Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal.

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

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.

Refocusing vitamin A supplementation programmes to reach the most vulnerable.

WHO recommends vitamin A supplementation (VAS) programmes for children 6-59 months where vitamin A deficiency is a public health problem. However, resources for VAS are falling short of current needs and programme coverage is suffering. The authors present the case for considering the options for shifting efforts and resources from a generalised approach, to prioritising resources to reach populations with continued high child mortality rates and high vitamin A deficiency prevalence to maximise child survival benefits . This includes evaluating where child mortality and/or vitamin A deficiency has dropped, as well as using under 5 mortality rates as a proxy for vitamin A deficiency, in the absence of recent data. The analysis supports that fewer countries may now need to prioritise VAS than in the year 2000, but that there are still a large number of countries that do. The authors also outline next steps for analysing options for improved targeting and cost-effectiveness of programmes. Focusing VAS resources to reach the most vulnerable is an efficient use of resources and will continue to promote young child survival.

Thinness and fecundability: Time to pregnancy after adolescent marriage in rural Bangladesh.

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001-2002, 5,516 newlywed women aged 12-19 years participated in a home-based, 5-weekly surveillance system for 5-6 years to enrol pregnant women into an antenatal vitamin A or ß-carotene supplementation trial. Thinness was defined as a left mid-upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan-Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58-68] vs. 51 [49-54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy.

Prevalence of damaged and missing teeth among women in the southern plains of Nepal: Findings of a simplified assessment tool.

OBJECTIVE: To assess the prevalence of missing and damaged teeth among women in the rural southern plains of Nepal using an interviewer-administered tooth assessment module. SETTING: 21wards in seven Village Development Committees across the Tarai of Nepal in 2015. PARTICIPANTS: Resident, married women of children less than 5 years of age or those married in the 2 years prior to the survey, 14 to 49 years of age participating in a mid-year nutrition and health survey in the Tarai region of Nepal. OUTCOME MEASURES: Prevalence of missing and damaged teeth, history of dental problems, oral hygiene practices, access to dental treatment and risk factors for missing and damaged teeth. RESULTS: Of 3007 assessed women, aged 14 to 49 years of age, 22.8% (95% CI: 21.4-24.4) reported ≥ 1 missing or damaged teeth; 81.5% (95% CI 80.1-82.9) reported regularly practicing oral hygiene, typically with standard local dentifrices. Pain or discomfort in the oral cavity in the previous 6 months affected 17.6% of women. Among these, 43.8% had sought treatment from a dental facility, pharmacy or village doctor. Home remedies were commonly applied to relieve pain. CONCLUSION: Broken and missing teeth are common, affecting nearly one-quarter of adult women of reproductive age in rural Southern Nepal, as assessed by an interviewer-administered questionnaire.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries.

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

Determinants of infant breastfeeding practices in Nepal: a national study.

Background: Optimal breastfeeding practices, reflected by early initiation and feeding of colostrum, avoidance of prelacteal feeds, and continued exclusivity or predominance of breastfeeding, are critical for assuring proper infant nutrition, growth and development. Methods: We used data from a nationally representative survey in 21 district sites across the Mountains, Hills and Terai (southern plains) of Nepal in 2013. Determinants of early initiation of breastfeeding, feeding of colostrum, prelacteal feeding and predominant breastfeeding were explored in 1015 infants < 12 months of age. Prelacteal feeds were defined as food/drink other than breast milk given to newborns in first 3 days. Predominant breastfeeding was defined as a child < 6 months of age is mainly breastfed, not fed solid/semi-solid foods, infant formula or non-human milk, in the past 7 days. Adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated, using log Poisson regression models with robust variance for clustering. Results: The prevalence of breastfeeding within an hour of birth, colostrum feeding, prelacteal feeding and predominant breastfeeding was 41.8, 83.5, 32.7 and 57.2% respectively. Compared to infants not fed prelacteal feeds, infants given prelacteal feeds were 51% less likely to be breastfed within the first hour of birth (APR 0.49; 95% CI 0.36, 0.66) and 55% less likely to be predominantly breastfed (APR 0.45; 95% CI 0.32, 0.62). Infants reported to have received colostrum were more likely to have begun breastfeeding within an hour of birth (APR 1.26; 95% CI 1.04, 1.54) compared to those who did not receive colostrum. Infants born to mothers ≥ 20 years of age were less likely than adolescent mothers to initiate breastfeeding within 1 hour of birth. Infants in the Terai were 10% less likely to have received colostrum (APR 0.90; 95% CI 0.83, 0.97) and 2.72 times more likely to have received prelacteal feeds (APR 2.72; 95% CI 1.67, 4.45) than those in the Mountains. Conclusions: Most infants in Nepal receive colostrum but less than half initiate breastfeeding within an hour of birth and one-third are fed prelacteal feeds, which may negatively affect breastfeeding and health throughout early infancy.

