Household food security and dietary diversity in south-eastern Nigeria.

The aim of this study was to investigate household food security (access) level and the dietary diversity of households in the Nsukka Local Government Area in South-eastern Nigeria. From 20 local communities of Nsukka, 390 women were randomly sampled from the women's group and asked to complete a survey that determined the Household Food Insecurity Access Scale scores and the Household Dietary Diversity Scores (HDDS). The descriptive results indicated a high level of food insecurity with 82.6% households reporting various degrees of food insecurity. Over half of the sampled population experienced insufficient food quality. They either ate unwanted food (65.9%), limited variety (63.1%), or unpreferred food (64.6%). Some households experienced insufficient food intake by going a whole day without food (38.2%), go to sleep hungry (45.1%), or have no food of any kind (49%). The analysis of variance showed no significant difference (p = 0.428) in the food security level of households headed by males as compared with those headed by females. Approximately 53.6% of households fell at or below the average HDDS; males headed 48% of these households, while females headed 64%. The chi-square test indicated factors associated with household food security including age, education, work status and income, whereas the gender of the household head, household size and marital status were not significantly associated. Public-private partnerships, nutrition orientation and food intervention programs could improve food security in this area.

An educational intervention to prevent overweight in pre-school years: a cluster randomised trial with a focus on disadvantaged families.

BACKGROUND: Early prevention is a promising strategy for reducing obesity in childhood, and Early Years settings are ideal venues for interventions. This work evaluated an educational intervention with the primary aim of preventing overweight and obesity in pre-school children. METHODS: A pragmatic, cluster randomised trial with a parallel, matched-pair design was undertaken. Interventions were targeted at both the cluster (Early Years' Centres, matched by geographical area) and individual participant level (families: mother and 2-year old child). At the cluster level, a staff training intervention used the educational resource Be Active, Eat Healthy. Policies and provision for healthy eating and physical activity were evaluated at baseline and 12-months. The intervention at participant level was the Healthy Heroes Activity Pack: delivered over 6 months by Centre staff to promote healthy eating and physical activity in a fun, interactive way. Child and parent height and weight were measured at four time-points over 2 years. The trial primary outcome was the change in BMI z-score of the child between ages 2 and 4 years. Secondary outcomes consisted of parent-reported measures administered at baseline and two-year follow-up. RESULTS: Five pairs of Early Years' Centres were recruited. Four pairs were analysed as one Centre withdrew (47 intervention families; 34 control families). At the cluster level, improvement in Centre policies and practices was similar for both groups (p = 0.830). At the participant level, the intervention group reduced their mean BMI z-score between age 2 and 4 years (p = 0.002; change difference 0.49; 95% CI 0.17 to 0.80) whereas the control group showed increasing BMI z-score throughout. Changes in parent-reported outcomes and parent BMI (p = 0.582) were similar in both groups. CONCLUSIONS: The Healthy Heroes educational resource deterred excess weight gain in pre-school children from poor socioeconomic areas. With training, Early Years' staff can implement the Healthy Heroes programme. TRIAL REGISTRATION: ISRCTN22620137 Registered 21st December 2016.

A realist qualitative study to explore how low-income pregnant women use Healthy Start food vouchers.

Healthy Start is the UK government's food voucher programme for low-income pregnant women and young children. It was introduced in 2006, but the impact of the programme on nutritional outcomes remains understudied. This study sought to explore potential outcomes of the Healthy Start programme (including intended and unintended outcomes) and develop explanations for how and why these outcomes might occur. A realist review preceded this study, in which programme theories were developed and tested using existing evidence. This qualitative study aimed to further refine and consolidate the programme theories from the realist review while remaining open to new and emerging theories (or hypotheses) about how low-income pregnant women use Healthy Start vouchers. Semistructured interviews were conducted with 11 low-income women from North West England, who received Healthy Start vouchers during pregnancy. A realist logic of analysis was applied to generate clear and transparent linkages between outcomes and explanations. The findings suggested that some women used the vouchers to improve their diets during pregnancy (intended outcome), whereas some women were diverted towards alternative or unintended outcomes. Women's circumstances, values, beliefs, and motivations influenced how they perceived and responded to the vouchers. This paper presents four evidence-based programme theories to explain four contrasting (and potentially overlapping) outcomes: dietary improvements (theory refined from review), shared benefits (new theory), financial assistance (theory refined from review), and stockpiling formula (new theory). It considers how the Healthy Start programme could be improved, to increase the possibilities for low-income women to experience the intended outcome of dietary improvements.

