Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions.

Paramount among the challenges to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance. The Integration to Effective Implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the food and nutrition enterprise. The 2014 Micronutrient Forum (MNF) Global Conference held in Addis Ababa, Ethiopia, in June 2014 offered the opportunity to apply the I-to-I approach with the use of current concerns about the safety and effectiveness of interventions to prevent and treat iron deficiency (ID) as a case study. ID is associated with a range of adverse outcomes, especially in pregnant and nonpregnant women, infants, and primary school-age children. Strategies to combat ID include iron supplementation, multiple micronutrient powders, and food-based interventions to enhance dietary iron intake. Recent reports indicate potential increased adverse risks when iron is provided in areas with high infection burdens (e.g., malaria). This paradox has weakened iron intervention programs. Furthermore, the selection and interpretation of available biomarkers for assessing iron nutrition have been found to be compromised by the inflammatory process. These issues highlight the need for a comprehensive approach that considers basic biology, assessment, interventions, and how these can be translated into appropriate programs and policies. The application of the I-to-I with the use of the MNF offered an opportunity to explore how that might be achieved.

Effect of long-term intermittent supplementation with multiple micronutrients compared with iron-and-folic acid supplementation on Hb and micronutrient status of non-anaemic adolescent schoolgirls in rural Bangladesh.

The present study examined whether long-term supplementation with once- and twice-weekly multiple micronutrients (MMN-1 and MMN-2) can improve Hb and micronutrient status more than twice-weekly Fe-folic acid (IFA-2) supplementation in non-anaemic adolescent girls in Bangladesh. An equal number of 324 rural schoolgirls aged 11-17 years were given MMN-1 or MMN-2 or IFA-2 supplements for 52 weeks in a randomised, double-blind trial. Blood samples were collected at baseline, and at 26 and 52 weeks of supplementation. The girls receiving IFA-2 supplements were more likely to be anaemic than the girls receiving MMN-2 supplements for 26 weeks (OR 5·1, 95% CI 1·3, 19·5; P = 0·018). All three supplements reduced Fe deficiency effectively. Both the MMN-1 and MMN-2 groups showed significantly greater improvements in vitamins A, B(2) and C status than the girls in the IFA-2 group, as might be expected. Receiving a MMN-1 supplement was found to be less effective than MMN-2 supplement in improving Fe, vitamins A, B(2) and folic acid status. Receiving micronutrient supplements beyond 26 weeks showed little additional benefit in improving micronutrient status. In conclusion, given twice-weekly for 26 weeks, MMN supplements can improve micronutrient status effectively with no significant increase in Hb concentration compared with IFA supplements in non-anaemic Bangladeshi adolescent girls. However, it significantly reduces the risk of anaemia. Before any recommendations can be made, further research, including into cost-effectiveness, is needed to see whether MMN supplementation has any additional longer-term health benefits over that of IFA supplementation in this population.

Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron + folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia.

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Addressing tuberculosis in the context of malnutrition and HIV coinfection.

BACKGROUND: Tuberculosis is the second leading cause of infectious disease mortality (1.8 million/year), after HIV/AIDS. There are more than 9 million new cases each year. One-third of the world's population, and 50% of adults in sub-Saharan Africa, South Asia, and SouthEast Asia, are infected, representing an enormous pool of individuals at risk for developing the disease. The situation is complicated by the HIV/AIDS pandemic, widespread undernutrition, smoking, diabetes, increased mobility, and emergence of multi- and extensively drug-resistant tuberculosis. OBJECTIVE: To review the scientific evidence about the interactions among tuberculosis, nutrition, and HIV coinfection. RESULTS: HIV infection and malnutrition lower immunity, increasing the risk of reactivation tuberculosis and primary progressive disease. Having either tuberculosis or HIV infection causes weight loss. Malnutrition markedly increases mortality among both tuberculosis and HIV/AIDS patients and should be treated concurrently with treatment of the infections. Tuberculosis treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. Additional pharmaceutical treatment to reduce the catabolic impact of inflammation or promote growth may be needed. Specific nutrients can contribute to faster sputum smear clearance, which is important for reducing transmission, as well as faster weight gain when combined with an adequate diet. Adequate nutrition and weight gain in undernourished populations might reduce the incidence of tuberculosis. CONCLUSIONS: The many risk factors for the development of tuberculosis need to be addressed simultaneously, especially HIV/AIDS and food insecurity and undernutrition. For stronger evidence-based guidelines, existing recommendations and clinical applications need to be more widely applied and evaluated.

Addressing tuberculosis in the context of malnutrition and HIV coinfection.

BACKGROUND: Tuberculosis is the second leading cause of infectious disease mortality (1.8 million/year), after HIV/AIDS. There are more than 9 million new cases each year. One-third of the world's population, and 50% of adults in sub-Saharan Africa, South Asia, and South-East Asia, are infected, representing an enormous pool of individuals at risk for developing the disease. The situation is complicated by the HIV/AIDS pandemic, widespread undernutrition, smoking, diabetes, increased mobility, and emergence of multi- and extensively drug-resistant tuberculosis. OBJECTIVE: To review the scientific evidence about the interactions among tuberculosis, nutrition, and HIV coinfection. RESULTS: HIV infection and malnutrition lower immunity, increasing the risk of reactivation tuberculosis and primary progressive disease. Having either tuberculosis or HIV infection causes weight loss. Malnutrition markedly increases mortality among both tuberculosis and HIV/AIDS patients and should be treated concurrently with treatment of the infections. Tuberculosis treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. Additional pharmaceutical treatment to reduce the catabolic impact of inflammation or promote growth may be needed. Specific nutrients can contribute to faster sputum smear clearance, which is important for reducing transmission, as well as faster weight gain when combined with an adequate diet. Adequate nutrition and weight gain in undernourished populations might reduce the incidence of tuberculosis. CONCLUSIONS; The many risk factors for the development of tuberculosis need to be addressed simultaneously, especially HIV/AIDS and food insecurity and undernutrition. For stronger evidence-based guidelines, existing recommendations and clinical applications need to be more widely applied and evaluated.

