Development of a bioelectrical impedance analysis-based prediction equation for body composition of rural children aged 4-8 years in Myanmar.

Background: Reliable and accurate estimates of body composition are essential when studying the various health correlates of disease. Bioelectrical impedance analysis (BIA) is an affordable and feasible body composition assessment technique for clinical and field settings. Total body water (TBW) and hence fat-free mass is estimated by predictive regression algorithms using anthropometric measurements plus the resistance index. Aim: The study aimed to develop a BIA prediction equation for TBW in children in Myanmar using the deuterium dilution technique as the reference method. Methods: The study design was cross-sectional in a school setting with convenience sampling of participants. One hundred and two healthy children (57 boys and 45 girls) with aged 4 and 8 years participated; randomly divided into the prediction group (29 boys and 22 girls) and cross-validation group (28 boys and 23 girls). Whole-body impedance, anthropometric and TBW (by D2O dilution) measurements. The prediction equation was cross-validated using a split-group design and compared to published equations for contemporaneous populations. Results: TBW could be predicted by the following equation. TBW = 0.4597 * Weight (kg) + 0.1564 * Impedance index + 0.6075 (R2 = 0.891, P < 0.0001) with a correlation coefficient of 0.942 and limits of agreement of 0.98 kg TBW on cross-validation. Conclusions: This equation can be used to predict body composition in young (aged 4-8 years) children in Myanmar but because the age range of the participants in the present study was relatively narrow, more research in different age groups is required to establish its broader applicability.

Context and Perspectives for Establishing a Novel Database for Protein Quality of Human Foods, as Proposed by a Joint Food and Agriculture Organization of the United Nations/International Atomic Energy Agency Expert Technical Meeting in October 2022.

United Nations agencies have a long history of leading work on establishing global human nutrient requirements. Dietary protein contributes to metabolism and homeostasis and plays an essential role in human health for growth, maintenance, reproduction, and immune function (or immunity). Accurately defining the quantity and quality of protein provided by foods and diets required to meet human nutritional needs is essential to achieving global environmental and nutrition goals. There have been many scientific developments related to protein quality over the past decades, with the preferred method being the scoring approach that relates the capacity of protein sources to provide an adequate amount and proportion of nitrogen and indispensable amino acids (IAAs) in a bioavailable form (often referred to as digestibility). Questions surrounding the scoring approach and IAA metabolic availability have been discussed during past and recent expert consultations. Recently, an Food and Agriculture Organization of the United Nations/International Atomic Energy Agency technical meeting, held in Vienna, 10-13 October, 2022, reviewed and updated evidence and related methods on protein requirements and protein quality assessment and designed a framework for the development of a Protein Digestibility Database to aid dialog on the evaluation of protein quality and protein sufficiency in different populations. The database should be a living document and align with national food compositional databases.

Approaches to Address the Anemia Challenge.

Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.

HIV-Infected and HIV-Uninfected Western Kenyan Women Produce Equivalent Amounts of Breast Milk at 6 Wk and 6 Mo Postpartum: A Prospective Cohort Study Using Deuterium Oxide Dose-to-Mother Technique.

