 to 9 eggs/month and led to reduced egg wastage and better biosecurity, reducing the risk of children's exposure to chicken feces and infections. The achievements of this Egg Hub in Malawi allowed the model to be replicated in Ethiopia, Peru, and Brazil, producing 40 million eggs annually and benefiting more than half a million consumers. Conclusion: The Egg Hub model is a comprehensive and scalable solution to increase egg supply, address malnutrition and food insecurity, and improve livelihoods. The advantages include centralizing key activities through a community-centered approach, empowering female farmers, increasing access to a highly nutritious food, and economic benefits for farmers and their communities.

Evaluating Double-Duty Actions in Rwanda's Secondary Cities.

The double burden of malnutrition (DBM) is escalating in low- and middle-income countries (LMICs), including in Rwanda, most notably in urbanizing areas. The 2019-2020 Rwanda Demographic Health Survey (DHS) revealed that 33% of children under 5 years old are stunted while 42% of women in urban areas are overweight or obese. This coexistence has contributed to a surge in non-communicable diseases (NCDs), particularly in secondary cities. Using the World Health Organization's (WHOs) "double-duty action" (DDA) concept, this study aims to identify and evaluate interventions with double-duty potential in Rwanda's Rusizi and Rubavu districts and generate key recommendations for their improvement. A desk review of national policies pinpointed four programs with the greatest DDA potential: early childhood development (ECD) centers, the school feeding program, farmer field schools (FFS), and the provision of nutrition-sensitive direct support. In-person interviews with key stakeholders assessed the implementation of each program and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was used to generate context-specific recommendations for their improvement. The main finding of this research is that Rwanda's potential to address the DBM can be improved across multiple sectors by implementing a few key changes: targeting beliefs surrounding nutrition, improving trainings for community educators, enhancing parent-particularly father-involvement, and engaging in close monitoring and follow-up. These findings offer actionable streps that governments and nutrition stakeholders can take to improve similar interventions in other rapidly urbanizing LMICs.

PROTOCOL: Breakfast consumption, anthropometry, and nutrition-related outcomes in adolescents from low- and middle-income countries: Protocol for a systematic review and meta-analysis.

Objectives This is the protocol for a Campbell systematic review. The objectives are as follows: The aim of this systematic review is to examine the scientific evidence available from low- and middle-income countries on the association of breakfast consumption habits and anthropometry/adiposity- and nutrition-related outcomes in adolescents aged 10-19 years old.

A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar.

BACKGROUND: Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy. METHODS: This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches. RESULTS: In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso. CONCLUSIONS: The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Plain language titleA comparison of How Pregnant Women Make Decisions About What to Eat in Burkina Faso and Madagascar Using a Model Called the Food Choice Process ModelPlain language summaryHaving a proper diet is very important for the health of pregnant women. In Burkina Faso and Madagascar, many women do not get enough nutritious food due to lack of knowledge on what to eat, lack of money, cultural traditions, and not having control over their own choices. This study wants to find out (1) what women eat during pregnancy in Burkina Faso and Madagascar, (2) what influences the decisions women make about what to eat during pregnancy, and (3) explore how women had decision-making autonomy during pregnancy. The study took place in Burkina Faso and Madagascar. The researchers talked to women who could have babies and women who were already pregnant or breastfeeding. They used different methods like focus group discussions and semi-structured interviews to gather information. They recorded and translated everything that was said from the local languages to French. They used special software to analyze the information from the interviews. They also used a free list to understand the things women mentioned most often when talking about food. In Burkina Faso and Madagascar, women mostly ate basic foods like rice and tô during pregnancy. Sometimes they ate fruits and vegetables when they were available, but they did not eat much meat or other foods from animals. In both places, the women's food choices during pregnancy were influenced by different things like what their friends and family thought, how much money they had, their personal preferences, and other factors. In Madagascar, men and women made decisions together about important things like money, but in Burkina Faso, men were usually the ones making the decisions. The lack of a proper diverse diet during pregnancy in Burkina Faso and Madagascar is primarily caused by social factors and resources. To help women make better food choices during pregnancy, it's important to understand what affects their ability to have a healthy diet. This can help programs that aim to improve the nutrition of pregnant women by encouraging them to change their behavior.