Solutions to nutrition-related health problems of preschool children: education and nutritional policies for children.

OBJECTIVE: By reviewing the literature, lessons learned and experience regarding the nutrition-related health problems of preschool children, draw conclusions and make recommendations on education and nutrition policies for young children. RESULTS: The most common causes of under-5 mortality in low-income countries have been identified as neonatal disorders, diarrhoea, respiratory infections, malaria, measles, and in some developing countries, AIDS. More than half (56%) of all child deaths have underlying malnutrition and undernutrition as a contributing factor. Children must have optimal growth and physical and intellectual development to learn and achieve their potential in society. Solutions include both preventive and curative interventions at all levels and include both improved health and education systems. Recent focus has been on health systems interventions that address averting deaths by cause for the 42 countries that account for 90% of worldwide under-5 deaths (the majority in sub-Saharan Africa). However, parallel or multisectoral interventions must be addressed to all children at risk for death, poor health and compromised growth and development. Adequate health care and nutrition is a human right, legally established in the Convention on the Rights of the Child. CONCLUSIONS: Improved health and nutrition will lead to enhanced economic development, but having a poverty focus appears to be essential, if poor people are not to be marginalized further. The HIV/AIDS pandemic illustrates this challenge clearly. The role of education, especially girls' education, in improved health and nutrition status of children and birth-spacing is now clear, as is improving women's status. Increases in female status and education have been estimated to account for half of the reduction in child malnutrition rates during the past 25 years.

Carotenoid-rich bananas: a potential food source for alleviating vitamin A deficiency.

This review article points out that bananas are an important food for many people in the world. Thus, banana cultivars rich in provitamin A carotenoids may offer a potential food source for alleviating vitamin A deficiency, particularly in developing countries. Many factors are associated with the presently known food sources of vitamin A that limit their effectiveness in improving vitamin A status. Acceptable carotenoid-rich banana cultivars have been identified in Micronesia, and some carotenoid-rich bananas have been identified elsewhere. Bananas are an ideal food for young children and families for many regions of the world, because of their sweetness, texture, portion size, familiarity, availability, convenience, versatility, and cost. Foods containing high levels of carotenoids have been shown to protect against chronic disease, including certain cancers, cardiovascular disease, and diabetes. Because the coloration of the edible flesh of the banana appears to be a good indicator of likely carotenoid content, it may be possible to develop a simple method for selecting carotenoid-rich banana cultivars in the community. Research is needed on the identification of carotenoid-rich cultivars, targeting those areas of the world where bananas are a major staple food; investigating factors affecting production, consumption, and acceptability; and determining the impact that carotenoid-rich bananas may have on improving vitamin A status. Based on these results, interventions should be undertaken for initiating or increasing homestead and commercial production.

Assessment and control of vitamin A deficiency disorders.

The XX International Vitamin A Consultative Group (IVACG) meeting in Hanoi, Vietnam, in February 2001 celebrated 25 y of progress in prevention and control of vitamin A deficiency disorders (VADD). Programmatic themes included the following: 1) intervention innovations, 2) integration of vitamin A interventions, 3) the increased risk to health of women who are deficient, 4) measurement of progress and impact and 5) programmatic sustainability. The history of IVACG was remembered and the growth of the group from a meeting of 30 to 40 persons in 1975 to nearly 600 delegates from 63 countries was described. Successful adaptation to new challenges and scientific advances, in moving science to practice, was noted. Guidelines for indicators and interventions were reviewed. A set of revised recommendations were made, including the following indicators for assessment (and, for some, outcome evaluation) of VADD: 1) under-five mortality rate >50 as a surrogate indicator to trigger action, 2) maternal night blindness >5%, 3) rapid dark adaptation worse than -1.11 log cd/m(2) and 4) serum retinol <0.7 micro mol/L (>15%) in young children (<6 y). Key recommendations for specific interventions were to double the existing dose of prophylactic vitamin A supplementation to 50,000 international units (IU) at the three Expanded Programme on Immunization contacts for young infants (<6 mo) and to two doses of 200,000 IU each for women within 6 wk after delivery; to support fortification as a valid and necessary strategy to combat VADD; and to recognize that food-based approaches should include promoting breast-feeding and consuming animal products, because promoting plant-based foods alone will not eliminate VADD in young children due to the low bioefficacy of dietary beta-carotene. This meeting clearly set the agenda for the twenty-first century and called for successful implementation of integrated approaches that will eliminate VADD.

A global response to a global problem: the epidemic of overnutrition.

It is estimated that by 2020 two-thirds of the global burden of disease will be attributable to chronic noncommunicable diseases, most of them strongly associated with diet. The nutrition transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other noncommunicable conditions. Sedentary lifestyles and the use of tobacco are also significant risk factors. The epidemics cannot be ended simply by encouraging people to reduce their risk factors and adopt healthier lifestyles, although such encouragement is undoubtedly beneficial if the targeted people can respond. Unfortunately, increasingly obesogenic environments, reinforced by many of the cultural changes associated with globalization, make even the adoption of healthy lifestyles, especially by children and adolescents, more and more difficult. The present paper examines some possible mechanisms for, and WHO's role in, the development of a coordinated global strategy on diet, physical activity and health. The situation presents many countries with unmanageable costs. At the same time there are often continuing problems of undernutrition. A concerted multisectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.