Developing health service delivery in a poor and marginalised community in North West Pakistan.

OBJECTIVES: To improve maternal health and reduce child mortality through developing health service delivery in a poor and marginalised community in North West Pakistan. METHODS: This was a multifaceted intervention to extend and strengthen the range and quality of services provided at an existing health centre, in a rural community in Peshawar District, Khyber Pakhtunkhwa Province. The intervention was developed with community involvement and had four main components: service development, staff capacity development, community engagement and the introduction of a micro-credit scheme. The evaluation assessed the efficiency and effectiveness of project implementation, including a survey of maternal and child health indicators. RESULTS: Between 2014 and 2017, a range of new health services were developed at the health centre. Local volunteers were trained to promote health awareness in the community and refer pregnant women to the health centre. The survey indicated health improvements, such as increased vaccination rates for women and children, and a dramatic reduction in unskilled deliveries. CONCLUSIONS: Community engagement was essential to achieve much needed maternal and child health improvements in this poor and marginalised community. Sustainability was achieved by training local volunteers as community health workers.

Report of the International Society for Zinc Biology 5th Meeting, in Collaboration with Zinc-Net (COST Action TD1304)-UCLan Campus, Pyla, Cyprus.

From 18 to 22 June 2017, the fifth biennial meeting of the International Society for Zinc Biology was held in conjunction with the final dissemination meeting of the Network for the Biology of Zinc (Zinc-Net) at the University of Central Lancashire, Cyprus campus. The meeting attracted over 160 participants, had 17 scientific symposia, 4 plenary speakers and 2 poster discussion sessions. In this report, we give an overview of the key themes of the meeting and some of the highlights from the scientific programme.

Assessing zinc in humans.

PURPOSE OF REVIEW: To examine the most recent literature that provides new data regarding the potential and emerging biomarkers for zinc status in individuals. RECENT FINDINGS: Suboptimal dietary zinc intake is estimated to affect 17% of the world's population; however, the assessment of zinc status is notoriously difficult. A systematic review and meta-analysis of studies investigating biochemical biomarkers of zinc status was conducted by the European Micronutrient Recommendations Aligned network. This review summarized the data published from inception to 2007. More recently (2016), an international expert panel, convened by the biomarker of nutrition for development initiative, published an extensive review of the literature addressing biomarkers of zinc status in populations and individuals and categorized the biomarkers as useful [dietary intake, serum Zn concentration and stunting], potentially useful [hair Zn concentration, urine Zn concentration and neurobehavioural function] and emerging [nail Zn concentration, oxidative stress and DNA integrity, zinc kinetics, zinc-dependent proteins and taste acuity]. SUMMARY: The most recent data on the potentially useful biomarkers support the further investigation of hair Zn concentration and indices of neurological function, particularly those assessing memory and attention. Of the emerging biomarkers, the measurement of DNA integrity and the expression of zinc transport proteins look promising.

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan.

BACKGROUND: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision-making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study: to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention. METHODS: A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over 40 years old. The aim of these was to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement. RESULTS: Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision-making processes within the household have been highlighted as restricting women's autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of 'wisdom'- an amalgamation of age, experience and education- presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making. CONCLUSIONS: The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study.

Biomarkers of Nutrition for Development (BOND)-Zinc Review.

