The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh.

BACKGROUND: Iron deficiency is highly prevalent in South Asia, especially among women and children in Bangladesh. Declines in cognitive performance are among the many functional consequences of iron deficiency. OBJECTIVE: We tested the hypothesis that, over the course of a 4-month iron fortification trial, cognitive performance would improve, and that improvement would be related to improvements in iron status. METHODS: Participants included 359 adolescent girls attending Bangladesh Rural Advancement Committee (BRAC) clubs as a subsample of a larger double-blind, cluster-randomized community trial in which participants were assigned to one of three conditions: a condition in which no lentils were supplied (NL, n = 118, but which had the usual intake of lentils), a control (non-fortified) lentil condition (CL, n = 124), and an iron-fortified lentil condition (FL, n = 117). In the FL and CL conditions, approximately 200 g of cooked lentils were served five days per week for a total of 85 feeding days. In addition to biomarkers of iron status, five cognitive tasks were measured at baseline (BL) and endline (EL): simple reaction time task (SRT), go/no-go task (GNG), attentional network task (ANT), the Sternberg memory search Task (SMS), and a cued recognition task (CRT). RESULTS: Cognitive performance at EL was significantly better for those in the FL relative to the CL and NL conditions, with this being true for at least one variable in each task, except for the GNG. In addition, there were consistent improvements in cognitive performance for those participants whose iron status improved. Although there were overall declines in iron status from BL to EL, the declines were smallest for those in the FL condition, and iron status was significantly better for those in FL condition at EL, relative to those in the CL and NL conditions. CONCLUSIONS: the provision of iron-fortified lentils provided a protective effect on iron status in the context of declines in iron status and supported higher levels of cognitive performance for adolescent girls at-risk of developing iron deficiency.

Design, Methods, and Select Baseline Results from a School Nutrition Project for Adolescents in Bangladesh.

Background: The School Nutrition for Adolescents Project (SNAP) provided weekly iron and folic acid (WIFA) supplementation and menstrual hygiene management (MHM) support for girls; actions to improve water, sanitation, and hygiene (WASH) practices; and behavior change interventions to adolescents aged 10-19 y in 65 intervention schools in 2 districts of Bangladesh. Objectives: We aimed to describe the project design and select baseline results of students and school project implementers. Methods: Girls (n = 2244) and boys (n = 773) in 74 schools (clusters) and project implementers [headteachers (n = 74), teachers (n = 96), and student leaders (n = 91)] participated in a survey assessing nutrition, MHM, and WASH knowledge and experience. Hemoglobin, inflammation-adjusted ferritin, retinol-binding protein, and serum and RBC folate (RBCF) levels in girls were measured. School WASH infrastructure was observed and drinking water was tested for E. coli. Results: IFA and deworming tablet intake in the last 1 and 6 mo were 4% and 81% for girls and 1% and 86%, respectively. Applying the Minimum Dietary Diversity for Women (MDD-W) tool, most (63%-68%) girls and boys achieved minimum dietary diversity. Fewer adolescents (14%-52%) had ever heard of anemia, IFA tablets, or worm infestation than project implementers (47%-100%). Girls (35%) missed school during menstruation; 39% reported of ever leaving school due to unexpected menstruation. The micronutrient status and deficiency severity varied: anemia (25%), RBCF insufficiency (76%), risk of serum folate deficiency (10%), deficiencies of iron (9%), and vitamin A (3%). WASH in school sustainable development goal (SDG) indicators achievement varied: basic drinking water service (70%), basic sanitation service (42%), and basic hygiene service (3%); 59% of sampled drinking water access points complied with WHO E. coli standards. Conclusions: There is room for improvement of nutrition and health awareness, practices, micronutrient status, SDG basic WASH in-school services, and E coli contamination in school drinking water.This trial was registered in clinicaltrials.gov as NCT05455073.

Determination of an Acceptable Portion Size of Daal for a Bangladeshi Community-Based Iron Intervention in Adolescent Girls: A Feasibility Study.

