Assessing the influence of COVID-19 lockdown measures on cognition and behavior in school age children in Arba Minch Health and Demographic Surveillance site, Southern Ethiopia: A cross-sectional study.

Ethiopian schools were closed for nearly 40 weeks as a measure to control the COVID-19 pandemic. The objective of the study was to evaluate the role of COVID-19 pandemic's restrictive measures on cognition and behavioral difficulties of schoolchildren in Arba Minch Health and Demographic Surveillance Site. Two cross-sectional surveys were conducted in November 2019 (pre-COVID-19-lockdown) and November 2020 (post-COVID-19 lockdown). Data were collected both at the school and homes of the children. Cognitive development of the children was assessed using digit span, Raven's coloured progressive matrices (RCPM) and Visual search using cancellation task. Behavioral difficulties score of the children was assessed using Strengths and Difficulties Questionnaire. Analysis of covariance (ANCOVA) was used to compare between the cognition outcomes and behavioral difficulties score pre- and post-COVID-19-lockdown. In a sub-group of children who provided data in both surveys, the difference in cognitive and behavioral outcomes was tested using a mixed effect model. Compared to the pre-COVID-19-lockdown, schoolchildren post-COVID-19-lockdown scored lower in the standardized performance index for the visual search task, which measures attention (0.27 SD, 95% confidence intervals (95%CI): -0.40, -0.13). However, they scored higher by 0.26 SD (95%CI: 0.13, 0.40) and 0.36 SD (95%CI: 0.22, 0.49) in digit span and RCPM, respectively, measuring working memory and non-verbal intelligence. There was no significant difference in total difficulties score between pre- and post-COVID-19-lockdown (0.01 SD, 95%CI: -0.12, 0.15). The subgroup analysis showed a significant increase in digit span among children post-COVID-19-lockdown while the other domains did not show a significant change. Factors contributing to the improvement of children's cognitive domains while away from the school environment should be explored and utilized to enhance child development. This study was registered at clinicaltrials.gov as NCT04137354 on October 14, 2019.

Investigating the effect of a school-based WASH intervention on soil-transmitted helminth and schistosome infections and nutritional status of school children in Ethiopia: a quasi-experimental study.

BACKGROUND: The impact of access to improved water, sanitation and hygiene (WASH) and health education on large-scale deworming programs aimed at controlling soil-transmitted helminth (STH) and schistosome (SCH) infections has not been well studied. We assessed the additional impact of improved WASH infrastructure and health education at schools on STH and SCH infections in Ethiopia. METHODS: The study used a quasi-experimental design under which 30 schools were assigned to either an intervention (15 schools) or control (15 schools) arm. Both arms received a standard deworming treatment and lunch. In the intervention arm, improved WASH and health education were provided. At three consecutive time points (baseline in 2013, 2014 and 2015), the prevalence and intensity of STH and SCH infections and the nutritional status [hemoglobin concentrations and physical growth (height and weight)] were determined. To verify whether interventions were successfully implemented, the WASH status at school and the student knowledge, attitudes and practices related to WASH (WASH-KAP) were recorded. Differences in metrics between arms at baseline (2013) and follow-up (2015) were assessed both within and between the arms. RESULTS: A significant increase in scores for both the school WASH and student KAP was found in the intervention arm, indicating successful implementation of the intervention. The prevalence of any STH infection was significantly reduced in the intervention arm but not in the control arm (F = 4.486, p = 0.034). There was a significantly greater reduction in the intensity of infection of hookworm and Ascaris lumbricoides compared to baseline in both arms. The intervention did not affect school children's height-for-age z-score (intervention arm * time coef = 0.12, p = 0.400) and body mass index-for-age z-scores (intervention * time coef = - 0.06, p = 0.526). Hemoglobin concentrations increased significantly more in the control than the intervention arm (coef = - 0.16, p = 0.006). CONCLUSIONS: Although the intervention did increase school WASH and student WASH-KAP, our study found poor evidence of the additional benefit of improved WASH and health education to deworming and school food programs on parasite re-infection and the health outcomes of children.

Effects of community-based educational video interventions on nutrition, health, and use of health services in low- and middle-income countries: systematic review and meta-analysis.