Biomarkers in growth.

BACKGROUND: The current approaches to assess growth are limited to anthropometry, are insensitive and nonspecific, and do not enable an improved understanding of how nutrition might impact growth. Consequently, new tools to develop better standards of care and programs to address ongoing concerns about nutrition and health are needed. METHODS: The Biomarkers of Nutrition for Development (BOND) project is designed to support the discovery, development, and use of current and new biomarkers of nutritional exposure, status, function, and effect. The Biomarkers in Growth (BIG) project was initiated as a BOND program to develop a roadmap for moving the nutrition and growth agenda forward. The first step in this project was a session jointly organized by the BOND Secretariat and Sight and Life at the 20th International Congress on Nutrition in Granada, Spain. RESULTS: The BIG session outlined current approaches to evaluating growth and understanding of the role of nutrition in linear growth, body composition, and long-term health outcomes and the potential role of systems biology in the assessment of the nutrition-growth relationship. CONCLUSION: The session presentations and deliberations highlighted the need for a concerted effort to address the critical gaps in our understanding of the biology and assessment of growth.

Innovative Research for Nutrition- and Climate-Smart Food Systems in Low- and Middle-Income Countries.

The world is off-track to end world hunger, food insecurity, and malnutrition in all its forms by 2030 [...].

Knowledge, Attitudes and Practices of Pregnant Women and Healthcare Providers in Bangladesh regarding Multivitamin Supplements during Pregnancy.

Micronutrient deficiencies are widespread among pregnant women in low- and middle-income countries (LMIC) and lead to potentially adverse effects for mother and baby. In Bangladesh, maternal malnutrition remains a severe problem, with high rates of anemia (49.6% of pregnant women and 47.8% of lactating women are anemic) and other nutritional deficiencies. A Knowledge, Attitudes, and Practices (KAP) study was conducted to assess Bangladeshi pregnant women's perceptions and related behaviors, as well as awareness and knowledge among pharmacists and healthcare professionals concerning prenatal multivitamin supplements. This was done in both rural and urban areas across Bangladesh. A total of 732 quantitative interviews were conducted (330 with providers and 402 with pregnant women, with an equal split between urban and rural areas for both sets of audiences; 200 women were users of prenatal multivitamin supplements, while 202 women were aware non-users). The study identified a few findings that can guide further research or market-based interventions to reduce micronutrient deficiencies. These include most pregnant women not knowing the right time to start multivitamin supplements (56.0%, [n = 225], stating that a woman should start taking supplements 'after the first trimester'), not knowing their benefits, and how they help both the mother and baby-only 29.5% [n = 59] stated that they believed the supplements helped their baby to grow well). Further, barriers to taking the supplements include women believing a nutritious diet is a substitute (88.7% [n = 293]), and a perceived lack of support from other family members (21.8%, [n = 72]). This suggests that there is a need for further awareness-raising among all pregnant women, their family members, and providers.

Precision Nutrition Opportunities to Help Mitigate Nutrition and Health Challenges in Low- and Middle-Income Countries: An Expert Opinion Survey.