Widely consumed daal (lentils) in Bangladesh are an ideal vehicle for iron (Fe) fortification; however, an acceptable portion size in meals needs to be determined to carry out a community feeding study in at-risk adolescent girls. A non-randomized crossover trial was conducted with n = 100 Bangladeshi girls (12.9 ± 2.0 years of age). Two recipes (thin and thick) and three portion sizes (25 g, 37.5 g, 50 g of raw lentil) of daal were served with 250 g of cooked white rice in a counter-balanced manner over 12 weeks. Each meal was fed to participants 5 days/week for two weeks. Ratings of hunger, satiety, and palatability were measured before and after each meal using Visual Analog Scales (VAS). The thick preparation in the 37.5 g portion (~200 g cooked) elicited higher VAS ratings of hunger, satiety, and palatability compared to all other meals. The 50 g portion of the thin preparation had VAS ratings similar to those of the 37.5 g thick preparation. Consuming the 37.5 g portion of fortified daal would provide 6.9 mg Fe/day to girls in a community-based effectiveness study. This would meet ~86% and ~46% of the Recommended Dietary Allowance (RDA) for Fe for girls aged 9-13 and 14-18 years, respectively.

Iron-fortified lentils to improve iron (Fe) status among adolescent girls in Bangladesh - study protocol for a double-blind community-based randomized controlled trial.

BACKGROUND: Lentils are generally considered to be a nutrient-dense food, and a good source of iron (Fe). This study aims to establish novel evidence of the effectiveness of the consumption of Fe-fortified lentils in improving the body Fe status and thus cognitive performance in non-pregnant adolescent girls in rural Bangladesh, compared to consumption of ordinary lentils. METHODS: We have designed a double-blind (both trial participants and outcome assessors), community-based, cluster-randomized controlled trial among 1260 Bangladeshi adolescent girls between the ages of 10-17 years who are non-smoking, not married, not pregnant, not breastfeeding, and generally healthy at the time of enrollment. The intervention will include three arms who will receive: (1) Fe-fortified lentils; (2) unfortified lentils; or (3) usual intake. Participants will be served a thick preparation of cooked Fe-fortified lentils (37.5 g raw lentils, approximately 200 g cooked lentils) 5 days per week for 85 feeding days (around 4 months) using a locally acceptable recipe. Lentils were fortified with Fe in the laboratory at the Department of Plant Sciences at the University of Saskatchewan in Canada. A subsample of participants (n = 360) will be randomly invited to be included in cognitive testing. DISCUSSION: Data on socio-demographic characteristics, household food security status, adolescent food habits and cognitive testing will be collected at baseline and endline (4 months). Venous blood samples will be collected at baseline, midline (2 months) and endline to measure adolescents' Fe status. Computerized cognitive testing will include five common measures of attentional (three of attention) and mnemonic functioning (two of memory) carried out using DMDX software. The results of this study will be used to garner support for and to substantiate large-scale production and market expansion of Fe-fortified lentils, and will contribute to knowledge about how to enhance Fe status in adolescents worldwide in resource-poor settings, using staple food crops. TRIAL REGISTRATION: ClinicalTrials.gov NCT03516734 . Registered on 24 May 2018.

Sensory Acceptability of Iron-Fortified Red Lentil (Lens culinaris Medik.) Dal.