BACKGROUND: Regardless of their HIV serostatus, mothers are advised to exclusively breastfeed infants ≤6 mo postpartum. How this guidance impacts breast milk intake among HIV-exposed infants in varied contexts needs to be better understood. OBJECTIVES: The objective of this study was to compare breast milk intake of HIV-exposed and HIV-unexposed infants at 6 wk and 6 mo of age, as well as the associated factors. METHODS: In a prospective cohort design, which we followed from a western Kenya postnatal clinic, 68 full-term HIV-uninfected infants born to HIV-1-infected mothers (HIV-exposed) and 65 full-term HIV-uninfected infants born to HIV-uninfected mothers were assessed at 6 wk and 6 mo of age. Breast milk intake of infants (51.9% female) weighing 3.0-6.7 kg (at 6 wk of age) was determined using the deuterium oxide dose-to-mother technique. Student t test for independent samples compared the variations in breast milk intake between the 2 groups. Correlation analysis detected the associations between breast milk intake and maternal and infant factors. RESULTS: Daily breast milk intakes by HIV-exposed and HIV-unexposed infants were not significantly different at either 6 wk (721 ± 111 g/d and 719 ± 121 g/d, respectively) or 6 mo (960 ± 121 g/d and 963 ± 107 g/d, respectively) of age. Maternal factors that significantly correlated with infant breast milk intake were FFM at both 6 wk (r = 0.23; P < 0.05) and 6 mo (r = 0.36; P < 0.01) of age and weight at 6 mo postpartum (r = 0.28; P < 0.01). Infant factors that significantly correlated at 6 wk were birth weight (r = 0.27; P < 0.01), present weight (r = 0.47; P < 0.01), length-for-age z-score (r = 0.33; P < 0.01), and weight-for-age (r = 0.42; P > 0.01). At 6 mo, they were infant length-for-age (r = 0.38; P < 0.01), weight-for-length (r = 0.41; P > 0.01), and weight-for-age (r = 0.60; P > 0.01). CONCLUSIONS: Full-term breastfeeding infants born to HIV-1-infected and HIV-1-uninfected women attending standard Kenyan postnatal care clinics ≤6 mo of age in this resource-poor setting consume comparable amounts of breast milk. This trial was registered at clinicaltrials.gov as PACTR201807163544658.

Indispensable Amino Acid Digestibility of Moroccan Fava Bean Using the Dual Isotope Method in Healthy Adults.

BACKGROUND: Assessment of protein quality is necessary to satisfy the nutritional needs of populations across the world. In addition to indispensable amino acid (IAAs) composition, protein digestibility is a major component of IAA bioavailability, playing a crucial role in human health and affecting the linear growth of children. OBJECTIVES: This study aimed to evaluate IAA digestibility of fava beans, a legume widely consumed in Morocco using the dual-tracer method. METHODS: 2H-intrinsically labeled Fava beans supplemented with 12 mg/kg BW of 13C spirulina were given to 5 healthy volunteers (3 men and 2 women), aged 25.8 ± 3.3 y, with a mean BMI of 20.0 kg/m2. The meal was spread in small portions and was given hourly throughout 7 h. Blood was sampled at baseline and hourly from 5 to 8 h after meal ingestion. IAA digestibility was evaluated by gas chromatography-combustion-isotope ratio mass spectrometry using the 2H/13C ratio in plasma IAA. Digestible indispensable amino acid ratios (DIAAR) were calculated using the scoring pattern for people older than 3 y. RESULTS: Fava beans had an adequate level of lysine but were limiting in several IAAs, especially methionine. Under our experimental conditions, the average IAA digestibility of fava bean was 61.1% ± 5.2%. Valine had the highest digestibility (68.9% ± 4.3%) and threonine had the lowest (43.7% ± 8.2%). In consequence, the lowest DIAAR was 67% for threonine and only 47% for sulfur amino acids (SAA). CONCLUSIONS: The present study is the first to determine the digestibility of fava bean amino acids in humans. The mean IAA digestibility was moderate, and consequently, we conclude that fava bean provides a limited amount of several IAAs, especially SAA, but adequately for lysine. Preparation and cooking methods of fava beans should be improved to increase digestibility. This study was registered at ClinicalTrials.gov as NCT04866927.

Associations between Stunting, Wasting and Body Composition: A Longitudinal Study in 6- to 15-Month-Old Kenyan Children.