Precision nutrition involves several data collection methods and tools that aim to better inform nutritional recommendations and improve dietary intake, nutritional status, and health outcomes. While the benefits of collecting precise data and designing well-informed interventions are vast, it is presently unclear whether precision nutrition is a relevant approach for tackling nutrition challenges facing populations in low- and middle-income countries (LMIC), considering infrastructure, affordability, and accessibility of approaches. The Swiss Food & Nutrition Valley (SFNV) Precision Nutrition for LMIC project working group assessed the relevance of precision nutrition for LMIC by first conducting an expert opinion survey and then hosting a workshop with nutrition leaders who live or work in LMIC. The experts were interviewed to discuss four topics: nutritional problems, current solutions, precision nutrition, and collaboration. Furthermore, the SFNV Precision Nutrition for LMIC Virtual Workshop gathered a wider group of nutrition leaders to further discuss precision nutrition relevance and opportunities. Our study revealed that precision public health nutrition, which has a clear focus on the stratification of at-risk groups, may offer relevant support for nutrition and health issues in LMIC. However, funding, affordability, resources, awareness, training, suitable tools, and safety are essential prerequisites for implementation and to equitably address nutrition challenges in low-resource communities.

Nutrition in City Ecosystems (NICE): Protocol of a multi-sectoral development project to improve food and nutrition security of secondary city populations in Bangladesh, Kenya and Rwanda.

Background: Secondary cities tend to be better linked with local food systems than primate cities, acting as important platforms to trade agricultural produce with rural surrounding. COVID-19, conflicts and climate change continue to expose inefficiencies in food systems and have further exacerbated malnutrition, calling for substantial food systems transformations. However, tackling current food systems' challenges requires new approaches to ensure food and nutrition security. Nutritious and agroecologically produced food offer the potential to transform food systems by improving diets and alleviating pressure on the environment, as well as by creating jobs and reducing poverty. This paper describes the design of a project by a Swiss public-private consortium to improve food and nutrition security and to reduce poverty in city ecosystems in six secondary cities in Bangladesh, Kenya and Rwanda through governance/policy and supply and demand side interventions. Methods: The Nutrition in City Ecosystems (NICE) project promotes well-balanced nutrition for city populations through interdisciplinary agricultural, food, and health sector collaborations along city-specific value chains. Adopting a transdiciplinary systems approach, the main interventions of NICE are (i) advocacy and policy dialogue, (ii) building of decentralized institutional capacity in multi-sectoral collaborations, (iii) support of data-driven planning, coordination and resource mobilization, (iv) anchoring of innovations and new approaches in city-level partnerships, (v) capacity building in the agricultural, retail, health and education sectors, as well as (vi) evidence generation from putting policies into practice at the local level. NICE is coordinated by in-country partners and local offices of the Swiss public-private consortium partners. Discussion: The NICE project seeks to contribute to urban food system resilience and enhanced sustainable nutrition for city populations by (A) strengthening urban governance structures involving key stakeholders including women and youth, (B) generating income for producers along the supply chain, (C) triggering change in producers' and consumers' behavior such that nutritious and agroecologically produced foods are both in demand as well as available and affordable in urban markets, and (D) allowing a scale up of successful approaches to other national and international cities and city networks.

Evidence in multiple micronutrient nutrition: from history to science to effective programs.

The workshop involved key researchers from academic and development organizations reviewing what we have learned about multiple micronutrients and applying that knowledge to providing guidance to public health policy and program design. The participants highlighted the importance of evidence-based interventions, not to restrict evidence slanted toward one single origin but to appreciate the totality of evidence from history, epidemiology, basic science, randomized-controlled studies, and meta-analyses to inform policy and guideline development for the implementation of effective programs. It has to be understood and accepted that although the need for an evidence-based approach to nutritional recommendations is fundamental and cannot be disputed, there are distinct differences between evidence-based medicine and evidence-based nutrition practice. The level of confidence and certainty needed to launch programs to reduce micronutrient deficiencies can be different from what is required to treat a disease. An effective approach would be to ensure that both research and programs at scale are running in parallel and that both receive adequate attention and funding to fine tune the program or stop it when it is no longer required. There was much valuable discussion on the topic of what types of research methodologies are suitable for what type of intervention and, importantly, what is required before public health policy can be set. This paper is an introduction to a series of articles in this supplement that discuss the evidence on multiple micronutrients and what is required to establish policies and launch effective multiple micronutrient programs.

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.