Modelling the potential cost-effectiveness of food-based programs to reduce malnutrition.

Poor quality diets contribute to malnutrition globally, but evidence is weak on the cost-effectiveness of food-based interventions that shift diets. This study assessed 11 candidate interventions developed through Delphi techniques to improve diets in India, Nigeria, and Ethiopia. A Markov simulation model incorporated time, individual-level, nutrition, and policy parameters to estimate health impacts and cost-effectiveness for reducing stunting, anaemia, diarrhea, and mortality in preschool children. At an assumed 80% coverage, interventions considered would potentially save between 0·16 and 3·20 years of life per child. The average cost-effectiveness ratio ranged from US$9 to US$2000 per life year saved. This approach, linking expert knowledge, known costs, and modelling, offers potential for estimating cost-effective investments for better informed policy choice where empirical evidence is limited.

Global Dietary Database 2017: data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide.

BACKGROUND: We aimed to systematically identify, standardise and disseminate individual-level dietary intake surveys from up to 207 countries for 54 foods, beverages and nutrients, including subnational intakes by age, sex, education and urban/rural residence, from 1980 to 2015. METHODS: Between 2008-2011 and 2014-2020, the Global Dietary Database (GDD) project systematically searched for surveys assessing individual-level intake worldwide. We prioritised nationally or subnationally representative surveys using 24-hour recalls, Food-Frequency Questionnaires or short standardised questionnaires. Data were retrieved from websites or corresponding members as individual-level food group microdata or aggregate stratum-level data. Standardisation included quality assessment; data cleaning; categorising of foods and nutrients and their units; aggregation by demographic strata and energy adjustment. RESULTS: We standardised and incorporated 1220 surveys into the final GDD 2017 database, together represented 188 countries and 99.0% of the world's population in 2015. 72.1% were nationally, 17.0% subnationally, and 10.9% community-level representative. 41.2% used Food-Frequency Questionnaires; 23.4%, 24-hour recalls; 15.8%, Demographic Health Survey questionnaires; 13.1%, biomarkers and 6.4%, household surveys. 73.9% of surveys included data on children; 52.2%, by urban and rural residence; and 30.2%, by education. Most surveys were in high-income countries, followed by sub-Saharan Africa and Asia. Most commonly ascertained foods were fruits (N=803 surveys), non-starchy vegetables (N=787) and sugar-sweetened beverages (N=440); and nutrients, sodium (N=343), energy (N=256), calcium (N=224) and fibre (N=200). Least available data were on iodine, vitamin A, plant protein, selenium, added sugar and animal protein. CONCLUSIONS: This systematic search, retrieval and standardised effort provides the most comprehensive empirical evidence on dietary intakes across and within countries worldwide.

Effects of animal protein supplementation of mothers, preterm infants, and term infants on growth outcomes in childhood: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Child stunting is a major public health problem, afflicting 155 million people worldwide. Lack of animal-source protein has been identified as a risk, but effects of animal protein supplementation are not well established. OBJECTIVE: The aim of this study was to investigate effects of animal protein supplementation in mothers, preterm infants, and term infants/children on birth and growth outcomes. METHODS: PubMed, EMBASE, Cochrane library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature were searched for randomized controlled trials of animal protein supplementation in mothers or infants and children (≤age 5 y), evaluating measures of anthropometry (≤age 18 y). Main outcomes included birth weight, low birth weight, small for gestational age at birth; height, height-for-age, weight, weight-for-age, weight-for-length, stunting, and wasting ≤18 y of age. Data were extracted independently in duplicate, and findings pooled using inverse variance meta-analysis. Heterogeneity was explored using I2, stratified analysis, and meta-regression, and publication bias by funnel plots, Egger's test, and fill/trim methods. RESULTS: Of 6808 unique abstracts and 357 full-text articles, 62 trials were included. The 62 trials comprised over 30,000 participants across 5 continents, including formula-based supplementation in infants and food-based supplementation in pregnancy and childhood. Maternal supplementation increased birth weight by 0.06 kg, and both formula and food-based supplementation in term infants/young children increased weight by ≤0.14 kg. Neither formula nor food-based supplementation for term infants/young children increased height, whereas the height-for-age z-score was increased in the food-based (+0.06 z-score) but not formula-based (-0.11 z-score) trials reporting this outcome. In term infants, the weight-for-length z-score was increased in trials of formula (+0.24 z-score) and food supplementation (+0.06 z-score), whereas food supplementation was also associated with reduced odds of stunting (-13%). CONCLUSIONS: Supplementation of protein from animal-source foods generally increased weight and weight-for-length in children, but with more limited effects on other growth outcomes such as attained height.