BACKGROUND: Early growth and body composition may influence the risk of obesity and health in adulthood. Few studies have examined how undernutrition is associated with body composition in early life. OBJECTIVES: We assessed stunting and wasting as correlates of body composition in young Kenyan children. METHODS: Nested in a randomized controlled nutrition trial, this longitudinal study assessed fat and fat-free mass (FM, FFM) using deuterium dilution technique among children at age 6 and 15 months. This trial was registered at http://controlled-trials.com/ (ISRCTN30012997). Cross-sectional and longitudinal associations between z-score categories of length-for-age (LAZ) or weight-for-length (WLZ) and FM, FFM, fat mass index (FMI), fat-free mass index (FFMI), triceps, and subscapular skinfolds were analyzed by linear mixed models. RESULTS: Among the 499 children enrolled, breastfeeding declined from 99% to 87%, stunting increased from 13% to 32%, and wasting remained at 2% to 3% between 6 and 15 mo. Compared with LAZ >0, stunted children had a 1.12 kg (95% CI: 0.88, 1.36; P < 0.001) lower FFM at 6 mo and increased to 1.59 kg (95% CI: 1.25, 1.94; P < 0.001) at 15 mo, corresponding to differences of 18% and 17%, respectively. When analyzing FFMI, the deficit in FFM tended to be less than proportional to children's height at 6 mo (P ≤ 0.060) but not at 15 mo (P > 0.40). Stunting was associated with 0.28 kg (95% CI: 0.09, 0.47; P = 0.004) lower FM at 6 mo. However, this association was not significant at 15 mo, and stunting was not associated with FMI at any time point. A lower WLZ was generally associated with lower FM, FFM, FMI, and FFMI at 6 and 15 mo. Differences in FFM, but not FM, increased with time, whereas FFMI differences did not change, and FMI differences generally decreased with time. CONCLUSIONS: Overall, low LAZ and WLZ among young Kenyan children were associated with reduced lean tissue, which may have long-term health consequences.

Childhood BMI and other measures of body composition as a predictor of cardiometabolic non-communicable diseases in adulthood: a systematic review.

OBJECTIVE: There is growing evidence that childhood malnutrition is associated with non-communicable diseases (NCD) in adulthood and that body composition mediates some of this association. This review aims to determine if childhood body composition can be used to predict later-life cardiometabolic NCD and which measures of body composition predicts future NCD. DESIGN: Electronic databases were searched for articles where: children aged under 5 years had body composition measured; cardiometabolic health outcomes were measured a minimum of 10 years later. SETTING: The databases Embase, Medline and Global Health were searched through July 2020. PARTICIPANTS: Children aged under 5 years with a follow-up of minimum 10 years. RESULTS: Twenty-nine studies met the inclusion criteria. Though a poor proxy measure of body composition, body mass index (BMI) was commonly reported (n 28, 97 %). 25 % of these studies included an additional measure (ponderal index or skinfold thickness). Few studies adjusted for current body size (n 11, 39 %). CONCLUSIONS: Many studies reported that low infant BMI and high childhood BMI were associated with an increased risk of NCD-related outcomes in later life but no conclusions can be made about the exact timing of child malnutrition and consequent impact on NCD. Because studies focussed on BMI rather than direct measures of body composition, nothing can be said about which measures of body composition in childhood are most useful. Future research on child nutrition and long-term outcomes is urgently needed and should include validated body composition assessments as well as standard anthropometric and BMI measurements.

13C-sucrose breath test for the non-invasive assessment of environmental enteropathy in Zambian adults.

Objectives: Environmental enteropathy (EE) is a subclinical disorder highly prevalent in tropical and disadvantaged populations and is thought to play a role in growth faltering in children, poor responses to oral vaccines, and micronutrient deficiencies. This study aims to evaluate the potential of a non-invasive breath test based on stable isotopes for evaluation of impaired digestion and absorption of sucrose in EE. Methods: We optimized a 13C-sucrose breath test (13C-SBT) in 19 young adults in Glasgow, United Kingdom. In a further experiment (in 18 adults) we validated the 13C-SBT using Reducose, an intestinal glucosidase inhibitor. We then compared the 13C-SBT to intestinal mucosal morphometry, immunostaining for sucrose-isomaltase (SI) expression, and SI activity in 24 Zambian adults with EE. Results: Fully labeled sucrose (0.3 mg/kg) provided clear breath enrichment signals over 2-3 h in both British and Zambian adults, more than fivefold higher than naturally enriched sucrose. Reducose dramatically impaired 13C-sucrose digestion, reducing 4 h 13CO2 breath recovery by > 50%. Duodenal biopsies in Zambian adults confirmed the presence of EE, and SI immunostaining was present in 16/24 adults. The kinetics of 13CO2 evolution were consistently faster in participants with detectable SI immunostaining. Although sucrase activity was strongly correlated with villus height (r = 0.72; P < 0.05) after adjustment for age, sex and body mass index, there were no correlations between 13C-SBT and villus height or measured sucrase activity in pinch biopsies. Conclusion: A 13C-SBT was developed which was easy to perform, generated clear enrichment of 13CO2 in breath samples, and clearly reports sucrase activity. Further work is needed to validate it and understand its applications in evaluating EE.

