Morbidity and nutrition status of rural drug-naïve Kenyan women living with HIV.

This paper describes morbidity in a group of HIV-positive drug-naïve rural women in western Kenya. A total of 226 drug-naïve HIV-positive women were evaluated for baseline morbidity, immune function, and anthropometry before a food-based nutrition intervention. Kenyan nurses visited women in their homes and conducted semi-structured interviews regarding symptoms and physical signs experienced at the time of the visit and during the previous week and physical inspection. Blood and urine samples were examined for determination of immune function (CD4, CD8, and total lymphocyte counts), anaemia, malaria, and pregnancy status. Intradermal skin testing with tuberculin (PPD), candida, and tetanus toxoid antigens was also performed to evaluate cell-mediated immunity. Anthropometry was measured, and body mass index (BMI) was calculated. Seventy-six per cent of the women reported being sick on the day of the interview or within the previous week. Illnesses considered serious were reported by 13.7% of women. The most frequent morbidity episodes reported were upper respiratory tract infections (13.3%), suspected malaria (5.85%), skeletal pain (4.87%), and stomach pain (4.42%). The most common morbidity signs on physical inspection were respiratory symptoms, most commonly rhinorrhea and coughing. Confirmed malaria and severe diarrhea were significantly associated with a higher BMI.

Determining minimum food intake amounts for diet diversity scores to maximize associations with nutrient adequacy: an analysis of schoolchildren's diets in rural Kenya.

OBJECTIVE: To explore multiple methods of calculating diet diversity scores (DDS) to maximize associations with predicted dietary micronutrient adequacy among schoolchildren in rural Kenya. DESIGN: Up to three 24 h recall interviews were administered for each child for a total of 1544 d of intake from all schoolchildren. Daily amounts of food consumed were assigned to one of eight food groups. Five DDS were developed based on various minimum intake amounts from each food group: (i) 1 g; (ii) 15 g; (iii) a variable minimum based on the content of a target nutrient for each group; (iv) the median intake level for each group; and (v) the 90th percentile intake level for each group. A diet was assigned 1 point towards the daily DDS if the food group intake was above the defined minimum level. Five scores were calculated for each child, and bivariate longitudinal random-effects models were used to assess the correlation between each DDS and the mean probability of adequacy for fourteen nutrients. SETTING: Embu District, Kenya. SUBJECTS: Schoolchildren (n 529), mean age 7·00 (sd 1·41) years. RESULTS: Only DDS based on a 15 g minimum and DDS based on nutrient content were significantly associated with mean probability of adequacy after adjusting for energy intake (0·21 and 0·41, respectively). CONCLUSIONS: A DDS using minimum intakes based on nutrients contributed by a food group best predicted nutrient adequacy in this population. These analyses contribute to the continued search for simpler and more valid dietary quality indicators among low-income nations.

Animal source foods have a positive impact on the primary school test scores of Kenyan schoolchildren in a cluster-randomised, controlled feeding intervention trial.

Micronutrient deficiencies and suboptimal energy intake are widespread in rural Kenya, with detrimental effects on child growth and development. Sporadic school feeding programmes rarely include animal source foods (ASF). In the present study, a cluster-randomised feeding trial was undertaken to determine the impact of snacks containing ASF on district-wide, end-term standardised school test scores and nutrient intake. A total of twelve primary schools were randomly assigned to one of three isoenergetic feeding groups (a local plant-based stew (githeri) with meat, githeri plus whole milk or githeri with added oil) or a control group receiving no intervention feeding. After the initial term that served as baseline, children were fed at school for five consecutive terms over two school years from 1999 to 2001. Longitudinal analysis was used controlling for average energy intake, school attendance, and baseline socio-economic status, age, sex and maternal literacy. Children in the Meat group showed significantly greater improvements in test scores than those in all the other groups, and the Milk group showed significantly greater improvements in test scores than the Plain Githeri (githeri+oil) and Control groups. Compared with the Control group, the Meat group showed significant improvements in test scores in Arithmetic, English, Kiembu, Kiswahili and Geography. The Milk group showed significant improvements compared with the Control group in test scores in English, Kiswahili, Geography and Science. Folate, Fe, available Fe, energy per body weight, vitamin B12, Zn and riboflavin intake were significant contributors to the change in test scores. The greater improvements in test scores of children receiving ASF indicate improved academic performance, which can result in greater academic achievement.