Analyzing candidemia guideline adherence identifies opportunities for antifungal stewardship.

Candidemia epidemiology varies significantly by region; thus, local data are essential for evidence-based decision-making in prophylaxis and treatment. Current management strategies are derived from large randomized controlled trials mostly executed in large high-volume tertiary care centers. Results may not be entirely transferable to smaller hospitals. This study investigates epidemiology, diagnosis, and treatment standards in six hospitals in the Cologne metropolitan area (number of inhabitants approx. one million). We assessed adherence to the current guideline of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the Infectious Diseases Society of America (IDSA) using the EQUAL Candida Score of the European Confederation of Medical Mycology (ECMM). Data were documented by trained medical students as part of an integrated research and teaching concept at the University of Cologne. Between January 2014 and June 2017, 77 patients had candidemia, corresponding to an incidence of 0.2 cases/1000 admissions. While 55 patients were enrolled, 22 patients were excluded due to incompletely retrievable health records. Fluconazole monotherapy was the preferred first-line treatment in cases with Candida albicans infection (21/29). A central vascular catheter was present in 40 patients and was removed in 17 (43%) during treatment. Overall mortality at 30 days was 44%. Patients reached a mean EQUAL Candida Score of 9.9 (range 8-14), which was well below the maximum score of 22 for perfect guideline adherence. In summary, management of candidemia differed from current European recommendations. It remains unclear to what extent enhanced adherence would improve patient outcome. Larger prospective studies need to answer that question.

Effect of Zinc Supplementation on Growth Outcomes in Children under 5 Years of Age.

(1) Background: The effects of zinc supplementation on child growth, and prior reviews of these studies, have shown mixed results. We aim to systematically review and meta-analyze randomized controlled trials evaluating effects of preventive zinc supplementation for 3 months or longer during pregnancy or in children up to age 5 years on pregnancy outcomes and child growth; (2) Methods: We searched PubMed, EMBASE, Cochrane Library, Web of Science, and trial registries for eligible trials up to October 10, 2017. Inclusion selection and data extractions were performed independently and in duplicate. Study quality was evaluated by the Cochrane Risk of Bias tool. Findings were pooled using random effects meta-analysis, with heterogeneity assessed by I² and τ² statistic, stratified analyses, and meta-regression, and publication bias by Egger's and Begg's tests; (3) Results: Seventy-eight trials with 34,352 unique participants were identified, including 24 during pregnancy and 54 in infancy/childhood. Maternal zinc supplementation did not significantly increase birth weight (weighted mean difference (WMD) = 0.08 kg, 95%CI: -0.05, 0.22) or decrease the risk of low birth weight (RR = 0.76, 95%CI: 0.52-1.11). Zinc supplementation after birth increased height (WMD = 0.23 cm, 95%CI: 0.09-0.38), weight (WMD = 0.14 kg, 95%CI: 0.07-0.21), and weight-for-age Z-score (WMD = 0.04, 95%CI: 0.001-0.087), but not height-for-age Z-score (WMD = 0.02, 95%CI: -0.01-0.06) or weight-for-height Z score (WMD = 0.02, 95%CI: -0.03-0.06). Child age at zinc supplementation appeared to modify the effects on height (P-interaction = 0.002) and HAZ (P-interaction = 0.06), with larger effects of supplementation starting at age ≥2 years (WMD for height = 1.37 cm, 95%CI: 0.50-2.25; WMD for HAZ = 0.12, 95%CI: 0.05-0.19). No significant effects of supplementation were found on the risk of stunting, underweight or wasting; (4) Conclusion: Although the possibility of publication bias and small study effect could not be excluded, the current meta-analysis indicates that zinc supplementation in infants and early childhood, but not pregnancy, increases specific growth outcomes, with evidence for a potentially stronger effect after 2 years of age. These findings inform recommendation and policy development for zinc supplementation to improve growth among young children.

n-3 Fatty Acid Supplementation in Mothers, Preterm Infants, and Term Infants and Childhood Psychomotor and Visual Development: A Systematic Review and Meta-Analysis.