Antenatal Multiple Micronutrient Supplementation Compared to Iron-Folic Acid Affects Micronutrient Status but Does Not Eliminate Deficiencies in a Randomized Controlled Trial Among Pregnant Women of Rural Bangladesh.

BACKGROUND: Antenatal multiple micronutrient (MM) supplementation improves birth outcomes relative to iron-folic acid (IFA) in developing countries, but limited data exist on its impact on pregnancy micronutrient status. OBJECTIVE: We assessed the efficacy of a daily MM (15 nutrients) compared with IFA supplement, each providing approximately 1 RDA of nutrients and given beginning at pregnancy ascertainment, on late pregnancy micronutrient status of women in rural Bangladesh. Secondarily, we explored other contributors to pregnancy micronutrient status. METHODS: Within a double-masked trial (JiVitA-3) among 44,500 pregnant women, micronutrient status indicators were assessed in n = 1526 women, allocated by cluster to receive daily MM (n = 749) or IFA (n = 777), at 10 wk (baseline: before supplementation) and 32 wk (during supplementation) gestation. Efficacy of MM supplementation on micronutrient status indicators at 32 wk was assessed, controlling for baseline status and other covariates (e.g., inflammation and season), in regression models. RESULTS: Baseline status was comparable by intervention. Prevalence of deficiency among all participants was as follows: anemia, 20.6%; iron by ferritin, 4.0%; iron by transferrin receptor, 4.7%; folate, 2.5%; vitamin B-12, 35.4%; vitamin A, 6.7%; vitamin E, 57.7%; vitamin D, 64.0%; zinc, 13.4%; and iodine, 2.6%. At 32 wk gestation, vitamin B-12, A, and D and zinc status indicators were 3.7-13.7% higher, and ferritin, γ-tocopherol, and thyroglobulin indicators were 8.7-16.6% lower, for the MM group compared with the IFA group, with a 15-38% lower prevalence of deficiencies of vitamins B-12, A, and D and zinc (all P < 0.05). However, indicators typically suggested worsening status during pregnancy, even with supplementation, and baseline status or other covariates were more strongly associated with late pregnancy indicators than was MM supplementation. CONCLUSIONS: Rural Bangladeshi women commonly entered pregnancy deficient in micronutrients other than iron and folic acid. Supplementation with MM improved micronutrient status, although deficiencies persisted. Preconception supplementation or higher nutrient doses may be warranted to support nutritional demands of pregnancy in undernourished populations. This trial was registered at clinicaltrials.gov as NCT00860470.

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.

Identifying maternal and infant factors associated with newborn size in rural Bangladesh by partial least squares (PLS) regression analysis.