Panelists in Saskatoon, Canada (n = 45) and Dhaka, Bangladesh (n = 98) participated in sensory evaluations of the sensory properties of both cooked and uncooked dehulled red lentil dal fortified with FeSO4 ·7H2 O, NaFeEDTA or FeSO4 ·H2 O at fortificant Fe concentrations of 800, 1,600 (both cooked and uncooked), or 2,800 ppm. Appearance, odor, and overall acceptability of cooked and uncooked samples were rated using a 9-point hedonic scale (1 = dislike extremely to 9 = like extremely). Taste and texture were rated for the cooked samples prepared as typical south Asian lentil meals. Significant differences in sensory quality were observed among all uncooked and cooked samples at both locations. Overall, scores for all sensory attributes and acceptability of uncooked lentil decreased with increasing concentration of Fe in the fortificant; however, Fe fortification (particularly with NaFeEDTA) had small effects on acceptability. Panelists from Saskatoon provided a wider range of scores than those from Bangladesh for all attributes of cooked lentil. Overall, sensory evaluation of Fe fortification using NaFeEDTA minimally affected consumer perception of color, taste, texture, odor, and overall acceptability of cooked lentil. Reliability estimates (Cronbach's alpha [CA]) indicated that consumer scores were generally consistent for all attributes of all lentil samples (mean CA > 0.80). NaFeEDTA was found to be the most suitable Fe fortificant for lentil based on consumer acceptability. Consumption of 45 to 50 g of NaFeEDTA-fortified lentil (fortificant Fe concentration of 1,600 ppm) per day meets the estimated average requirements (EARs) of Fe for humans (10.8 to 29.4 mg). PRACTICAL APPLICATION: Iron fortification of dehulled lentil dal may change organoleptic attributes that can influence consumer acceptability. Sensory evaluation by consumers helps to determine the effect on appearance, odor, taste, texture, and overall acceptability of fortified lentils. In this study, consumer acceptability was evaluated with panelists who consume lentil regularly. Panelists provided significantly different scores for 5 sensory attributes for 10 uncooked and 3 cooked lentil samples. Panelists reliably preferred NaFeEDTA as the most suitable Fe fortificant for dehulled lentils for 5 attributes. Overall, lentil dal fortified with NaFeEDTA can offer a simple and low-cost solution to human health problems associated with iron-related malnutrition.

Estimating nutrient fortification levels in condiments and seasonings for public health programs: considerations and adaptations.

Condiments and seasonings have been considered as potential vehicles for fortification in place of, or in addition to, fortifiable staple foods. Methodologies for establishing fortification programs focus primarily on use of staple foods, which are consumed in larger portions than condiments and seasonings. Some fortification models assume self-limiting consumption relative to the maximum energy consumed by target populations. However, this assumption may prove incorrect for estimating fortification concentrations of condiments and seasonings because they may only provide negligible energy. Although flavor or color may limit consumption, these limits would vary across each condiment or seasoning vehicle. In addition, the small volume of condiments and seasonings consumed relative to staple foods can lead to proportionally larger potential errors than with staple foods when measuring usual dietary intakes for establishing safe and effective fortification concentrations. This paper reviews available methods for setting fortification levels, whether or how available methods or conceptual frameworks could be adapted to condiments and seasonings, and gaps in knowledge for appropriately using condiments and seasonings as vehicles for fortification in public health.

Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh.

BACKGROUND: The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. OBJECTIVE: We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. DESIGN: The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. RESULTS: When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). CONCLUSIONS: The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.

Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh.

BACKGROUND: Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. OBJECTIVE: To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. METHODS: From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. RESULTS: Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. CONCLUSIONS: Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

A multiple-micronutrient-fortified beverage affects hemoglobin, iron, and vitamin A status and growth in adolescent girls in rural Bangladesh.

Adolescent girls have high nutrient needs and are susceptible to micronutrient deficiencies. The objective of this study was to test the effect of a multiple-micronutrient-fortified beverage on hemoglobin (Hb) concentrations, micronutrient status, and growth among adolescent girls in rural Bangladesh. A total of 1125 girls (Hb > or = 70 g/L) enrolled in a randomized, double-blind, placebo-controlled trial and were allocated to either a fortified or nonfortified beverage of similar taste and appearance. The beverage was provided at schools 6 d/wk for 12 mo. Concentrations of Hb and serum ferritin (sFt), retinol, zinc, and C-reactive protein were measured in venous blood samples at baseline, 6 mo, and 12 mo. In addition, weight, height, and mid-upper arm circumference (MUAC) measurements were taken. The fortified beverage increased the Hb and sFt and retinol concentrations at 6 mo (P < 0.01). Adolescent girls in the nonfortified beverage group were more likely to suffer from anemia (Hb <120 g/L), iron deficiency (sFt <12 microg/L), and low serum retinol concentrations (serum retinol <0.70 micromol/L) (OR = 2.04, 5.38, and 5.47, respectively; P < 0.01). The fortified beverage group had greater increases in weight, MUAC, and BMI over 6 mo (P < 0.01). Consuming the beverage for an additional 6 mo did not further improve the Hb concentration, but the sFt level continued to increase (P = 0.01). The use of multiple-micronutrient-fortified beverage can contribute to the reduction of anemia and improvement of micronutrient status and growth in adolescent girls in rural Bangladesh.