Factors associated with diet diversity among infants and young children in the Eastern and Southern Africa region.

This study explores common factors associated with not meeting minimum dietary diversity (MDD) among 27,072 children aged 6-23 months in Eastern and Southern Africa using data from nine Demographic and Health Surveys from 2013 to 2016. MDD was defined as consumption of more than or equals to five of eight food groups including breast milk in the past 24 h. Equity gaps were calculated as the difference in MDD prevalence between the top and bottom wealth quintiles. Logistic regression was conducted to identify common factors for not meeting MDD at the household, maternal and child levels across two or more countries to inform regional policies to improve children's diets. Kenya had the highest MDD wealth equity gap (40.4 pts), and South Africa had the smallest (14.4 pts). Equity gaps for flesh foods or eggs (up to 39.8 pp) were larger than for grain or legumes (up to 20 pp). Common risk factors for not reaching MDD included younger child age (6-11 months) (n = 9 countries), no formal maternal occupation (n = 6), not receiving vitamin-A supplementation (n = 3), younger maternal age (n = 3), lower maternal education (n = 3), no media (n = 3) or newspaper (n = 3) exposure, lower household wealth quintile (n = 3), use of nonefficient cooking fuel (n = 2), longer time to get to the water source (n = 2), not listening to the radio (n = 2) and higher birth order (n = 2). Priorities for improving MDD in the region include introducing diverse foods at a young age from 6 months with early nutrition counselling, promoting higher maternal education, increasing food purchasing power and ensuring the support of younger mothers.

Harmonization of maternal balanced energy-protein supplementation studies for individual participant data (IPD) meta-analyses - finding and creating similarities in variables and data collection.

BACKGROUND: Public health and clinical recommendations are established from systematic reviews and retrospective meta-analyses combining effect sizes, traditionally, from aggregate data and more recently, using individual participant data (IPD) of published studies. However, trials often have outcomes and other meta-data that are not defined and collected in a standardized way, making meta-analysis problematic. IPD meta-analysis can only partially fix the limitations of traditional, retrospective, aggregate meta-analysis; prospective meta-analysis further reduces the problems. METHODS: We developed an initiative including seven clinical intervention studies of balanced energy-protein (BEP) supplementation during pregnancy and/or lactation that are being conducted (or recently concluded) in Burkina Faso, Ethiopia, India, Nepal, and Pakistan to test the effect of BEP on infant and maternal outcomes. These studies were commissioned after an expert consultation that designed recommendations for a BEP product for use among pregnant and lactating women in low- and middle-income countries. The initiative goal is to harmonize variables across studies to facilitate IPD meta-analyses on closely aligned data, commonly called prospective meta-analysis. Our objective here is to describe the process of harmonizing variable definitions and prioritizing research questions. A two-day workshop of investigators, content experts, and advisors was held in February 2020 and harmonization activities continued thereafter. Efforts included a range of activities from examining protocols and data collection plans to discussing best practices within field constraints. Prior to harmonization, there were many similar outcomes and variables across studies, such as newborn anthropometry, gestational age, and stillbirth, however, definitions and protocols differed. As well, some measurements were being conducted in several but not all studies, such as food insecurity. Through the harmonization process, we came to consensus on important shared variables, particularly outcomes, added new measurements, and improved protocols across studies. DISCUSSION: We have fostered extensive communication between investigators from different studies, and importantly, created a large set of harmonized variable definitions within a prospective meta-analysis framework. We expect this initiative will improve reporting within each study in addition to providing opportunities for a series of IPD meta-analyses.

Gender-common and gender-specific determinants of child dietary diversity in eight Asia Pacific countries.

Background: Optimal child feeding practices contribute to reducing child undernutrition in low- and middle-income countries. Minimum dietary diversity (MDD) is a key indicator of complementary feeding quality for children aged 6-23 months. We aimed to examine the gender-common and gender-specific factors associated with the failure to meet MDD in eight Asia Pacific countries. Methods: The study used data of children aged 6-23 months from the Demographic and Health Surveys (DHS) conducted in Afghanistan (n = 8410), Bangladesh (n = 2371), Nepal (n = 1478), Pakistan (n = 3490), Cambodia (n = 2182), Indonesia (n = 5133), Myanmar (n = 1379), and Timor-Leste (n = 2115). A total of 41 household, maternal, and child-level variables were examined for association with MDD using univariate and multivariable logistic regressions. All analyses accounted for the survey design and sampling weights. Results: Being aged 6-11 months, not receiving Vitamin A supplementation, low maternal education, belonging to a low wealth quintile, and having two or more young children in the household were factors related to the failure to meet MDD among both male and female children. Mothers' not watching TV or not being exposed to media at least once a week, delivery at home, young age, and engagement to non-agricultural work were only significant risk factors among female children. Non-professional delivery assistance, unsafe disposal of children's stool, tolerant attitudes towards domestic violence, and rural residence were significant factors only among male children. Conclusions: It is possible that male and female children in the region may consume food in various ways, because the factors for meeting MDD are not the same for different genders of children. It is advised to enhance dietary diversity in child nutrition programmes through gender-specific activities.

Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study: protocol of a pragmatic clinical effectiveness study to improve birth outcomes in Ethiopia.

INTRODUCTION: The WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia. METHODS AND ANALYSIS: ENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron-folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of <23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at <72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy. ETHICS AND DISSEMINATION: ENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders. REGISTRATION NUMBER: ISRCTN15116516.

Birth anthropometry predicts neonatal and infant mortality in rural Bangladesh: a focus on circumferential measurements.

BACKGROUND: Low birth weight predicts risk of infant death. However, several birth measurements may be equally predictive, for which cutoffs and associated risks are less explored. OBJECTIVES: We assessed and optimized population cutoffs of birth length, weight, and midupper arm circumference (MUAC), head circumference (HC), and chest circumference (CC) for predicting neonatal (≤28 d) and infant (≤365 d) mortality in northwest Bangladesh. METHODS: Among 28,026 singletons born in an antenatal micronutrient supplement trial, 21,174 received anthropometry ≤72 h after birth, among whom 583 died in infancy. Optimization for predicting mortality for each measurement was guided by the Youden Index (sensitivity + specificity - 1). Relative risk ratios (RRRs) and positive predictive values (PPVs) were calculated across cutoff ranges for individual and any pair of measurements. RESULTS: Optimal cutoffs, harmonized to 100-g or 0.5-cm readings, for neonatal and infant mortality were 44.5 cm for length, 2200 g for weight, 9.0 cm for MUAC, 31.0 cm for HC, and 28.5 cm for CC, below which all predicted mortality. However, a CC <28.5 cm, alone and combined with HC <31.0 cm, yielded the highest RRR [9.68 (95% CI: 7.84, 11.94) and 15.74 (95% CI: 12.54, 19.75), respectively] and PPV (11.3% and 10.7%) for neonatal mortality and highest RRR [6.02 (95% CI: 5.15, 7.02) and 9.19 (95% CI: 7.72, 10.95)] and PPV (16.3% and 14.5%) for infant mortality. Pairs of measurements revealed a higher RRR for neonatal and infant mortality than individual measurements of any one pair, although the ranges of PPV remained comparable. CONCLUSIONS: In Bangladesh, multiple birth measurements alone or in combination, particularly chest circumference, predict neonatal and infant mortality.

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi.

BACKGROUND: Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES: To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS: This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS: We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS: The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

The Potential Contribution of Fortified Maize Flour, Oil, Rice, Salt, and Wheat Flour to Estimated Average Requirements and Tolerable Upper Intake Levels for 15 Nutrients in 153 Countries.

Food fortification is designed to improve the nutritional profile of diets. The purpose of this research was to estimate the potential nutrient contribution of fortified maize flour, oil, rice, salt, and wheat flour in 153 countries, using the national intake (or availability) of the food and the nutrient levels required for fortification. This was done under two scenarios-maximum, where 100% of the food is assumed to be industrially processed and fortified, and realistic, where the maximum value is adjusted based on the percent of the food that is industrially processed and fortified. Under the maximum scenario, the median Estimated Average Requirements (EARs) met ranged from 22-75% for 14 nutrients (vitamins A, B1, B2, B3, B6, B12, D, E, folic acid and calcium, fluoride, iron, selenium and zinc), and 338% for iodine. In the realistic scenario, the median EARs met were 181% for iodine and <35% for the other nutrients. In both scenarios, the median Tolerable Upper Intake Levels (ULs) met were <55% for all nutrients. Under the realistic scenario, no country exceeded 100% of the UL for any nutrient. Current fortification practices of the five foods of interest have the global potential to contribute up to 15 nutrients to the diets of people, with minimal risk of exceeding ULs.

Age-specific risk factors for child anaemia in Myanmar: Analysis from the Demographic and Health Survey 2015-2016.