Birth weight, length and circumferences of the head, chest and arm are key measures of newborn size and health in developing countries. We assessed maternal socio-demographic factors associated with multiple measures of newborn size in a large rural population in Bangladesh using partial least squares (PLS) regression method. PLS regression, combining features from principal component analysis and multiple linear regression, is a multivariate technique with an ability to handle multicollinearity while simultaneously handling multiple dependent variables. We analyzed maternal and infant data from singletons (n = 14,506) born during a double-masked, cluster-randomized, placebo-controlled maternal vitamin A or ß-carotene supplementation trial in rural northwest Bangladesh. PLS regression results identified numerous maternal factors (parity, age, early pregnancy MUAC, living standard index, years of education, number of antenatal care visits, preterm delivery and infant sex) significantly (p<0.001) associated with newborn size. Among them, preterm delivery had the largest negative influence on newborn size (Standardized ß = -0.29 - -0.19; p<0.001). Scatter plots of the scores of first two PLS components also revealed an interaction between newborn sex and preterm delivery on birth size. PLS regression was found to be more parsimonious than both ordinary least squares regression and principal component regression. It also provided more stable estimates than the ordinary least squares regression and provided the effect measure of the covariates with greater accuracy as it accounts for the correlation among the covariates and outcomes. Therefore, PLS regression is recommended when either there are multiple outcome measurements in the same study, or the covariates are correlated, or both situations exist in a dataset.

Experiences and lessons learned for planning and supply of micronutrient powders interventions.

Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale-up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale-up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.

Executive summary for the Micronutrient Powders Consultation: Lessons Learned for Operational Guidance.

Iron deficiency anaemia is estimated to be the leading cause of years lived with disability among children. Young children's diets are often inadequate in iron and other micronutrients, and provision of essential vitamin and minerals has long been recommended. With the limited programmatic success of iron drop/syrup interventions, interest in micronutrient powders (MNP) has increased. MNP are a mixture of vitamins and minerals, enclosed in single-dose sachets, which are stirred into a child's portion of food immediately before consumption. MNP are an efficacious intervention for reducing iron deficiency anaemia and filling important nutrient gaps in children 6-23 months of age. As of 2014, 50 countries have implemented MNP programmes including 9 at a national level. This paper provides an overview of a 3-paper series, based on findings from the "Micronutrient Powders Consultation: Lessons Learned for Operational Guidance" held by the USAID-funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project. The objectives of the Consultation were to identify and summarize the most recent MNP programme experiences and lessons learned for operationalizing MNP for young children and prioritize an implementation research agenda. The Consultation was composed of 3 working groups that used the following methods: deliberations among 49 MNP programme implementers and experts, a review of published and grey literature, questionnaires, and key informant interviews, described in this overview. The following articles summarize findings in 3 broad programme areas: planning, implementation, and continual programme improvement. The papers also outline priorities for implementation research to inform improved operationalization of MNP.

Determinants of successful vitamin A supplementation coverage among children aged 6-59 months in thirteen sub-Saharan African countries.

OBJECTIVE: Vitamin A supplementation (VAS) for children aged 6-59 months occurs regularly in most sub-Saharan African countries. The present study aimed to explore child, household and delivery platform factors associated with VAS coverage and identify barriers to compliance in thirteen African countries. DESIGN: We pooled data (n ~60 000) from forty-four household coverage surveys and used bivariate and multivariable regression analyses to assess the effects of supplementation strategy, rural v. urban residence, child sex, child age, caregiver education and campaign awareness on child VAS status. Setting/Subjects Primary caregivers of children aged 6-59 months in thirteen countries. RESULTS: Door-to-door distribution resulted in higher VAS coverage than fixed-site plus outreach approaches (91 v. 63 %) and was a significant predictor of supplementation in the adjusted model (OR=19·0; 95 % CI 17·2, 21·1; P<0·001). Having been informed about the campaign was the main predictor of VAS in the door-to-door (OR=6·8; 95 % CI 5·8, 7·9; P<0·001) and fixed-site plus outreach (OR=72·5; 95 % CI 66·6, 78·8; P<0·001) groups. CONCLUSIONS: Door-to-door provision of VAS may achieve higher coverage than fixed-site models in the African context. However, the phase-out of door-to-door polio immunization campaigns in most sub-Saharan African countries threatens the main distribution vehicle for VAS. Our findings suggest well-informed communities are key to attaining higher coverage using fixed-site delivery alternatives.

Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency.

Vitamin A supplementation (VAS) programs targeted at children aged 6-59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.