Zinc is required for multiple metabolic processes as a structural, regulatory, or catalytic ion. Cellular, tissue, and whole-body zinc homeostasis is tightly controlled to sustain metabolic functions over a wide range of zinc intakes, making it difficult to assess zinc insufficiency or excess. The BOND (Biomarkers of Nutrition for Development) Zinc Expert Panel recommends 3 measurements for estimating zinc status: dietary zinc intake, plasma zinc concentration (PZC), and height-for-age of growing infants and children. The amount of dietary zinc potentially available for absorption, which requires an estimate of dietary zinc and phytate, can be used to identify individuals and populations at risk of zinc deficiency. PZCs respond to severe dietary zinc restriction and to zinc supplementation; they also change with shifts in whole-body zinc balance and clinical signs of zinc deficiency. PZC cutoffs are available to identify individuals and populations at risk of zinc deficiency. However, there are limitations in using the PZC to assess zinc status. PZCs respond less to additional zinc provided in food than to a supplement administered between meals, there is considerable interindividual variability in PZCs with changes in dietary zinc, and PZCs are influenced by recent meal consumption, the time of day, inflammation, and certain drugs and hormones. Insufficient data are available on hair, urinary, nail, and blood cell zinc responses to changes in dietary zinc to recommend these biomarkers for assessing zinc status. Of the potential functional indicators of zinc, growth is the only one that is recommended. Because pharmacologic zinc doses are unlikely to enhance growth, a growth response to supplemental zinc is interpreted as indicating pre-existing zinc deficiency. Other functional indicators reviewed but not recommended for assessing zinc nutrition in clinical or field settings because of insufficient information are the activity or amounts of zinc-dependent enzymes and proteins and biomarkers of oxidative stress, inflammation, or DNA damage.

Fortification or biofortification: complimentary strategies or duplication of effort?

Micronutrient deficiencies continue to be a global concern, with the most common deficiencies being vitamin A, iron, zinc and B vitamins (folate and B12). Addressing this requires strategies that are scalable and equitable such that they reach all members of a population irrespective of socioeconomic status and geography. Fortification and biofortification offer potential large-scale solutions, however each have strengths and limitations depending on the context, particularly the cultural and political factors that may create barriers or opportunities for effectiveness. Planning how to target scarce resources for maximum impact requires an in-depth knowledge and understanding of local food systems and market dynamics, alongside strong government policy and legislative support. A food fortification programme was launched in Pakistan in 2016, supported by UK Aid and designed to address the high prevalence of vitamin A, iron and zinc deficiency, particularly in women and children. In the same year, the first zinc biofortified variety of wheat, Zincol-2016, was released in Pakistan, supported and developed through the HarvestPlus programme in collaboration with the Pakistan National Agriculture Research Centre. This review explores the challenges faced by fortification and biofortification, initiated independently, (but around the same time) in Pakistan.

Preventing and Controlling Zinc Deficiency Across the Life Course: A Call to Action.

Through diverse roles, zinc determines a greater number of critical life functions than any other single micronutrient. Beyond the well-recognized importance of zinc for child growth and resistance to infections, zinc has numerous specific roles covering the regulation of glucose metabolism, and growing evidence links zinc deficiency with increased risk of diabetes and cardiometabolic disorders. Zinc nutriture is, thus, vitally important to health across the life course. Zinc deficiency is also one of the most common forms of micronutrient malnutrition globally. A clearer estimate of the burden of health disparity attributable to zinc deficiency in adulthood and later life emerges when accounting for its contribution to global elevated fasting blood glucose and related noncommunicable diseases (NCDs). Yet progress attenuating its prevalence has been limited due, in part, to the lack of sensitive and specific methods to assess human zinc status. This narrative review covers recent developments in our understanding of zinc's role in health, the impact of the changing climate and global context on zinc intake, novel functional biomarkers showing promise for monitoring population-level interventions, and solutions for improving population zinc intake. It aims to spur on implementation of evidence-based interventions for preventing and controlling zinc deficiency across the life course. Increasing zinc intake and combating global zinc deficiency requires context-specific strategies and a combination of complementary, evidence-based interventions, including supplementation, food fortification, and food and agricultural solutions such as biofortification, alongside efforts to improve zinc bioavailability. Enhancing dietary zinc content and bioavailability through zinc biofortification is an inclusive nutrition solution that can benefit the most vulnerable individuals and populations affected by inadequate diets to the greatest extent.