Calcium status assessment at the population level: Candidate approaches and challenges.

Inadequate dietary calcium intake is a global public health problem that disproportionately affects low- and middle-income countries. However, the calcium status of a population is challenging to measure, and there are no standard methods to identify high-risk communities even in settings with an elevated prevalence of a disease caused or exacerbated by low calcium intake (e.g., rickets). The calcium status of a population depends on numerous factors, including intake of calcium-rich foods; the bioavailability of the types of calcium consumed in foods and supplements; and population characteristics, including age, sex, vitamin D status, and genetic attributes that influence calcium retention and absorption. The aim of this narrative review was to assess candidate indicators of population-level calcium status based on a range of biomarkers and measurement methods, including dietary assessment, calcium balance studies, hormonal factors related to calcium, and health outcomes associated with low calcium status. Several promising approaches were identified, but there was insufficient evidence of the suitability of any single indicator to assess population calcium status. Further research is required to develop and validate specific indicators of calcium status that could be derived from the analysis of data or samples that are feasibly collected in population-based surveys.

Development of bioelectrical impedance-based equations for the prediction of body composition of Malawian adolescents aged 10-18 years: a cross-sectional study.

OBJECTIVES: The accuracy of bioelectrical impedance analysis (BIA) depends on population-specific prediction equations and there is no population-specific equation for predicting fat-free mass (FFM) in Malawian adolescents. This study aimed at determining the agreement between FFM measured by deuterium oxide dilution technique (the reference) and FFM by BIA; and propose BIA-based prediction equations to estimate FFM for Malawian adolescents. DESIGN: This was a cross-sectional study. SETTING: The study was conducted in Blantyre, Malawi PARTICIPANTS: 186 Malawian adolescents aged between 10 and 18 years were included in this study. Body composition was estimated by both the BodyStat BIA analyser and the deuterium oxide dilution method. RESULTS: BIA inbuilt equation underestimated FFM compared with deuterium oxide dilution (p=0.039). The new prediction equation for FFM (kg)=-4.316+ 0.425* height2(cm)/resistance (Ω)+1.287* sex (male=1, female=0)+0.307*age(years)+0.344* weight(kg)+0.019*reactance(Ω) yielded an R2 of 0.926. The equation for total body water (TBW) (kg)=-2.152 + 0.328*height2(cm)/resistance (Ω) 0.910*sex (male=1, female=0)+0.307 *age (years)+0.249*weight(kg)+0.015*reactance(Ω) yielded an R2 of 0.922. The Bland-Altman plot illustrated a good level of concordance between the FFM and TBW predicted by the new equations and the values derived using deuterium dilution method. CONCLUSIONS: The new BIA prediction equations for estimating FFM and TBW could be used to assess with very good accuracy and precision the body composition of Malawian and adolescents with similar characteristics.

Calcium deficiency worldwide: prevalence of inadequate intakes and associated health outcomes.