High-nutrition biscuits to increase animal protein in diets of HIV-infected Kenyan women and their children: a study in progress.

BACKGROUND: Preliminary evidence suggests that improved nutrition early in HIV infection may delay progression to AIDS and delay the initiation or improve the effectiveness of antiretroviral drug therapy. There are few studies that evaluate food-based interventions in drug-naïve, HIV-infected women and their children. Meat provides several nutrients identified as important in maintaining immune function and lean body mass. OBJECTIVE: To design supplemental meat and soybean biscuits for use in a randomized trial examining the effect of meat in the diet of drug-naïve, HIV-infected rural Kenyan women on changes in weight, lean body mass, morbidity, nutritional status, and activities of daily living of the women and growth and development of their children. METHODS: We designed three supplemental biscuits: one with added dried beef another with added soybean flour, and a wheat biscuit to serve as a control biscuit to be used in a randomized feeding intervention in drug-naïve, HIV-infected rural Kenyan women and their children. The nutritional contents of the different types of biscuit were examined and compared. RESULTS: The three biscuits were isocaloric. Meat biscuits provided more lysine, vitamin B12, and bioavailable zinc. Soybean biscuits provided more total and absorbable iron; however, higher fiber and phytate contents may inhibit nutrient absorption. Data analysis for clinical outcomes of the trial is ongoing. CONCLUSIONS: The "biscuit model" is useful for nutrition supplementation studies because it can be provided in a blinded and randomized fashion, safely and privately in a home under directly observed consumption by a highly stigmatized population. It is well received by adults and children, and the biscuits can be produced locally with available, simple, affordable technology.

Low vitamin B12 intake during pregnancy and lactation and low breastmilk vitamin 12 content in rural Kenyan women consuming predominantly maize diets.

BACKGROUND: Vitamin B12 deficiency during pregnancy and lactation may negatively affect fetal growth, brain development, pregnancy outcome, and breastmilk vitamin B12 content. OBJECTIVE: To examine associations between pregnant and lactating women's vitamin B12 intake and pregnancy outcomes, breastmilk vitamin B12 concentration, and growth and development of breastfed infants from birth to 6 months. METHODS: One hundred thirty-eight Kenyan women were followed during pregnancy, with 98 followed through 6 months of lactation and providing 294 randomly collected breastmilk samples. Maternal hematologic analyses were performed for erythrocyte morphology, erythrocyte size, and serum vitamin B12 concentration. Women's and infants'food intake was assessed. Breastmilk vitamin B12 was measured by a competitive binding isotope dilution technique. Infant anthropometric data and the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) were assessed within 3 days after birth. The Infant Bayley Motor Scale was assessed at 6 months. Statistical analyses included simple regression and correlation analyses in relation to vitamin B12 status and gestational age. RESULTS: Intrauterine growth restriction and stillbirths were correlated with maternal macrocytic anemia and hypersegmented polymorphonuclear nuclei. Postpartum maternal vitamin B12 intake influenced breastmilk vitamin B12 levels 1 to 6 months postpartum. No associations were found between vitamin B12 intake during pregnancy or vitamin B12 levels in breastmilk and infant length, weight, or head circumference at birth or 6 months. Vitamin B12 intake during pregnancy was correlated with improved scores on infants' BNBAS reflex subscale (R = -0.19, p = .05) with adjustment for gestational age. Bayley Motor Scale results at 6 months were not significantly associated with breastmilk or supplemental feeding vitamin B12 content. CONCLUSIONS: Vitamin B12 deficiency may adversely affect pregnancy outcome, infant reflexes at birth, and breastmilk vitamin B12 content.