Methods of Assessment of Zinc Status in Humans: An Updated Review and Meta-analysis.

CONTEXT: The assessment of zinc status is difficult but essential for the identification of zinc deficiency and evaluation of interventions to improve zinc status. OBJECTIVE: The purpose of this systematic review (SR) and meta-analysis was to update the previously published SR of biomarkers of zinc status, conducted by the European Micronutrient Recommendations Aligned (EURRECA) network in 2009, to answer the question: Which putative measures (biomarkers) of zinc status appropriately reflect a change in zinc intake of at least 2 weeks? DATA SOURCES: A structured search strategy was used to identify articles published between January 2007 and September 2022 from MEDLINE (Ovid), Embase (Ovid), Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL). Relevant articles were identified using previously defined eligibility criteria. DATA EXTRACTION: Data were extracted and combined with data from the previous SR. DATA ANALYSIS: A random-effects model was used to calculate pooled mean differences using STATA (StataCorp). The risk of bias and the certainty of evidence for all outcomes were assessed. Additional data on 7 of the 32 previously reported biomarkers were identified, along with data on an additional 40 putative biomarkers from studies published since 2007. Pooled data analysis confirmed that, in healthy participants, both plasma/serum zinc concentration and urinary zinc excretion responded to changes in zinc intake (plasma/serum: mean effect [95% CI], controlled studies: 2.17 µmol/L [1.73, 2.61]; P < .005, I2 = 97.8; before-and-after studies: 2.87 µmol/L [2.45, 3.30]; P < .005, I2 = 98.1%; urine zinc: 0.39 mmol/mol creatinine [0.17, 0.62]; P < .005, I2 = 81.2; 3.09 µmol/day [0.16, 6.02]; P = .039, I2 = 94.3). CONCLUSION: The updated analyses support the conclusion that plasma/serum and urinary zinc respond to changes in zinc intake in studies of healthy participants. Several additional putative biomarkers were identified, but more studies are needed to assess the sensitivity and reliability. SYSTEMATIC REVIEW REGISTRATION: PROSPERO no. CRD42020219843.

EURRECA-Estimating zinc requirements for deriving dietary reference values.

Zinc was selected as a priority micronutrient for EURRECA, because there is significant heterogeneity in the Dietary Reference Values (DRVs) across Europe. In addition, the prevalence of inadequate zinc intakes was thought to be high among all population groups worldwide, and the public health concern is considerable. In accordance with the EURRECA consortium principles and protocols, a series of literature reviews were undertaken in order to develop best practice guidelines for assessing dietary zinc intake and zinc status. These were incorporated into subsequent literature search strategies and protocols for studies investigating the relationships between zinc intake, status and health, as well as studies relating to the factorial approach (including bioavailability) for setting dietary recommendations. EMBASE (Ovid), Cochrane Library CENTRAL, and MEDLINE (Ovid) databases were searched for studies published up to February 2010 and collated into a series of Endnote databases that are available for the use of future DRV panels. Meta-analyses of data extracted from these publications were performed where possible in order to address specific questions relating to factors affecting dietary recommendations. This review has highlighted the need for more high quality studies to address gaps in current knowledge, in particular the continued search for a reliable biomarker of zinc status and the influence of genetic polymorphisms on individual dietary requirements. In addition, there is a need to further develop models of the effect of dietary inhibitors of zinc absorption and their impact on population dietary zinc requirements.

Effect of zinc intake on mental and motor development in infants: a meta-analysis.

