Improved sanitation is associated with reduced child stunting amongst Indonesian children under 3 years of age.

Growing evidence suggests that household sanitation is associated with child nutritional status in low- and middle-income countries. This paper examined whether household access to improved sanitation facilities and sources of drinking water was associated with stunting and anaemia amongst children aged 6-35 months of age in Indonesia. The sample for the analysis comprised 1,450 children aged 6-35 months who participated in the end-line survey of the maternal and young child nutrition security project in Asia, conducted in three selected districts in Indonesia. Logistic regression models were used to determine the association between household sanitation and water source, and stunting and anaemia. Approximately 26% and 56% of children 6-35 months of age were stunted and anaemic, respectively. Children living in a household with improved sanitation facilities had 29% reduced odds of being stunted compared with those in a household with unimproved sanitation facilities, after adjusting for potential confounders including child's age and gender, maternal education, and iron-folic acid supplementation, as well as household wealth status and source of drinking water (OR = 0.68, 95% CI:0.48-0.96). No association between household sanitation and childhood anaemia was observed. Source of drinking water was not associated with stunting or anaemia amongst children. There were no synergistic effects of household sanitation and water supply on stunting and anaemia. This suggests that efforts to improve household sanitation condition may need to be considered an essential, integral part of the programmatic responses by governments and development partners for the prevention of childhood nutritional status. Further randomised research is necessary to determine the causal link.

Towards universal salt iodisation in India: achievements, challenges and future actions.

India is one of the first countries to introduce salt iodisation, but the national programme has experienced major setbacks. The purpose of this paper is to review the national efforts towards universal salt iodisation (USI) in India and highlight key challenges in programme implementation. A brief historical overview of the salt iodisation programme is provided and the current status of the household usage of iodised salt and population iodine status is described. The present status of the USI programme together with the challenges being faced towards achieving USI are classified in five categories, which represent the five guiding principles crucial to sustained USI programme success: ensuring political commitment, forming partnerships and coalition, ensuring availability of adequately iodised salt, strengthening the monitoring system and maintaining continuous advocacy, education and communication. A future agenda towards the achievement of USI is also proposed.

A review of the vitamin A supplementation program in India: reasons for success in the states of Bihar and Odisha.

BACKGROUND: Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation. OBJECTIVE: To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors. METHODS: A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners. RESULTS: Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff. CONCLUSIONS: The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable.

Reaching the poor with adequately iodized salt through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh, India.

PROBLEM: In India, adequately iodized salt needs to be made accessible to the most marginalized. APPROACH: In an effort to provide adequately iodized salt to the most vulnerable, in 2009 Madhya Pradesh launched a state-wide initiative through two national flagship nutrition programmes: the Supplementary Nutrition Programme of the Integrated Child Development Services and the Midday Meal Scheme. Programme staff members were taught how to correctly store salt and monitor its iodine content. Field monitors assessed the iodine content of the salt in the common kitchens of participating schools and anganwadi centres monthly. LOCAL SETTING: Madhya Pradesh, a state in central India, is home to a substantial proportion of India's poor. In 2009, household coverage of adequately iodized salt in the state was nearly 90% among the richest but only about 50% among the poorest. RELEVANT CHANGES: Two hot meals prepared with adequately iodized salt were served daily for more than 21 days per month to approximately 89% of the 12,113,584 children aged 3 to 6 years enrolled in anganwadi centres (June 2011 to March 2012). One meal on school days was served to 78% of 5,751,979 primary-school children and to 79% of 2,704,692 secondary-school children (April 2011 to March 2012). Most of the kitchens visited in 2010 (79%) and 2011 (83%) were consistently using adequately iodized salt to prepare hot meals. LESSONS LEARNT: India has large-scale social safety net programmes for the poorest. Both national and state policies should mainstream the use of adequately iodized salt in these programmes.

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.

Difference in ponderal growth and body composition among pregnant vs. never-pregnant adolescents varies by birth outcomes.