Dietary calcium deficiency is considered to be widespread globally, with published estimates suggesting that approximately half of the world's population has inadequate access to dietary calcium. Calcium is essential for bone health, but inadequate intakes have also been linked to other health outcomes, including pregnancy complications, cancers, and cardiovascular disease. Populations in low- and middle-income countries (LMICs) are at greatest risk of low calcium intakes, although many individuals in high-income countries (HICs) also do not meet recommendations. Paradoxically, many LMICs with lower calcium intakes show lower rates of osteoporotic fracture as compared with HICs, though data are sparse. Calcium intake recommendations vary across agencies and may need to be customized based on other dietary factors, health-related behaviors, or the risk of calcium-related health outcomes. The lack of standard methods to assess the calcium status of an individual or population has challenged efforts to estimate the prevalence of calcium deficiency and the global burden of related adverse health consequences. This paper aims to consolidate available evidence related to the global prevalence of inadequate calcium intakes and associated health outcomes, with the goal of providing a foundation for developing policies and population-level interventions to safely improve calcium intake and status where necessary.

Human Milk output among mothers previously treated for severe acute malnutrition in childhood in Democratic Republic of Congo.

BACKGROUND: Malnutrition is a public health problem, as wasting affects 7.5% of children worldwide. The harmful effects of severe acute malnutrition (SAM) can last a lifetime, but how SAM in childhood affects later breastfeeding ability is not clear. In the present study, we assessed the human milk output and body composition among mothers with a history of childhood SAM. METHODS: This retrospective cohort study was carried out in Miti-Murhesa Health Zone (Democratic Republic of Congo) from January 15 to March 17, 2020. We selected lactating mothers with breastfed infants aged 2-12 months. Two categories of mothers were included: those who had been treated for SAM during their childhood (years 1988-2003; n = 39) and a community control with no history of SAM (n = 40). The weight, height, and mid-upper arm circumference were measured and body mass index (BMI) calculated as weight/height2. Body composition and human milk output were assessed using standard deuterium dilution methods. Student t and chi2 tests ware applied to compare two groups. RESULTS: The mean age ± standard deviation of the mothers was 24.4 ± 5.1 and 26.0 ± 6.1 years for the SAM and control groups, respectively (p = 0.186). The age of their infants was 5.4 ± 2.3 months in both groups (p = 0.962). In the SAM and control groups, the mean maternal BMI was 23.8 ± 2.3 and 23.6 ± 3.7 kg/m2 (p = 0.849), mean Fat Mass 27.1% ± 5.0 and 27.1% ± 5.8% (p = 0.708), and the mean Fat Free mass 72.9% ± 5.0 and 72.9% ± 5.8% (p = 0.998), respectively. Human milk output was 833.7 ± 152.1 g/d in SAM group and 827.4 ± 171.4 g/d in the control group (p = 0.864). CONCLUSIONS: We found no significant difference in human milk output and body composition in mothers treated for SAM during childhood compared to community controls.

Body composition of adults with a history of severe acute malnutrition during childhood using the deuterium dilution method in eastern DR Congo: the Lwiro Cohort Study.

BACKGROUND: Few studies have evaluated the body composition (BC) of adults who suffered from severe acute malnutrition (SAM) during childhood, a population at risk of long-term noncommunicable diseases. OBJECTIVE: We performed an observational cohort study to evaluate BC in a group of young adults aged 11-30 y after nutritional rehabilitation for SAM, in the Democratic Republic of the Congo (DRC). METHODS: We evaluated 151 adults in eastern DRC who were treated for SAM during childhood between 1988 and 2007. They were compared with 120 aged- and sex-matched control adults living in the same community who had not been exposed to malnutrition as children. The main variables of interest were the different compartments of adult BC (fat-free mass [FFM], fat mass [FM], and 2 indices of height-normalized BC: FFM index [FFMI] and FM index [FMI]) measured by deuterium dilution. RESULTS: The mean age in both groups was 23 y, and females represented 49% and 56% of the exposed and nonexposed groups, respectively. SAM-exposed males had lower mean ± SD weight (53.6 ± 6.4 compared with 56.4 ± 7.9 kg, P = 0.029) and lower height (159.9 ± 6.6 compared with 163.6 ± 6.7 cm, P = 0.003) compared to unexposed males. SAM-exposed subjects had less FFM (-1.56 kg [-2.93, -0.20]; P = 0.024) but this observation was more marked in males (45.4 ± 5.4 compared with 48.2 ± 6.9 kg, P = 0.01) than in females. No differences in FM were noted between SAM-exposed and unexposed subjects. Adjusting for height, FFMI and FMI showed no difference between SAM-exposed and unexposed in either sex. CONCLUSION: SAM during childhood is associated with reduced FFM in adulthood which is probably due to a shorter height.