Background: Epidemiologic studies link maternal seafood and n-3 (ω-3) polyunsaturated fatty acid (PUFA) consumption with improved childhood cognitive development; trials show mixed results. Objective: We investigated effects of n-3 PUFA supplementation on child cognitive and visual outcomes. Methods: We systematically reviewed and meta-analyzed randomized controlled trials of n-3 PUFA supplementation in mothers or infants (age ≤2 y) and evaluated standardized measures of cognitive or visual development up to age 18 y. Of 6286 abstracts and 669 full-text articles, 38 trials with 53 intervention arms were included. Data were extracted independently in duplicate. Findings were pooled using random-effects meta-analysis across supplementation periods (maternal, preterm, term infant); we also explored subgroup analyses stratified by supplementation period. Heterogeneity was explored using I2, stratified analysis, and meta-regression. Cognitive development was assessed by Bayley Scales of Infant Development mental and psychomotor developmental indexes (MDI, PDI) and intelligence quotient (IQ); visual acuity was assessed by electrophysiological or behavioral measures. Results: The 38 trials (mothers: n = 13; preterm infants: n = 7; term infants: n = 18) included 5541 participants. When we explored effects during different periods of supplementation, n-3 PUFA supplementation improved MDI in preterm infants (3.33; 95% CI: 0.72, 5.93), without statistically significant effects on PDI or IQ in different intervention period subgroups. Visual acuity [measured as the logarithm of the minimum angle of resolution (logMAR)] was improved by supplementation in preterm (-0.08 logMAR; 95% CI: -0.14, -0.01 logMAR) and term infants (-0.08 logMAR; 95% CI: -0.11, -0.05 logMAR), with a nonsignificant trend for maternal supplementation (-0.02 logMAR; 95% CI: -0.04, 0.00 logMAR). In main analyses pooling all supplementation periods, compared with placebo, n-3 PUFA supplementation improved MDI (n = 21 trials; 0.91; 95% CI: 0.005, 1.81; P = 0.049), PDI (n = 21 trials; 1.06 higher index; 95% CI: 0.10, 2.03; P = 0.031), and visual acuity (n = 24; -0.063 logMAR; 95% CI: -0.084, -0.041 logMAR; P < 0.001) but not IQ (n = 7; 0.20; 95% CI: -1.56, 1.96, P = 0.83), although few studies assessed this endpoint. Potential publication bias was identified for MDI (Eggers P = 0.005), but not other endpoints. Significant differences in findings were not identified by world region, race, maternal education, age at outcome assessment, supplementation duration, DHA or EPA dose, DHA:AA ratio, or study quality score (P-interaction > 0.05 each). Conclusions: n-3 PUFA supplementation improves childhood psychomotor and visual development, without significant effects on global IQ later in childhood, although the latter conclusion is based on fewer studies.

Designing programs to improve diets for maternal and child health: estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India.

Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality. This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India. These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country. Across the 12 programs, total cost per child reached (net present value, purchasing power parity adjusted) ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India. When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day). These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes.

Priority interventions to improve maternal and child diets in Sub-Saharan Africa and South Asia.

Nutrition-sensitive interventions to improve overall diet quality are increasingly needed to improve maternal and child health. This study demonstrates feasibility of a structured process to leverage local expertise in formulating programmes tailored for current circumstances in South Asia and Africa. We assembled 41 stakeholders in 2 regional workshops and followed a prespecified protocol to elicit programme designs listing the human and other resources required, the intervention's mechanism for impact on diets, target foods and nutrients, target populations, and contact information for partners needed to implement the desired programme. Via this protocol, participants described 48 distinct interventions, which we then compared against international recommendations and global goals. Local stakeholders' priorities focused on postharvest food systems to improve access to nutrient-dense products (75% of the 48 programmes) and on production of animal sourced foods (58%), as well as education and social marketing (23%) and direct transfers to meet food needs (12.5%). Each programme included an average of 3.2 distinct elements aligned with those recommended by United Nations system agencies in the Framework for Action produced by the Second International Conference on Nutrition in 2014 and the Compendium of Actions for Nutrition developed for the Renewed Efforts Against Child Hunger initiative in 2016. Our results demonstrate that a participatory process can help local experts identify their own priorities for future investments, as a first step in a novel process of rigorous, transparent, and independent priority setting to improve diets among those at greatest risk of undernutrition.

Comparative Study of a New Dietary Screener to Assess Food Groups of Concern in Children.