A systematic review and meta-analysis of available randomized controlled trials (RCTs) was conducted to evaluate the effect of zinc (Zn) intake on mental and motor development in infants. Out of 5500 studies identified through electronic searches and reference lists, 5 RCTs were selected after applying the exclusion/inclusion criteria. The influence of Zn intake on mental and motor development was considered in the overall meta-analysis. Other variables were also taken into account as possible effect modifiers: doses of Zn intake, intervention duration, nutritional situation, and risk of bias. Indices of mental and motor development assessed were the Mental Development Index (MDI) and Psychomotor Development Index (PDI). Additionally we carried out a sensitivity analysis. The pooled ß was -0.01 (95 %CI -0.02, 0) for MDI and 0 (95 %CI -0.03, 0.02) for PDI, with a substantial heterogeneity in both analyses. When we performed a meta-regression, the effect of Zn supplementation on MDI changed depending on the dose of supplementation. Regarding PDI, there was a differential effect of Zn intake depending on intervention duration, dose of supplementation, nutritional situation, and risk of bias. Zn supplementation showed a negative, weak and significant effect on PDI score in those studies with a length of 4 to 20 weeks (ß= -0.05; CI 95 % -0.06 to -0.04). In conclusion, no association was found between Zn intake and mental and motor development in infants. Further standardized research is urgently needed to clarify the role of Zn supplementation upon infant mental and motor development, particularly in Europe.

Effect of zinc intake on serum/plasma zinc status in infants: a meta-analysis.

A systematic review and meta-analysis of available randomised controlled trials (RCTs) was conducted to evaluate the effect of zinc (Zn) intake on serum/plasma Zn status in infants. Out of 5500 studies identified through electronic searches and reference lists, 13 RCTs were selected after applying the exclusion/inclusion criteria. The influence of Zn intake on serum/plasma Zn concentration was considered in the overall meta-analysis. Other variables were also taken into account as possible effect modifiers: doses of Zn intake, intervention duration, nutritional status and risk of bias. The pooled ß of status was 0.09 [confidence interval (CI) 0.05 to 0.12]. However, a substantial heterogeneity was present in the analyses (I(2) = 98%; P = 0.00001). When we performed a meta-regression, the effect of Zn intake on serum/plasma Zn status changed depending on the duration of the intervention, the dose of supplementation and the nutritional situation (P ANCOVA = 0.054; <0.001 and <0.007, respectively). After stratifying the sample according to the effect modifiers, the results by duration of intervention showed a positive effect when Zn intake was provided during medium and long periods of time (4-20 weeks and >20 weeks). A positive effect was also seen when doses ranged from 8.1 to 12 mg day(-1). In all cases, the pooled ß showed high evidence of heterogeneity. Zn supplementation increases serum/plasma Zn status in infants, although high evidence of heterogeneity was found. Further standardised research is urgently needed to reach evidence-based conclusions to clarify the role of Zn supplementation upon infant serum/plasma Zn status, particularly in Europe.

Effects of a Nutrition Education Programme in Stage IV Cardiac Rehabilitation Patients: A 3-Arm Randomised Controlled Trial.