Recently, we showed that following pregnancy and 6 months of lactation, adolescents cease linear growth and have reduced fat and lean mass in rural Bangladesh. Here, we examined whether these changes varied by pregnancy outcomes such as fetal loss, low birthweight (LBW) and neonatal mortality. Anthropometric measurements were taken among 12-19-year-old primigravidae (n = 229) in early pregnancy and at 6 months post-partum. Never-pregnant adolescents (n = 456) matched on age and time since menarche were also measured at the same time. Change in anthropometry among pregnant vs. never-pregnant adolescents was compared by pregnancy outcome adjusting for confounders using mixed effects regression models. Pregnant girls, irrespective of birth outcome, did not gain in stature, while never-pregnant girls increased in height by 0.36 +/- 0.04 cm year(-1) (P < 0.05). Body mass index, mid-upper arm circumference (MUAC) and % body fat among pregnant adolescents whose infants survived the neonatal period had decreased at 6 months post-partum, whereas those who experienced a fetal loss or neonatal death did not change in any of the measurements. Consequently, the difference in change in ponderal size and body composition measures between pregnant and never-pregnant girls was higher among those whose neonates survived vs. those who experienced a fetal loss/neonatal death (BMI: -0.64 +/- 0.11 vs. 0.01 +/- 0.16 kg m(-2) year(-1); MUAC: -0.96 +/- 0.12 vs. -0.35 +/- 0.17 cm year(-1), both P < 0.05). LBW and preterm birth did not have a similar effect modification. Linear growth ceased among pregnant girls regardless of birth outcome. Maternal weight loss and depletion of fat and lean mass at 6 months post-partum were more pronounced when the infants survived through the neonatal period.

Predictors of stunting and thinness in post-menarcheal adolescent girls in rural Bangladesh.

OBJECTIVE: To assess the nutritional status and risk factors of undernutrition in post-menarcheal girls in rural northern Bangladesh. DESIGN: Cross-sectional data on anthropometric measurements, dietary intake, work activity, morbidity and socio-economic status were collected from 12- to 19-year-old primigravidae (n 209) and never-pregnant adolescents (n 456) matched on age and time since menarche. Multiple regression analyses were conducted to determine predictors of stunting, thinness, upper-arm muscle (UAMZ) and fat area Z-scores (UAFZ) among the adolescent girls. RESULTS: A large proportion of adolescents (49 %) were stunted (height-for-age Z-score <-2) and underweight (40 %; weight-for-age Z-score <-2), but not thin (BMI-for-age <5th percentile; approximately 10 %). The mean (sd) UAMZ and UAFZ of the adolescent girls was -0.3 (0.64) and -0.9 (0.40), respectively. Lean mass increased whereas fat mass declined with age. Both stunting and thinness were positively associated with age and time since menarche (P < 0.05). Young age (12-14 years) and literacy were protective against stunting among pregnant adolescents (OR = 0.29, 95 % CI 0.09, 0.88 and OR = 0.50, 95 % CI 0.26, 0.96, respectively). Having symptoms of diarrhoea or dysentery (OR = 7.40, 95 % CI 1.43, 38.29) predicted thinness and was associated with lower UAMZ and UAFZ among never-pregnant girls (both P < 0.05). Performing light-to-moderate activities was protective against thinness among never-pregnant girls (OR = 0.43, 95 % CI 0.22, 0.82), whereas pregnant adolescents who performed high levels of strenuous activities had greater UAMZ (P < 0.05). CONCLUSION: Undernutrition was widespread among this post-menarcheal adolescent population. Younger and literate adolescents were less likely to be stunted, whereas thinness and body composition were associated with morbidity and work activity.

Age of onset, nutritional determinants, and seasonal variations in menarche in rural Bangladesh.