Optimisation, validation and field applicability of a 13C-sucrose breath test to assess intestinal function in environmental enteropathy among children in resource poor settings: study protocol for a prospective study in Bangladesh, India, Kenya, Jamaica, Peru and Zambia.

INTRODUCTION: Environmental enteropathy (EE) is suspected to be a cause of growth faltering in children with sustained exposure to enteric pathogens, typically in resource-limited settings. A major hindrance to EE research is the lack of sensitive, non-invasive biomarkers. Current biomarkers measure intestinal permeability and inflammation, but not the functional capacity of the gut. Australian researchers have demonstrated proof of concept for an EE breath test based on using naturally 13C-enriched sucrose, derived from maize, to assay intestinal sucrase activity, a digestive enzyme that is impaired in villus blunting. Here, we describe a coordinated research project to optimise, validate and evaluate the usability of a breath test protocol based on highly enriched 13C-sucrose to quantify physiological dysfunction in EE in relevant target populations. METHODS AND ANALYSIS: We use the 13C-sucrose breath test (13C-SBT) to evaluate intestinal sucrase activity in two phases. First, an optimisation and validation phase will (1) confirm that a 13C-SBT using highly enriched sucrose tracers reports similar information to the naturally enriched 13C-SBT; (2) examine the dose-response relationship of the test to an intestinal sucrase inhibitor; (3) validate the 13C-SBT in paediatric coeliac disease (4) validate the highly enriched 13C-SBT against EE defined by biopsy in adults and (5) validate the 13C-SBT against EE defined by the urinary lactulose:rhamnose ratio (LR) among children in Peru. Second, a cross-sectional study will be conducted in six resource-limited countries (Bangladesh, India, Jamaica, Kenya, Peru and Zambia) to test the usability of the optimised 13C-SBT to assess EE among 600 children aged 12-15 months old. ETHICS AND DISSEMINATION: Ethical approval will be obtained from each participating study site. By working as a consortium, the test, if shown to be informative of EE, will demonstrate strong evidence for utility across diverse, low-income and middle-income country paediatric populations. TRIAL REGISTRATION NUMBER: NCT04109352; Pre-results.

A Qualitative Exploration of the Determinants of Exclusive Breastfeeding (EBF) Practices in Wajir County, Kenya.

BACKGROUND: The World Health Organization recommends exclusive breastfeeding for the first six months of life. A qualitative study was conducted to assess the factors that influence the practice of exclusive breastfeeding amongst mothers attending Wajir County Hospital, Kenya. METHOD: This study was part of a cross-sectional study to compare the exclusive breastfeeding rates amongst primiparous and multiparous mothers with infants under 6 months old attending Wajir County Hospital. Focus group discussions and key informant interviews were conducted to collect information on exclusive breastfeeding and related factors. Four focus group discussions were conducted with mothers who exclusively breastfed and the same number with mothers who did not exclusively breastfeed their babies. Key informant interviews were conducted with nine healthcare providers. The data were transcribed, and a content analysis identified common themes and inferences. RESULTS: The exclusive breastfeeding rate among the mothers in the larger study was 45.5%. There was no disparity between the practice of exclusive breastfeeding between primiparous and multiparous mothers. Despite the high knowledge and positive attitudes towards exclusive breastfeeding of most mothers, the practice of exclusive breastfeeding was unsatisfactory. The major hindrances identified were cultural barriers propagated by mothers-in-law and traditional birth attendants; the belief that babies cannot live without water; and a few unsupportive health workers. The uptake of exclusive breastfeeding was enhanced by Islamic teaching on breastfeeding, education from a few supportive healthcare providers; support from husbands; and positive deviance among some lactating mothers who practiced exclusive breastfeeding. CONCLUSIONS: Deeply rooted cultural factors were the major hindrance to the practice of exclusive breastfeeding. Most of the mothers did not practice exclusive breastfeeding, despite the majority being knowledgeable and having positive attitudes towards the practice. The influence of mother-in-law's and traditional birth assistants were major barriers. Strengthening the Community Health Strategy through training traditional birth attendants on Infant Young Child Nutrition practices, designing mechanisms linking traditional birth assistants to existing health facilities for support, and capacity building and monitoring is critical in promoting exclusive breastfeeding. Behavior change and communication through multiple channels within the community should be utilized to maximize promotion of exclusive breastfeeding among all stakeholders.