School snacks decrease morbidity in Kenyan schoolchildren: a cluster randomized, controlled feeding intervention trial.

OBJECTIVE: To examine the effects of three different school snacks on morbidity outcomes. DESIGN: Twelve schools were randomized to either one of three feeding groups or a Control group. There were three schools per group in this cluster randomized trial. Children in feeding group schools received school snacks of a local plant-based dish, githeri, with meat, milk or extra oil added. The oil used was later found to be fortified with retinol. Physical status, food intake and morbidity outcomes were assessed longitudinally over two years. SETTING: Rural Embu District, Kenya, an area with high prevalence of vitamin A deficiency. SUBJECTS: Standard 1 schoolchildren (n 902; analytic sample) enrolled in two cohorts from the same schools one year apart. RESULTS: The Meat and Plain Githeri (i.e. githeri+oil) groups showed the greatest declines in the probability of a morbidity outcome (PMO) for total and severe illnesses, malaria, poor appetite, reduced activity, fever and chills. The Meat group showed significantly greater declines in PMO for gastroenteritis (mainly diarrhoea) and typhoid compared with the Control group, for jaundice compared with the Plain Githeri group, and for skin infection compared with the Milk group. The Milk group showed the greatest decline in PMO for upper respiratory infection. For nearly all morbidity outcomes the Control group had the highest PMO and the least decline over time. CONCLUSIONS: The intervention study showed beneficial effects of both animal source foods and of vitamin A-fortified oil on morbidity status.

Meat supplementation increases arm muscle area in Kenyan schoolchildren.

The present study examines the effect of animal-source-food (ASF) intake on arm muscle area growth as part of a larger study examining causal links between ASF intake, growth rate, physical activity, cognitive function and micronutrient status in Kenyan schoolchildren. This randomised, controlled feeding intervention study was designed with three isoenergetic feeding interventions of meat, milk, and plain traditional vegetable stew (githeri), and a control group receiving no snack. A total of twelve elementary schools were randomly assigned to interventions, with three schools per group, and two cohorts of 518 and 392 schoolchildren were enrolled 1 year apart. Children in each cohort were given feedings at school and studied for three school terms per year over 2 years, a total of 9 months per year: cohort I from 1998 to 2000 and cohort II from 1999 to 2001. Food intake was assessed by 24 h recall every 1-2 months and biochemical analysis for micronutrient status conducted annually (in cohort I only). Anthropometric measurements included height, weight, triceps skinfold (TSF) and mid-upper-arm circumference (MUAC). Mid-upper-arm muscle area (MAMA) and mid-upper-arm fat area (MAFA) were calculated. The two cohorts were combined for analyses. The meat group showed the steepest rates of gain in MUAC and MAMA over time, and the milk group showed the next largest significant MUAC and MAMA gain compared with the plain githeri and control groups (P< 0.05). The meat group showed the least increase in TSF and MAFA of all groups. These findings have implications for increasing micronutrient intake and lean body mass in primary schoolchildren consuming vegetarian diets.

A school-based supplementary food programme in rural Kenya did not reduce children's intake at home.

OBJECTIVE: To examine changes in energy intake along with markers of dietary quality (animal-source energy and protein intakes) among household members in the presence of supplementary school feeding in rural Kenya. DESIGN: A 2-year, longitudinal, randomized controlled feeding intervention study. SETTING: Kyeni South Division, Embu District, Kenya. SUBJECTS: A total of 182 schoolchildren and selected household members. RESULTS: There was no evidence that schoolchildren who received supplementary snacks at school experienced reduced intakes at home or that intakes by other family members were increased at the expense of the schoolchild's intake. CONCLUSIONS: This analysis highlights a number of factors useful in planning for supplementary feeding interventions in rural Kenya and similar communities.

Meat and milk intakes and toddler growth: a comparison feeding intervention of animal-source foods in rural Kenya.