Early newborn ritual foods correlate with delayed breastfeeding initiation in rural Bangladesh.

BACKGROUND: Early and exclusive breastfeeding may improve neonatal survival in low resource settings, but suboptimal breastfeeding still exists in areas with high infant mortality. Prelacteal feeding, the practice of giving a non-breastmilk food as a neonate's first food, has been associated with suboptimal breastfeeding practices. We examined the association of feeding a non-breastmilk food in the first three days of life (early neonatal food, or ENF) with time from birth to initiation of breastfeeding among 25,286 Bangladeshi mother-neonate pairs, in a secondary analysis of a randomized controlled trial in northwestern rural Bangladesh conducted from 2001-2007. METHODS: Trained interviewers assessed the demographic characteristics during pregnancy. At three months postpartum, the interviewers visited participants again and retrospectively assessed demographic and breastfeeding characteristics surrounding the birth. We assessed the relationship between ENF and time to initiation of breastfeeding in hours in both unadjusted and adjusted linear regression analyses. We also calculated reverse cumulative distribution curves for time to initiation of breastfeeding and analyses were stratified by an infant's ability to breastfeed normally at birth. RESULTS: The mean ± SD time from birth to initiation of breastfeeding was 30.6 ± 27.9 hours. Only 2,535 (10.0%) of women reported initiating breastfeeding in the first hour after birth and 10,207 (40.4%) reported initiating breastfeeding in the first 12 hours after birth. In adjusted linear regression analyses, feeding ENF was associated with a significant increase in time, in hours, to breastfeeding initiation both among children not able to breastfeed at birth (37.4; 95% CI 33.3, 41.5) and among children able to breastfeed at birth (13.3; 95% CI 12.7, 14.0). CONCLUSIONS: Feeding ENF was strongly associated with delayed initiation of breastfeeding, even after adjusting for other related factors and stratifying on the neonate's ability to suckle normally after birth. More research is needed to understand the impact of these findings on optimal breastfeeding in this setting. It is possible that ENF feeding and the ability to breastfeed immediately after birth are interrelated in their respective associations to suboptimal breastfeeding initiation. This study in a large population representative of other populations in rural South Asia, demonstrates significantly longer times to breastfeeding initiation than previously appreciated, with a possible important role of ENF feeding. TRIAL REGISTRATION: The randomized controlled trial on which this analysis is based, "Impact of Maternal Vitamin A or Beta-Carotene Supplementation on Maternal and Infant Mortality in Bangladesh", was registered with ClinicalTrials.gov as trial number ID GHS-A-00-03-00019-00 and identifier NCT00198822. The identifier was first received September 12, 2005 (retrospectively registered). The first participant was enrolled in August 2001.

Effects of prenatal multiple micronutrient supplementation on growth and cognition through 2 y of age in rural Bangladesh: the JiVitA-3 Trial.

BACKGROUND: Childhood undernutrition may have prenatal origins, and the impact of prenatal interventions on postnatal growth is not well known. OBJECTIVE: We assessed the effects of prenatal multiple micronutrient (MM) supplementation on child growth and cognitive development. DESIGN: In a cluster-randomized controlled trial in rural Bangladesh, prenatal MM supplementation compared with iron-folic acid (IFA) supplementation was examined for its impact on growth assessed longitudinally from birth up to 24 mo of age (n = 8529) and, in a subsample (n = 734), on cognitive function at 24 mo of age by use of the Bayley scales of infant and toddler development-third edition test. RESULTS: Prevalence of stunting at birth [length for age z score (LAZ): <-2] was 31.9% in the MM and 35.7% in the IFA groups (P < 0.001); however, LAZ increased during the first 3-4 mo in both groups. With the use of a linear random-effects model, prenatal MM-exposed children sustained a higher mean predicted LAZ of ∼0.10 at 1 and 3 mo and 0.06 at 6 mo of age compared with children in the IFA group. Supplementation reduced the prevalence of stunting at 1 (RR: 0.95; 95% CI: 0.92, 0.98) and 3 (RR: 0.91; 95% CI: 0.88, 0.94) mo of age. Differences between groups were absent by 6, 12, and 24 mo of age, when nearly 50% of children had stunted growth. Ponderal and linear growth velocities were somewhat slower from 3 to 12 mo of age in the MM group than in the IFA group, but not from 12 to 24 mo of age. There was no difference between groups on composite scores of cognition, language, and motor performance at 24 mo of age. CONCLUSIONS: In this Bangladeshi trial, maternal pre- and postnatal MM supplementation resulted in improvements in LAZ and reduction in stunting through 3 mo of age, but not thereafter and had no impact on cognitive and motor function at 2 y. This trial was registered at clinicaltrials.gov as NCT000860470.