Strengthened Data Systems to Mitigate the Double Burden of Malnutrition: The Role of Stable Isotope Technique-Derived Nutrition Indicators.

Indicators reflecting the double burden of malnutrition are rarely measured in nutrition surveys and are needed to strengthen national data systems. Indicators such as body composition reflect both metabolic response to undernutrition and obesity risk and nutrition-related noncommunicable diseases. Stable isotope techniques (SITs) provide accurate data on body composition, exclusive breastfeeding and vitamin A status that are otherwise problematic with routine methods. Integration of SIT-derived nutrition indicators in data systems could improve the design and evaluation of programmes focused on obesity prevention, food fortification and infant and young child feeding practices. The Working Group at the symposium considered "how SIT-derived nutrition indicators may be integrated into surveillance systems to strengthen data availability and capacity at national and regional levels". Practical considerations for the use of SITs include cost, sample size, rigorous training and logistics. It was concluded that SITs are best suited, at present, for use in sub-samples of population surveys and for validating tools that can be scaled-up more easily in population surveys. In the long term, SITs could be applied to larger surveys following potential innovations in more affordable, hand-held devices for analysis of stable isotope enrichment in the field and simpler specimen collection protocols.

Greater household food insecurity is associated with lower breast milk intake among infants in western Kenya.

Household food insecurity has been hypothesized to negatively impact breastfeeding practices and breast milk intake, but this relationship has not been rigorously assessed. To generate an evidence base for breastfeeding recommendations among food-insecure mothers in settings where HIV is highly prevalent, we explored infant feeding practices among 119 mother-infant dyads in western Kenya at 6 and 24 weeks postpartum. We used the deuterium oxide dose-to-the-mother technique to determine if breastfeeding was exclusive in the prior 2 weeks, and to quantify breast milk intake. Sociodemographic data were collected at baseline and household food insecurity was measured at each time point using the Household Food Insecurity Access Scale. Average breast milk intake significantly increased from 721.3 g/day at 6 weeks postpartum to 961.1 g/day at 24 weeks postpartum. Household food insecurity at 6 or 24 weeks postpartum was not associated with maternal recall of exclusive breastfeeding (EBF) in the prior 24 hr or deuterium oxide-measured EBF in the prior 2 weeks at a significance level of 0.2 in bivariate models. In a fixed-effects model of quantity of breast milk intake across time, deuterium oxide-measured EBF in the prior 2 weeks was associated with greater breast milk intake (126.1 ± 40.5 g/day) and every one-point increase in food insecurity score was associated with a 5.6 (±2.2)-g/day decrease in breast milk intake. Given the nutritional and physical health risks of suboptimal feeding, public health practitioners should screen for and integrate programs that reduce food insecurity in order to increase breast milk intake.

Effect of locally produced complementary foods on fat-free mass, linear growth, and iron status among Kenyan infants: A randomized controlled trial.