OBJECTIVE: To examine the effects of animal-source foods on toddler growth. DESIGN: A 5-month comparison feeding intervention study with one of three millet-based porridges randomized to eighteen feeding stations serving 303 children aged 11-40 months. Feeding stations served plain millet porridge (Plain group), porridge with milk (Milk group) or porridge with beef (Meat group). Anthropometry, morbidity and food intake were measured at baseline and regular intervals. Longitudinal mixed models were used to analyse growth. SETTING: Embu, Kenya. SUBJECTS: Two hundred and seventy-four children were included in final analyses. RESULTS: Linear growth was significantly greater for the Milk group than the Meat group (P = 0·0025). Slope of growth of mid-arm muscle area of the Plain group was significantly greater than in the Meat group (P = 0·0046), while the Milk group's mid-upper arm circumference growth rate was significantly greater than the Meat group's (P = 0·0418). The Milk and Plain groups' measures did not differ. CONCLUSIONS: Milk and meat porridges did not have a significantly greater effect on growth than plain porridge in this undernourished population. Linear growth was influenced by more than energy intakes, as the Plain group's total body weight-adjusted energy intakes were significantly greater than the Meat group's, although linear growth did not differ. Energy intakes may be more important for growth in arm muscle. The diverse age distribution in the study makes interpretation difficult. A longer study period, larger sample size and more focused age group would improve clarity of the results.

The need for collaboration among government agencies to reduce mosquito production in mandated stormwater treatment structures.

Efforts to improve water quality increasingly rely on structural stormwater best management practices (BMPs) to remove pollutants from urban runoff. These structures can unintentionally produce mosquitoes and may play a role in the spread of mosquito-borne diseases. A questionnaire was distributed to over 300 stormwater and mosquito control agencies in the United States to assess the prevalence of BMPs and associated mosquito production, identify current measures to control mosquitoes within BMPs, and elucidate the extent of collaboration between these agencies. Responses suggest that agencies often lack basic information relevant to minimizing mosquitoes in BMPs, such as the number of structures within an agency's jurisdiction and the frequency of their maintenance, and that greater interagency collaboration could improve control efforts. Approximately 40% of agencies reported regular collaboration to minimize mosquito production in BMPs; however, barriers to such collaborative work included confusion over roles and responsibilities and a lack of interest. The rapid increase of BMPs in urban environments resulting from increasingly stringent water-quality regulations provides justification for increased collaboration between stormwater and mosquito control sectors of government to aid and strengthen public health efforts.

Dietary micronutrients are associated with higher cognitive function gains among primary school children in rural Kenya.

With the exception of iodine and Fe, there is still very limited information on the effect of micronutrients on cognitive function, especially among school-age children. The present analysis evaluates the relationship between dietary Fe, Zn and B vitamins (B12, B6, folate and riboflavin) and gains in cognitive test scores among school children in rural Kenya. Data for the present study were obtained from The Child Nutrition Kenya Project, a 2-year longitudinal, randomised controlled feeding intervention study using animal source foods. Dietary nutrient values were based on monthly and bimonthly 24 h recall data collected during the study period. In longitudinal regression analyses, available Fe, available Zn, vitamin B12 and riboflavin showed significant relationships with improved cognitive test scores, after controlling for confounders such as energy intake, school, socio-economic status and morbidity. Available Fe intake was associated with significantly higher gains in Raven's Coloured Progressive Matrices test scores over time. Available Zn intake was associated with significantly higher gains in digit span-total test scores over time, while vitamin B12 and riboflavin intakes were each associated with significantly higher gains in digit span-forward test scores over time. This analysis demonstrates the influence of improved dietary micronutrient status on school children's cognitive function.

A comparison of weighed and recalled intakes for schoolchildren and mothers in rural Kenya.