This trial examined the influence of two nutrition intervention programmes on health-related and nutritional intake indices pertinent to cardiovascular disease compared to usual care in stage IV cardiac rehabilitation patients. Sixty-six patients were recruited from the Heartbeat North-West cardiac rehabilitation centre in Preston (United Kingdom). Patients were randomly assigned to Usual care, Biggest loser or Nutrition education arms. Usual care undertook their usual two exercise classes per week without nutritional support, Biggest loser underwent weekly education sessions focussing on weight loss using the themes within the British Heart Foundation 'So You Want to Lose Weight for Good' guidelines, and Nutrition education followed the same themes as Biggest loser but in a more focussed manner informed by patient focus groups. In total, this was a 12-week trial in which patients spent 6 weeks engaged in their allocated intervention arm, after which all participants switched to Usual care. The primary outcome was systolic blood pressure, and secondary measures of anthropometric, blood biomarker, nutritional knowledge (via the Mediterranean Diet Assessment Tool) and nutritional intake indices were measured at baseline, 6 weeks, and 12 weeks (follow-up). Intention-to-treat analyses revealed no significant alterations in the primary outcome (Usual care: baseline = 130.45 mmHg, 6 weeks = 127.83 mmHg, and follow-up = 126.35 mmHg, Biggest loser: baseline = 133.50 mmHg, 6 weeks = 123.06 mmHg, and follow-up = 135.22 mmHg, or Nutrition education: baseline = 135.23 mmHg, 6 weeks = 129.20 mmHg, and follow-up = 126.26 mmHg) between arms. However, at 6 weeks, improvements in triglycerides were significantly greater in Usual care (baseline = 1.61 mmol/L and 6 weeks = 1.43 mmol/L) group compared to Nutrition education (baseline = 1.70 mmol/L and 6 weeks = 2.21 mmol/L). Improvements in nutrition knowledge were significantly greater in Nutrition education (baseline = 8.48, 6 weeks = 9.77, and follow-up = 10.07) compared to Usual care (baseline = 7.71, 6 weeks = 8.00, and follow-up = 8.00) and Biggest loser (baseline = 7.71, 6 weeks = 8.73, and follow-up = 8.36). At 6 weeks, the Biggest loser group (baseline = 4.75 g and 6 weeks = 3.83 g) exhibited significantly greater improvements in salt intake compared to Usual care (baseline = 4.87 g and 6 weeks = 4.28 g) and Nutrition education (baseline = 19.25 g and 6 weeks = 16.78 g) in saturated fatty acids compared to Usual care (baseline = 20.26 g and 6 weeks = 21.34 g). This trial shows the effectiveness of nutritional interventions for improving nutritional knowledge and dietary practices in stage IV cardiac rehabilitation, but the mechanisms and longer-term effects of increased triglyceride levels in the Nutrition education group requires further exploration.

School Feeding to Improve Cognitive Performance in Disadvantaged Children: A 3-Arm Parallel Controlled Trial in Northwest Pakistan.

Malnutrition is associated with reduced learning aptitude and growth during childhood. We examined the impact of providing two school lunch variants, a standard school meal (school feeding, n = 70), or the standard meal with additional micronutrients (school feeding + micronutrient powder (MNP), n = 70), in children attending two schools in northwest Pakistan. A third local government school, where no lunch was provided (no school feeding, n = 70), served as the control. The primary outcome, cognitive function, was assessed using the Raven's Coloured Progressive Matrices (RCPM) test, alongside haemoglobin, at three-time points: T1 (baseline, before the initiation of the school lunch programme), T2 and T3 (5 and 12 months, respectively, after the introduction of the school lunch). Data were analysed using linear mixed-effects models to contrast between trial groups, the changes from T1 to T2 and T3. Adjusted for T1 and other co-variates, improvements in the RCPM scores were significantly greater in the school feeding group at T2 (b = 1.61, (95% CI = 0.71-2.52), t = 3.52, p = 0.001) and T3 (b = 1.28, (95% CI = 0.22-2.35), t = 2.38, p = 0.019) compared with no school feeding. In addition, at T2 (b = 1.63, (95% CI = -0.10-3.37), t = 1.86, p = 0.065), there were no significant differences between school feeding + MNP and no school feeding groups. However, improvements in the RCPM scores were significantly greater in the school feeding + MNP group at T3 (b = 2.35, (95% CI = 0.51-4.20), t = 2.53, p = 0.013) compared with no school feeding. The findings indicate an improvement in cognitive performance in children who received a school meal with and without MNP, over a 12-month period. Currently there is no operational school feeding programme at the national or provincial level in Pakistan. Our findings, therefore, highlight the need for school feeding programmes to improve learning opportunities for children from underprivileged communities.

Toward revising dietary zinc recommendations for children aged 0 to 3 years: a systematic review and meta-analysis of zinc absorption, excretion, and requirements for growth.