Menarche is an important milestone in the development of female adolescents. The study assessed the age at menarche using recall, its seasonality, and association with marital and nutritional status (using mid-upper arm circumference [MUAC]) among 3,923 female adolescents aged 12-19 years in a rural area of Bangladesh. At the time of assessment, most (88%) adolescents had attained menarche at the mean (standard deviation [SD]) age of 12.8 (1.4) years. Age of onset of menarche among married adolescents (13%) occurred earlier than in those who were unmarried (12.6 +/- 1.3 years vs 12.9 +/- 1.4 years, p < 0.01). Age at menarche was negatively associated with MUAC after adjusting for age and marital status (beta = -0.10, p < 0.01). More than 50% of the adolescents had an onset of menarche during winter (chi2 = 634.97; p < 0.001), with peaks in December and January. In this rural population, the current age at menarche was found to be slightly lower than the previous estimates of 13.0 years in Bangladesh. An early onset of menarche was associated with season and better nutritional status of the female adolescents and may be associated with early marriage.

Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh.

Adolescent pregnancy is associated with adverse birth outcomes. Less is known about its influence on maternal growth and nutritional status. We determined how pregnancy and lactation during adolescence affects postmenarcheal linear and ponderal growth and body composition of 12-19 y olds in rural Bangladesh. In a prospective cohort study, anthropometric measurements were taken among primigravidae (n = 229) in the early first trimester of pregnancy and at 6 mo postpartum. Randomly selected never-pregnant adolescents (n = 458) of the same age and time since menarche were measured within 1 wk of these assessments. Annual changes in anthropometric measurements were compared between the 2 groups adjusting for confounders using mixed effects regression models. The mean +/- SD age and age at menarche of adolescents were 16.3 +/- 1.6 y and 12.7 +/- 1.2 y, respectively. Unlike pregnant girls who did not grow in height (-0.09 +/- 0.08 cm/y), never-pregnant girls increased in stature by 0.35 +/- 0.05 cm/y. The adjusted mean difference between the 2 groups was 0.43 +/- 0.1cm (P < 0.001). Similarly, whereas never-pregnant girls gained BMI, mid-upper arm circumference, and percent body fat, pregnant girls declined in every measurement by 6 mo postpartum, resulting in adjusted mean +/- SD differences in annual changes of 0.62 +/- 0.11 kg/m(2), 0.89 +/- 0.12 cm, and 1.54 +/- 0.25%, respectively (all P < 0.001). Differences in changes in all anthropometric measurements except height were greater among adolescents whose first pregnancy occurred <24 mo vs. > or =24 mo since menarche (BMI, -1.40 +/- 0.18 vs. -0.60 +/- 0.11 kg/m(2); all interaction terms, P < 0.05). Pregnancy and lactation during adolescence ceased linear growth and resulted in weight loss and depletion of fat and lean body mass of young girls.

Predictors of maternal and child double burden of malnutrition in rural Indonesia and Bangladesh.

BACKGROUND: Many developing countries now face the double burden of malnutrition, defined as the coexistence of a stunted child and overweight mother within the same household. OBJECTIVE: This study sought to estimate the prevalence of the double burden of malnutrition and to identify associated maternal, child, and household characteristics in rural Indonesia and Bangladesh. DESIGN: A total of 247,126 rural households that participated in the Indonesia Nutrition Surveillance System (2000-2003) and 168,317 rural households in the Bangladesh Nutritional Surveillance Project (2003-2006) were included in the analysis. Maternal and child double burden (MCDB) and its association with individual and household characteristics were determined by using logistic regression models. RESULTS: MCDB was observed in 11% and 4% of the households in rural Indonesia and Bangladesh, respectively. Maternal short stature [Indonesia (OR: 2.32; 95% CI: 2.25, 2.40); Bangladesh (OR: 2.11; 95% CI: 1.96, 2.26)], and older age were strong predictors of MCDB. Child characteristics such as older age and being female were associated with an increased odds of MCDB, whereas currently being breastfed was protective against MCDB [Indonesia (OR: 0.84; 95% CI: 0.81, 0.84); Bangladesh (OR: 0.55; 95% CI: 0.52, 0.58)]. A large family size and higher weekly per capita household expenditure predicted MCDB [Indonesia (OR: 1.34; 95% CI: 1.28, 1.40); Bangladesh (OR: 1.94; 95% CI: 1.77, 2.12)]. CONCLUSIONS: Double burden is not exclusive to urban areas. Future policies and interventions should address under- and overweight simultaneously in both rural and urban developing country settings.