CONTEXT: Health education using videos has been promoted for its potential to enhance community health by improving social and behavior change communication. OBJECTIVE: To provide stakeholders in maternal and child health with evidence that can inform policies and strategies integrating video education to improve maternal, newborn, and child health. DATA SOURCES: Five databases (MEDLINE, Embase, Scopus, Web of Science, and CENTRAL) were searched on January 28, 2022, and November 10, 2022 (updated search). Quantitative and qualitative studies conducted in low- and middle-income countries on the effects of video-based interventions on nutrition, health, and health service use were eligible. There was no restriction on time or language. Study selection was done in 2 stages and in duplicate. DATA EXTRACTION: A total of 13 710 records were imported to EndNote. Of these, 8226 records were screened by title and abstract using Rayyan, and 76 records were included for full-text evaluation. RESULTS: Twenty-nine articles (n = 12 084 participants) were included in this systematic review, and 7 were included in the meta-analysis. Video interventions improved knowledge about newborn care (n = 234; odds ratio [OR], 1.20; 95% confidence interval [CI], 1.04-1.40), colostrum feeding (n = 990; OR, 60.38; 95%CI, 18.25-199.78), continued breastfeeding (BF; n = 1914; OR, 3.79; 95%CI, 1.14-12.64), intention to use family planning (FP) (n = 814; OR, 1.57; 95%CI, 1.10-2.23), and use of FP (n = 864; OR, 6.55; 95%CI, 2.30-18.70). Video interventions did not result in reduced prelacteal feeding or improvement in early initiation of BF. The qualitative studies showed that video interventions were acceptable and feasible, with perceived impacts on communities. CONCLUSION: This systematic review and meta-analysis indicated that video interventions improved knowledge of newborn care, colostrum feeding, and continuing BF, and the intention to use FP. Given the high levels of heterogeneity and inconsistency in reporting, more research with stronger designs is recommended. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42022292190.

Association between urbanization and metabolic syndrome in low- and middle-income countries: A systematic review and meta-analysis.

AIMS: The prevalence of metabolic syndrome (MetS) is on the rise in an increasingly urbanized world. The study aimed to review the association between urbanization and MetS in low- and middle-income countries (LMICs). DATA SYNTHESIS: A comprehensive search of five databases (MEDLINE, Web of Science, Scopus, EMBASE, and CENTRAL) was performed in January 2022 and updated in October 2022. Peer-reviewed studies that met the eligibility selection criteria were included. Search terms were used for the main concepts which are MetS, dietary patterns, and urbanization in LMICs. Study selection was done in two stages and in duplicate. Random effects models were used to calculate the overall pooled prevalence and main study-level characteristics. Out of 9,773 identified studies, nineteen were included in the systematic review and meta-analysis. The studies were done on 313,644 participants (149,616 urban and 164,028 rural). The pooled risk ratio (RR, 95% confidence interval) of MetS between urban and rural dwellers was RR = 1.24; 95%CI [1.15, 1.34] (I2 = 96.0%, P < 0.0001). A relatively higher prevalence of MetS among urban than rural residents has been observed, especially with the International Diabetes Federation criteria (RR = 1.54; 95%CI [1.21, 1.96]; I2 = 65.0%), and in the population in India (RR = 2.19; 95%CI = 1.24, 3.88, I2 = 85%). Overall, the role of dietary patterns in the development of MetS was inconsistent, and few studies showed a lower risk of MetS with adherence to recommended healthy dietary patterns. CONCLUSIONS: There was an association between urbanization and the high prevalence of MetS. Interventions and policies to reduce the risk of MetS are needed.

Effectiveness of intermittent iron and high-dose vitamin A supplementation on cognitive development of school children in southern Ethiopia: a randomized placebo-controlled trial.

BACKGROUND: Iron is an essential mineral whose deficiency results in cognitive alteration, impaired emotional behaviors, and altered myelination and neurotransmission. In animal models, it has been shown that vitamin A (VA) could affect cognition. OBJECTIVES: The study aimed to evaluate the effectiveness of intermittent iron and VA supplementation on cognitive development of schoolchildren, and to assess the interaction between these supplementations. METHODS: Considering a 2 × 2 factorial design, 504 children were randomly assigned to 1 of the 4 arms: placebo VA and placebo iron supplement; high-dose vitamin VA and placebo iron supplement; iron supplement and placebo VA; and iron and high-dose vitamin VA supplements. Cognitive development was assessed using Raven's Coloured Progressive Matrices, digit span, Tower of London, and visual search tasks. RESULTS: The mean [± standard deviation (SD)] age of the enrolled children was 9.6 (±1.6) y. One-fifth of the children had iron deficiency or anemia, whereas 2.9%, 3.9%, and 12.1% of children had low iron stores, iron deficiency anemia, and VA deficiency, respectively. Intermittent iron supplementation did not result in any significant improvement of children's cognitive development and had a negative effect on the performance index of the visual search task compared with placebo (-0.17 SD, 95% confidence interval: -0.32, -0.02). Effects were evident among children with stunting, thinness, or children coming from understimulating home environments. High-dose VA supplementation resulted in a significant improvement of digit span z-score with a mean difference of 0.30 SD (95% confidence interval: 0.14, 0.46) compared with placebo VA. VA had a more beneficial impact for girls, children infected with helminths, and those from food secure households. CONCLUSION: In a population where the prevalence of iron deficiency is low, intermittent iron supplementation did not have any or negative effect on the child's cognitive development outcomes. Conversely, VA supplementation improved the child's working memory. TRIAL REGISTRATION NUMBER: The study is registered at clinicaltrials.gov as NCT04137354 (https://clinicaltrials.gov/study/NCT04137354).

A comparative study on indicators of vitamin A status and risk factors for sensitivity and specificity of the methods to detect vitamin A deficiency.