Anaemia is prevalent among preschool-aged children in Myanmar, but few epidemiological studies of anaemia at the national level were reported. Using data from the Myanmar Demographic and Health Survey 2015-2016, we examined risk factors for anaemia at household, maternal, and individual levels for children aged 6-23 months (n = 1,133) and 24-59 months (n = 2,393) separately. Survey design and sampling weights were adjusted for in multivariate regression analyses. The prevalence of anaemia was 77.2% in children aged 6-23 months and 50.8% in those aged 24-59 months. Living in geographic zones other than the hilly zone was associated with a higher odds of anaemia in both age groups (OR = 1.86-2.51 [95% lower limit > 1.0]). Maternal anaemia predicted child anaemia in a dose-response manner in both groups (6-23 months of age, OR = 2.01, 95% CI [1.38, 2.92; mild] and OR = 2.41, 95% CI [1.12, 5.19; moderate]; and 24-59 months of age, OR = 1.42, 95% CI [1.12, 1.81; mild] and OR = 2.92, 95% CI [1.91,4.46; moderate]). A maternal age of 14-24 years (ref: 25-34 years, OR = 1.67, 95% CI [1.06, 2.64]) and maternal tolerant attitude to domestic violence (OR = 1.61, 95% CI [1.13, 2.31]) predicted anaemia in children aged 6-23 months only. Younger child age (OR = 0.97, 95% CI [0.96, 0.98]), stunting (OR = 1.35, 95% CI [1.08, 1.69]) and using unimproved drinking water sources (OR = 1.38, 95% CI [1.10, 1.75]) were associated with anaemia in children aged 24-59 months. Consideration of age-specific risks factors for child anaemia will help in planning anaemia control programmes in Myanmar.

Risk factors for undernutrition among children 0-59 months of age in Myanmar.

The prevalence of childhood stunting in Myanmar is one of the highest among the countries of Southeast Asia. Cross-sectional data from the Myanmar Demographic Health Survey 2015-2016 were used to examine risk factors for stunting, wasting, and underweight among children aged 0-59 months. The prevalence of stunting, wasting, and underweight was 29.0%, 7.3%, and 19.2%, respectively. Accounting for sampling design and weights, multivariable logistic regression was conducted with 35 household, maternal, and child characteristics. Current pregnancy and maternal height <145 cm, home delivery, child's small birth size recalled by mother, and older age (ref: 0-5 months) predicted both stunting and underweight. Larger than average birth size was protective for all stunting, wasting, and underweight. Maternal body mass index <18.5 kg m-2 was a common risk factor for wasting and underweight. Lower wealth quintiles, maternal engagement in nonagricultural occupation, and male child predicted stunting only. Younger child age and not receiving vitamin A supplementation in the previous 6 months were risk factors for wasting only. Regional variation was also seen, with a higher odds of stunting in the West-South Region, North-East States, and West States, compared with the Central Regions. In Myanmar, socio-economic and demographic factors, poor maternal nutritional status, and living in certain geographical locations are affecting children's undernutrition. It is recommended that interventions for growth faltering focus on the first 1,000 days of life; optimum maternal nutrition be ensured during and before pregnancy and at adolescence; societal support be provided for mothers in poverty or engaged in nonagriculture; and region-specific undernutrition pathways be understood.

Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program.

Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6-23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up.

Epidemiology of anaemia in children, adolescent girls, and women in Bhutan.

Anaemia inhibits health and development in Bhutan. We estimated anaemia prevalence and explored risk factors in children and women using data from Bhutan's National Nutrition Survey 2015. Prevalence was calculated using life-stage-specific cut-offs adjusted for altitude and survey design. Risk factors were evaluated in modified Poisson regressions. Anaemia affected 42%, 29%, 36%, and 28% of children, adolescent girls, and non-pregnant and pregnant women, respectively. Risk of anaemia was greater in children who were younger (RR 2.0, 95% CI [1.7, 2.3] and RR 1.9, 95% CI [1.6, 2.3], respectively, for 12-23 and 6-11 vs. 24-59 months), male (1.2, 1.1-1.4, ref.: female), and stunted (1.2, 1.0-1.3, ref.: height-for-age ≥ -2z). Older (15-19 years) versus younger (10-14 years) adolescents were at higher risk (1.5, 1.2-1.8), as were adolescents living at home versus at school (1.2, 0.9-1.6) and those working versus studying (1.3, 1.0-1.7). Among adult women, anaemia risk increased with age (1.2, 1.0-1.4 and 1.3, 1.1-1.5, for 30-39 and 40-49, respectively, vs. 20-29 years) and was higher for women without schooling (1.1, 1.0-1.3, vs. primary schooling), who were unmarried or separated (1.4, 1.2-1.7 and 1.3, 1.1-1.6, respectively, vs. married), without a child <5 years (1.1, 1.0-1.3), and lacking improved sanitation (1.1, 1.0-1.3). High coverage of antennal iron and folic acid supplementation may contribute to the lower prevalence of anaemia among pregnant women and women with young children. Expansion of iron supplementation programmes, fortification, and other strategies to improve dietary iron intake may reduce the prevalence of anaemia, but causes of anaemia other than iron deficiency (e.g., thalassemias) should also be investigated.