OBJECTIVE: To evaluate the relative validity of recalled intake among schoolchildren and mothers in rural Kenya. DESIGN: Cross-sectional study. Mothers' recall of both the schoolchild's intake and her own intake on the previous day were compared with intakes that were weighed by an interviewer in the home. SETTING: Karurumo location of Embu District in Kenya. SUBJECTS: A total of forty-two sets of grade 1 students and their mothers. RESULTS: Between 08.00 and 17.00 hours, when foods were both weighed and recalled, approximately 70 % of weighed food items were recalled the next day. Under-reporting of food amounts was seen across most food categories for the recall, with added sugars, sweets and fats being most affected. The recall underestimated energy intakes by approximately 6-9 % during this period. Correlation coefficients between nutrient intakes ranged from 0.43 to 0.65, while weighted kappa values ranged from 0.22 to 0.50. Higher levels of agreement were noted for nutrient densities, with correlation coefficients between 0.46 and 0.82 and weighted kappa values between 0.30 and 0.73. CONCLUSIONS: Although the recall method provides an acceptable alternative to the more labour-intensive and expensive food-weighing method, there is need to further improve its performance in this population through more accurate recall of single foods, especially fruits, as well as added sugars, fats, dairy products and meats, which are often added in small amounts to mixed dishes.

Out-of-home food intake is often omitted from mothers' recalls of school children's intake in rural Kenya.

Children often consume foods from outside the home (OH foods), which can decrease the accuracy of dietary recalls collected from the parents. The objectives of this study were to describe the types and composition of OH foods consumed by rural school-aged Kenyan children, to assess their contribution to the daily intake of the child, and to evaluate the ability of the mother to estimate intake of OH foods. To capture any seasonal differences, the study was conducted twice, once during a food shortage season and again during the subsequent harvest season. School children were asked to recall the types and amounts of OH foods consumed on the previous day. Mothers were asked to report on the types and amounts of all foods consumed by their children during the day of interest. OH foods contributed 13 and 19% of daily energy intake in the food shortage and harvest seasons, respectively, but mothers missed 77 and 41% of the OH energy intake. OH foods were most likely to be fruits (guavas, mangoes, and wild fruit) and starchy foods (bread and fried wheat dough). Nutrients most likely to be under-reported on the mothers' recalls were vitamin C (59 and 26% was missed in the food shortage and harvest seasons, respectively) and vitamin A (approximately 22% was missed in both seasons). To ensure that all food intake is recalled, it is important that school children be included in dietary assessment interviews about their own intakes.

Designing snacks to address micronutrient deficiencies in rural Kenyan schoolchildren.

Three snacks were designed to improve nutrient intakes among school-age children living in rural Kenya. Snacks containing animal-source foods (milk and meat) provided more nutrients than an equicaloric vegetarian snack. The vegetarian snack provided extra vitamin A (primarily from fortified cooking fat; the milk snack was rich in calcium, vitamin A, and vitamin B-12; and the meat snack supplied vitamin B-12, iron, and zinc. When changes in intakes from baseline to the feeding period were compared across the 4 groups, total energy intake increased the most for children in the meat group and the least for children in the control group. Differences in energy intakes across the 3 feeding groups were primarily caused by decreases in home intake for the vegetarian and milk snack groups. It is important to evaluate the change in home intakes as well as intakes from the foods provided by the study when evaluating the effect of feeding programs on nutrient adequacy.

Meat supplementation improves growth, cognitive, and behavioral outcomes in Kenyan children.

A randomized, controlled school feeding study was conducted in rural Embu District, Kenya to test for a causal link between animal-source food intake and changes in micronutrient nutrition and growth, cognitive, and behavioral outcomes. Twelve primary schools were randomly assigned to 1 of 4 groups. Children in Standard I classes received the local plant-based dish githeri as a midmorning school snack supplemented with meat, milk, or fat added to equalize energy content in all feedings. The Control children received no feedings but participated in data collection. Main outcome measures assessed at baseline and longitudinally were 24-h food intake recall, anthropometry, cognitive function, physical activity, and behaviors during school free play. For cognitive function, the Meat group showed the steepest rate of increase on Raven's Progressive Matrices scores and in zone-wide school end-term total and arithmetic test scores. The Plain githeri and Meat groups performed better over time than the Milk and Control groups (P < 0.02-0.03) on arithmetic tests. The Meat group showed the greatest increase in percentage time in high levels of physical activity and in initiative and leadership behaviors compared with all other groups. For growth, in the Milk group only younger and stunted children showed a greater rate of gain in height. The Meat group showed near doubling of upper midarm muscle area, and the Milk group a smaller degree of increase. This is the first randomized, controlled feeding study to examine the effect of meat- vs. milk- vs. plant-based snacks on functional outcomes in children.

Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods.

The high prevalence of vitamin B-12 deficiency in many regions of the world is becoming recognized as a widespread public health problem, but it is not known to what extent this deficiency results from a low intake of the vitamin or from its malabsorption from food. In rural Kenya, where a previous study identified a high prevalence of inadequate vitamin B-12 intakes, this study examined whether plasma vitamin B-12 concentrations were associated with dietary sources of the vitamin at baseline and could be increased by supplementation with animal source foods (ASF). The 4 experimental groups in 503 school children were: 1) control (no food provided); 2) githeri (a maize and bean staple with added oil); 3) githeri + meat (githeri + minced beef); or 4) githeri + milk (githeri + milk). Feedings were isocaloric. Dietary data were collected at baseline, and biochemical data at baseline and after 1 and 2 y of feeding. Baseline plasma vitamin B-12 concentration was 193.6 +/- 105.3 pmol/L and correlated with % energy from ASF (r = 0.308, P < 0.001). The odds ratio for low plasma vitamin B-12 (<148 pmol/L), which occurred in 40% of children, was 6.28 [95% CI: 3.07-12.82] for the lowest vs. highest ASF intake tertile (P < 0.001). Feeding ASF (meat or milk) greatly reduced the prevalence of low plasma vitamin B-12 (P < 0.001). The high prevalence of low plasma vitamin B-12 concentrations in these children is predicted by a low intake of ASF, and supplemental ASF improves vitamin B-12 status.

The potential of increased meat intake to improve iron nutrition in rural Kenyan schoolchildren.

Schoolchildren in developing countries often have inadequate intakes of iron, due primarily to poor bioavailability. Increasing meat in the diet could improve both the amount of iron consumed and its availability. The effect of increases in intakes of meat and ascorbic acid on absorbed iron was investigated by theoretically modifying the habitual diet of rural Kenyan schoolchildren. The projected changes in the amount of absorbed iron and prevalence of inadequate iron intakes were calculated for 78 children (6-9 years of age). The prevalence of inadequate iron intakes decreased from 77% to 54% through the theoretical addition of 50 g beef or 100 mg ascorbic acid and to 23% through the addition of both to dinner each day. To reduce the prevalence of inadequate iron intake to 5%, the addition of 100 g meat plus 150 mg ascorbic acid would be necessary. The combined addition of meat and ascorbic acid to a meal has the potential to reduce the projected prevalence of inadequate iron intakes among these schoolchildren.

Intake of micronutrients high in animal-source foods is associated with better growth in rural Kenyan school children.

Observational studies have shown that children in developing countries consuming diets containing high amounts of bioavailable nutrients, such as those found in animal-source foods, grow better. The present study investigated which specific nutrients from the diet of Kenyan school children predicted their growth. The children (n 544, median age 7 years) participated in a 2-year long food supplementation study with animal-source foods. Height gain during the intervention period was positively predicted by average daily intakes of energy from animal-source foods, haem Fe, preformed vitamin A, Ca and vitamin B12. Weight gain was positively predicted by average daily intakes of energy from animal-source foods, haem Fe, preformed vitamin A, Ca and vitamin B12. Gain in mid-upper-arm muscle area was positively predicted by average daily intakes of energy from animal-source foods and vitamin B12. Gain in mid-upper-arm fat area was positively predicted by average daily intakes of energy from animal-source foods. Gain in subscapular skinfold thickness was not predicted by any of the nutrient intakes. Negative predictors of growth were total energy and nutrients that are contained in high amounts in plant foods. The study shows that growth was positively predicted by energy and nutrients that are provided in high amounts and in a bioavailable form in meat and milk, and their inclusion into the diets of children in developing countries should be part of all food-based programmes in order to improve micronutrient status and growth.