CONTEXT: The Food and Agriculture Organization of the United Nations and the World Health Organization are updating their dietary zinc recommendations for children aged 0 to 3 years. OBJECTIVE: The aim of this review was to retrieve and synthesize evidence regarding zinc needs for growth as well as zinc losses, absorption, and bioavailability from the diet. DATA SOURCES: MEDLINE, Embase, and Cochrane Library databases were searched electronically from inception to August 2020. Studies assessing the above factors in healthy children aged 0 to 9 years were included, with no limits on study design or language. DATA EXTRACTION: Ninety-four studies reporting on zinc content in tissue (n = 27); zinc absorption (n = 47); factors affecting zinc bioavailability (n = 30); and endogenous zinc losses via urine, feces, or integument (n = 40) met the inclusion criteria. Four reviewers extracted data and two reviewers checked for accuracy. DATA ANALYSES: Studies were synthesized narratively, and meta-analyses of zinc losses and gains as well the subgroups of age, type of feeding, country's income, and molar ratio of phytate to zinc were conducted. Meta-analysis revealed an overall mean (95%CI) urinary and endogenous fecal zinc excretion of 17.48 µg/kg/d (11.80-23.15; I2 = 94%) and 0.07 mg/kg/d (0.06-0.08; I2 = 82%), respectively, with a mean fractional zinc absorption of 26.75% (23.69-29.81; I2 = 99%). Subgrouping by age revealed differences in mean values associated with the transition from milk-based diets to solid food during the first 3 years of life. CONCLUSION: This review synthesizes data that may be used to formulate zinc requirements in young children. Results should be interpreted with caution because of considerable heterogeneity in the evidence. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42020215236.

Farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan: a mixed methods study.

Background: Zinc biofortified wheat may be a sustainable strategy to increase zinc intake in areas where fortification and dietary diversification are not feasible or are limited by household purchasing power. This convergent mixed methods study aimed to explore the farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan. Methods: A telephone survey was conducted with farmers (n = 418) who were provided with Zincol-2016 biofortified wheat seed for the 2019-2020 growing season, as part of a wheat grain micronutrient mapping study across Punjab Province. The survey explored the farmers' experiences of growing Zincol-2016 and whether they opted to grow it again in the subsequent season. Semi-structured focus group discussions were undertaken in a separate group of farmers in Khyber Pakhtunkhwa (KP) province (n = 12) who grew Zincol-2016 for the BiZiFED2 RCT. Millers were also interviewed in KP, both those who had processed Zincol-2016 for the trial (n = 12) and those who had no experience of processing biofortified wheat (n = 12). Survey data were analyzed using descriptive statistics and transcripts of focus groups were analyzed using thematic analysis. Results: Nearly half of farmers who responded to the survey (47%) re-cultivated Zincol-2016 in the following season. The drivers for Zincol-2016 re-cultivation were seed availability (100%), grain yield and growth resistance (98%), quality of the flour from the previous harvest (97%) and nutritional benefit (94.5%). Discussions with farmers suggested that the main motivators for potential scale-up of biofortified wheat were the perceived quality of the grain, wheat, and flour. Millers saw it as an opportunity to expand their business. Farmers and millers valued the health benefits of the wheat. Challenges for scale-up include the need of additional support to produce it, unfamiliarity with the biofortification process, production costs, and external threats to the supply chain. Conclusion: Farmers and millers showed a strong implicit preference for Zincol-2016 over alternative varieties. Crop performance and product yield were the most cited motivators for growing Zincol-2016. Farmers and millers are willing to produce and process biofortified wheat if financial and educational support is provided.

Effectiveness of locally produced ready to use supplementary food on hemoglobin, anthropometrics, and plasma micronutrients concentrations of 6 to 23 months age children: a non-randomized community-based trial from Pakistan.