The impact of quality complementary food products on infant growth and body composition has not been adequately investigated. This study evaluated the effect on fat-free mass (FFM) accrual, linear growth, and iron status of locally produced complementary food products comparing to a standard product. In a randomized, double-blind trial, 499 infants at 6 months received nine monthly rations of (a) WinFood Classic (WFC) comprising germinated amaranth (71%), maize (10.4%), small fish (3%), and edible termites (10%); (b) WinFood Lite (WFL) comprising germinated amaranth (82.5%), maize (10.2%), and multimicronutrient premix; or (c) fortified corn-soy blend plus (CSB+). Primary outcomes were changes in FFM, length, and plasma ferritin and transferrin receptors (TfR). FFM was determined using deuterium dilution. Analysis was by intention to treat, based on available cases. Compared with CSB+, there were no differences in change from 6 to 15 months in FFM for WFC 0.0 kg (95% CI [-0.30, 0.29]) and WFL 0.03 kg (95% CI [-0.25, 0.32]) and length change for WFC -0.3 cm (95% CI [-0.9, 0.4]) and WFL -0.3 cm (95% CI [-0.9, 0.3]). TfR increased in WFC group 3.3 mg L-1 (95% CI [1.7, 4.9]) and WFL group 1.7 mg L-1 (95% CI [0.1, 3.4]) compared with CSB+. Compared with the increase in Hb in CSB+ group, there was a reduction in Hb in WFC of -0.9 g dl-1 (95% CI [-1.3, -0.5]) and a lower increase in WFL -0.4 g dl-1 (95% CI [-0.8, 0.0]). In conclusion, the tested WinFoods had the same effect on FFM and length as CSB+, whereas Hb and iron status decreased, suggesting inhibited iron bioavailability from the amaranth-based WinFoods.

Challenges and opportunities to tackle the rising prevalence of diet-related non-communicable diseases in Africa.

Africa is experiencing a sharp rise in non-communicable diseases (NCD) related to rapid globalisation and urbanisation leading to shifts in dietary and lifestyle patterns characterised by increased energy intake and physical inactivity. However, unlike more resource-endowed regions, Africa has a double burden of disease: NCD co-exist with infectious diseases including lower respiratory tract infections, HIV/AIDS and diarrhoeal diseases. The African economy is also relatively weaker, making it difficult to cope with this burden. It is postulated that NCD will soon overtake infectious diseases as the number one cause of death in the African region. The recognition of NCD as diseases and obesity as a related risk factor is weak in Africa, compounded by stigma associated with wasting in HIV/AIDS and obesity being perceived as a sign of wealth, achievement and care. There is also a dearth of data on overweight and obesity in the region and little knowledge that infant feeding practices, such as breast-feeding, are linked to reduced risk of NCD in both children and mothers. While complex multi-sectoral approaches to address this NCD menace are needed, Africa may benefit from taking simple initial steps to address NCD risk factors including: (1) behaviour change communication to challenge perceptions on NCD; (2) promoting and protecting breast-feeding; (3) formulating policies and regulations limiting wide availability of unhealthy foods; (4) mainstream nutrition education in school curricula and (5) collection of accurate data based on indicators that can reflect the double burden of disease and malnutrition; and fostering multi-sectoral actions against NCD.

Measuring growth and medium- and longer-term outcomes in malnourished children.

Severe and moderate acute malnutrition are among the leading causes of mortality among children in low- and middle-income countries. There is strong evidence that growth assessed anthropometrically from conception to 2 years of age marks later risk of ill health. This is central to the concept of the developmental origins of adult disease and is presumed to be related to modification of developmental processes during critical "window(s)" of vulnerability. Interventions to treat acute malnutrition have resulted in dramatic increase in the number of affected children surviving. Ensuring that these children thrive to fulfil their full physical and cognitive potential is a new challenge. Integral to this challenge is the need to be able to measure how earlier insults relate to the ability to survive and thrive to productive adulthood. Despite its obvious value, routine anthropometry does not adequately indicate how earlier adverse exposures affect more refined aspects of growth. Anthropometry is inadequate for predicting how disruption of healthy growth might modulate risk of disease or any subsequent interventions that correct this risk. A clear characterisation of healthy child growth is needed for determining which component best predicts later outcomes. The extent to which postnatal acute malnutrition is a consequence of maternal factors acting preconception or in utero and their relationship to postnatal health and long-term risk of non-communicable diseases is not clear. Body-composition measurement has significant untapped potential allowing us to translate and better understand the relationship between early insults and interventions on early growth in the short-term and long-term health outcomes.