Maternal Dietary Diversity Decreases with Household Food Insecurity in Rural Bangladesh: A Longitudinal Analysis.

BACKGROUND: Household food insecurity (HFI) can lead to a poor diet and malnutrition. Yet, little is known about the extent to which maternal diet covaries with food insecurity during pregnancy and lactation. OBJECTIVE: Longitudinal associations between HFI and maternal dietary diversity from early pregnancy to 3 mo postpartum were examined in rural Bangladesh. METHODS: We repeatedly assessed dietary intake by using a 7-d food-frequency questionnaire in the first and third trimesters of pregnancy and at 3 mo postpartum among 14,600 women enrolled into an antenatal micronutrient supplementation trial. Maternal dietary diversity score (DDS) was constructed as the sum of 10 food groups reportedly consumed at each assessment. Households were classified at 6 mo postpartum as being food secure or having mild, moderate, or severe HFI on the basis of a 9-item standard scale. Generalized estimating equations were used to estimate the longitudinal relation between HFI status and DDS and the likelihood of individual food-group consumption, adjusting for confounders at the maternal and household levels. RESULTS: The DDS decreased with progressively worse HFI, an association best explained by a derived household wealth index. Compared with women from food-secure households, women of mild, moderate, and severe HFI were less likely, in a dose-response fashion, to have consumed dairy products [adjusted ORs (95% CIs): 0.73 (0.69, 0.78), 0.62 (0.58, 0.66), and 0.52 (0.48, 0.55), respectively], eggs [0.81 (0.76, 0.85), 0.73 (0.68, 0.77), and 0.61 (0.57, 0.65)], meat [0.83 (0.79, 0.88), 0.73 (0.69, 0.78), and 0.60 (0.56, 0.64)], fish [0.87 (0.80, 0.94), 0.76 (0.70, 0.83), and 0.59 (0.54, 0.65)], legumes and nuts [0.88 (0.83, 0.93), 0.81 (0.76, 0.87), and 0.79 (0.74, 0.85)], and yellow and orange fruit and vegetables [0.85 (0.80, 0.91), 0.78 (0.73, 0.84), and 0.72 (0.67, 0.78)]. Neither intakes of dark-green leafy vegetables nor of vegetable oil were associated with HFI status. CONCLUSION: Antenatal and postnatal maternal dietary diversity, especially intakes of animal-source foods, fruit, and vegetables, declined with worsening food insecurity in rural Bangladesh.

Provitamin A-biofortified maize increases serum ß-carotene, but not retinol, in marginally nourished children: a cluster-randomized trial in rural Zambia.

BACKGROUND: Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to improve vitamin A status in maize-consuming populations. OBJECTIVE: We evaluated the efficacy of regular provitamin A carotenoid-biofortified "orange" maizemeal (∼15 µg ß-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children. DESIGN: This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ∼400-km(2) area were identified and grouped by proximity into clusters of ∼15-25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, ß-carotene, C-reactive protein, and α1-acid glycoprotein. RESULTS: Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 µmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum ß-carotene was 0.14 µmol/L (95% CI: 0.09, 0.20 µmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 µmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms. CONCLUSION: In this marginally nourished population, regular biofortified maizemeal consumption increased serum ß-carotene concentrations but did not improve serum retinol. This trial was registered at clinicaltrials.gov as NCT01695148.