Background: Micronutrient deficiencies including vitamin A, vitamin D, and zinc are highly prevalent in children below 5 years of age in low and -middle-income countries. We aimed to evaluate the effectiveness of ready-to-use Lipid-based Nutrient Supplement-Medium Quantity (LNS-MQ) local name "Wawa-mum" on plasma micronutrient status, hemoglobin concentration and anthropometric measurements. Methods: A community-based non-randomized trial was conducted in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019. A total of 110 children aged 6 to 23 months old were recruited and allocated to the intervention and control arm of the study. A total of 57 children in the intervention arm received a daily ration of 50 g of Wawa-mum, for one year. To assess the impact of the intervention on primary outcome measures, i.e., serum vitamin A, D concentration, plasma zinc, and hemoglobin concentration. Blood samples were collected at baseline and after one year following the intervention. The vitamins concentration in serum were assessed using Enzyme-Linked Immunosorbent Assay (ELISA) and plasma zinc by atomic absorption spectrometry. The hemoglobin concentration was measured by an automated hematology analyzer. A 24-h dietary recall interview was used to assess the nutrient intake adequacy. Multivariate Linear regression models were used to analyze the outcomes while controlling for potential confounders. Results: In the intervention arm, children had on average 6.2 µg/dL (95% CI 3.0-9.3, value of p<0.001) increase in the serum vitamin A concentration, 8.1 ng/mL (95% CI 1.3-14.9, value of p 0.02) increase in serum vitamin D concentration and 49.0 µg/dL (95% CI 33.5-64.5, value of p<0.001) increase in the plasma zinc concentration, and 2.7 g/dL (95% CI 2.0-3.3, value of p<0.001) increase in hemoglobin concentration while adjusted for covariates. An addition, length-for-age z-score (LAZ), weight-for-length z-score (WLZ), weight-for-age z-score (WAZ), and prevalence of undernutrition including stunting, wasting, and underweight were calculated as a secondary outcome to investigate the impact of micronutrients on growth parameters, that has been improved significantly after receiving the Wawa-mum. Conclusion: Wawa-mum (LNS-MQ) is an effective intervention to improve the micronutrient status, hemoglobin concentration, and growth parameters in 6 to 23 months children, which can be scaled up in the existing health system to address the alarming rates of under nutrition in Pakistan and other developing countries. Clinical trial registration: https://doi.org/10.1186/ISRCTN94319790, ISRCTN94319790.

Single hair analysis by X-ray fluorescence spectrometry detects small changes in dietary zinc intake: A nested randomized controlled trial.

The aim of this study was to determine whether X-ray fluorescence spectrometry (XRF) could be used to detect changes in hair zinc concentration in response to a modest daily increase in zinc from the consumption of zinc biofortified wheat flour. This study was conducted as part of an effectiveness trial (BiZiFED2) exploring the potential for zinc biofortified wheat to alleviate zinc deficiency in adolescent girls aged 10-16 years in Pakistan (trial registration ID ISRCTN17107812). A randomized controlled design was used. Participants received either control flour or zinc biofortified flour for 6 months. Consumption of biofortified flour resulted in an average daily increase in dietary zinc intake of 1.5 mg per day above that of the control flour. At baseline and at the end of the intervention, individual hair samples (control: n = 59, intervention: n = 64) were analyzed for zinc and sulfur content by XRF. Data were analyzed using linear mixed effects models to contrast between trial groups the changes from baseline to end point and also to compare baseline and end point values within each trial group. Increases from baseline to endpoint in both sulfur and zinc were significantly greater in the intervention group compared to control (sulfur counts. CONTROL: baseline = 119.87 ± 20.33 and endpoint = 121.58 ± 23.58/intervention: baseline = 122.67 ± 24.19 and endpoint = 131.60 ± 21.34); (Zinc counts. CONTROL: baseline = 50.88 ± 14.33 and endpoint = 54.82 ± 14.61/intervention: baseline = 49.61 ± 10.77 and endpoint = 58.79 ± 12.20). For these parameters, there were also significant increases from baseline to endpoint in the intervention group but not in control. Furthermore, for Zn:S count ratio there were no differences in terms of the magnitude of the change from baseline to endpoint in the control group, although significant increases from baseline to endpoint were evident in the intervention group (Zn:S count ratio. CONTROL: baseline = 0.42 ± 0.10 and endpoint = 0.45 ± 0.08/intervention: baseline = 0.41 ± 0.08 and endpoint = 0.45 ± 0.08). A modest increase in dietary zinc over 6 months resulted in a detectable increase in both sulfur and zinc counts in individual hairs measured using XRF. This offers a sensitive, non-invasive method to monitor changes within subjects in response to dietary zinc interventions.