BACKGROUND: Although there are several valid and reliable dietary screeners to measure child intake patterns, there is a paucity of brief assessment tools targeting under- and overconsumed foods. OBJECTIVE: To compare the Fueling Learning through Exercise study (FLEX) dietary questionnaire, a screener designed to assess consumption patterns in third to fifth graders, to a validated dietary assessment tool. METHODS: The FLEX dietary questionnaire was developed to assess fruit, vegetable, snack, and beverage consumption and was compared to the Block Kids Food Screener (BKFS). Correlations were analyzed using Pearson correlation coefficient. Agreement was assessed using Bland-Altman plots. RESULTS: The sample (n = 63) had mean age of 9.9 years (SD 0.7). Most participants were non-Hispanic white (70%) and eligible for free/reduced price lunch (57%). Correlations between food group categories were significant for all groups ( P < .05) except fruits ( r = 0.51) and sugar-sweetened beverages (SSBs) ( r = 0.21). We found moderate-to-strong correlations between reported vegetable, salty snack, sweet snack, total beverage, milk, and fruit juice consumption (0.62, 0.59, 0.69, 0.47, 0.48, and 0.46, respectively). The FLEX screener reported systematically higher mean servings per day (0.24-1.1) compared to the BKFS (0.05-0.51). CONCLUSION: Based on these correlations, the FLEX dietary questionnaire performs similarly to a validated tool in assessing intake of under- and overconsumed food groups in a diverse third to fifth grade population. Overall serving size discrepancies are likely due to more relevant food items on the FLEX questionnaire and a more child-friendly format. This study highlights the need to update older diet screeners to reflect current child consumption patterns.

Mortality Benefits of Vitamin A Are Not Affected by Varying Frequency, Total Dose, or Duration of Supplementation.

BACKGROUND: Although vitamin A supplementation reduces child mortality, it remains unclear whether dosing frequency, total dose, or duration modifies effectiveness. OBJECTIVE: Determine whether mortality effects of vitamin A vary by dosing frequency, total dose, or duration. METHODS: Meta-analysis of randomized controlled trials, identified by systematic review and expert opinion, utilizing relatively standard World Health Organization doses in children <5 years. Meta-regression evaluated whether mortality effects varied by dosing frequency, total dose, or supplementation duration. RESULTS: Identified 17 trials, including 1,180,718 children, mean (standard deviation [SD]) age 31.5 (15.4) months at baseline. Supplementation frequency ranged every 3 months-every 2 years, supplementation duration 4-60 months (mean = 15.4; SD = 12.8), and total dose 134,361-2,200,000 IU (mean = 667,132 IU; SD = 540,795). Compared with control, vitamin A reduced mortality 22% (95% confidence interval [CI] = 10-32; P = 0.002). This protective effect was not modified by increasing supplementation frequency (dose/year: relative risk [RR] = 1.02; 95% CI = 0.98-1.06; P = .22), total dose (per 200,000 IU: RR = 1.02; 95% CI = 0.97-1.06; P = .31), nor supplementation duration (per year: RR = 1.06; 95% CI = 0.97-1.15; P = 0.14). Multivariate meta-regression showed similar results. Sensitivity analyses excluding 1 controversial trial (Aswathi 2013) did not alter findings. CONCLUSION: Results confirm benefits of vitamin A supplementation in children <5 years in nations with vitamin A deficiency, without influence of frequency, total dose, or dosing duration within ranges evaluated. These findings inform design and efficiency of vitamin A supplementation policies.

Harvest date affects aronia juice polyphenols, sugars, and antioxidant activity, but not anthocyanin stability.

The goal of this work was to characterize how the date of harvest of 'Viking' aronia berry impacts juice pigmentation, sugars, and antioxidant activity. Aronia juice anthocyanins doubled at the fifth week of the harvest, and then decreased. Juice hydroxycinnamic acids decreased 33% from the first week, while proanthocyanidins increased 64%. Juice fructose and glucose plateaued at the fourth week, but sorbitol increased 40% to the seventh harvest week. Aronia juice pigment density increased due to anthocyanin concentration, and polyphenol copigmentation did not significantly affect juice pigmentation. Anthocyanin stability at pH 4.5 was similar between weeks. However, addition of quercetin, sorbitol, and chlorogenic acid to aronia anthocyanins inhibited pH-induced loss of color. Sorbitol and citric acid may be partially responsible for weekly variation in antioxidant activity, as addition of these agents inhibited DPPH scavenging 13-30%. Thus, aronia polyphenol and non-polyphenol components contribute to its colorant and antioxidant functionality.