BACKGROUND: Serum retinol (SR) and retinol-binding protein (RBP) are commonly used indicators, but they are affected by infections and inflammation. This study aimed to assess the sensitivity and specificity of VA indicators to detect vitamin A deficiency (VAD) in 36-59-month-old children living in a rural area in Burkina Faso. METHODS: In a community-based study, two cross-sectional surveys were carried out from November 2016 to September 2017 in the health district of Dandé in Burkina Faso. The surveys included 115 children 36-59 months old. Indicators of VA and inflammation assessed in all children included SR, RBP and total liver VA reserves (TLR) estimated by retinol isotope dilution, and inflammation markers (C-reactive protein (CRP) and alpha 1-acid glycoprotein (AGP)). We calculated the sensitivity, specificity, positive and negative predictive values. In addition, the effects of inflammation, helminth infection, and season on sensitivity and specificity were assessed. RESULTS: The prevalence of VAD assessed by SR (< 0.7 µmol/L), RBP (< 0.7 µmol/L), and TLR (< 0.1 µmol/g liver) were, respectively, 30.9%, 33.3%, and 0%. Compared to TLR, the specificity, positive predictive value, and negative predictive value of SR were 71.1%, 0%, and 100%, and of RBP, were 68.9%, 0%, and 100%, respectively. The sensitivity was indeterminable for SR and RBP. The specificity of SR and RBP was lower during the dry season. Elevated CRP (> 5.0 mg/L) and AGP (> 1.0 g/L) were detected in 1.9% and 28.6% of children, respectively. The adjustment of VA indicators for inflammation improved SR's specificity to 75.9% and decreased RBP's specificity to 67.8%. CONCLUSION: No cases of VAD were identified by TLR. However, (inflammation-adjusted) SR and RBP had varying accuracy in the estimation of VAD. TRIAL REGISTRATION: The study was registered, retrospectively, on 22 March 2018 as a clinical trial with the Pan African Clinical Trials Registry under the number Cochrane South Africa; PACTR201803002999356.

Sexual risk-taking behavior amongst emerging adults in a tertiary institution of learning in Coastal Kenya: A qualitative study of stakeholders' perspectives using causal loop mapping.

BACKGROUND: It is known from previous studies that university students in sub-Saharan Africa (sSA) engage in sexual risk-taking behaviour (SRTB). However, there is paucity of data on factors contributing to SRTB among university students (emerging adults) at the Kenyan Coast thus hindering intervention planning. This study seeks to provide an in-depth qualitative understanding of the factors contributing to SRTB and their interconnectedness among university students at the Kenyan Coast combining qualitative research with a systems thinking approach. METHODS: Using the ecological model, and employing in-depth interviews, we explored the perceptions of twenty-six key informants (twenty-one emerging adults and five other stakeholders) on what constitutes and influences SRTB among emerging adults at a tertiary institution of learning in Coastal Kenya. Data were analysed using a thematic framework approach. A causal loop diagram (CLD) was developed to map the interconnectedness of the correlates of SRTB. RESULTS: Our findings show that unprotected sex, transactional sex, cross-generational sex, multiple sex partnerships, gender-based violence, sex under influence of alcohol/drugs, early sex debut, and sharing sex toys were common SRTBs. Based on the ecological model and CLD, most of the reported risk factors were interconnected and operated at the individual level. CONCLUSION: Our study shows that emerging adults are frequently engaging in unprotected sex. Enhancing sexuality education programs for students in Kenyan universities and strengthening support systems including counselling for those using alcohol/drugs may help reduce SRTB among emerging adults in Kenyan universities.

Dietary intake of preformed vitamin A and provitamin A carotenoids are not associated with serum retinol and carotenoid concentrations among children 36-59 months of age in rural Burkina Faso: a cross-sectional study.

PURPOSE: This study aimed to assess the association between dietary intake of preformed vitamin A (VA) and pro-VA carotenoids and serum retinol and carotenoid concentrations among 36-59-month-old children in a rural area in Burkina Faso. METHODS: Two community-based cross-sectional studies were conducted in a rural area of Burkina Faso and included 115 children aged 36-59 months. Dietary intake of preformed VA and pro-VA was assessed directly by 24-h dietary recall. Serum retinol and carotenoid (α- and ß-carotene, and ß-cryptoxanthin) concentrations were measured. The associations between serum retinol and carotenoid concentrations and their respective dietary intake were assessed by multiple linear regression. RESULTS: Geometric mean [95% CI] adjusted serum retinol concentration in children was 0.86 [0.81; 0.92] µmol/L. The prevalence of low adjusted serum retinol concentration (< 0.7 µmol/L) was 26.8%. Geometric mean [95% CI] serum carotenoid concentrations were: α-carotene (0.03 [0.02; 0.03] µmol/L), ß-carotene (0.14 [0.12; 0.16] µmol/L), and ß-cryptoxanthin (0.17 [0.15; 0.21] µmol/L). Dietary intakes of α- and ß-carotene and adjusted serum retinol and α-carotene concentrations were significantly higher during the rainy season. In multiple linear regressions, no associations were found between dietary intakes of preformed VA and pro-VA carotenoids and serum retinol and carotenoid concentrations in children aged 36-59 months in Burkina Faso. There was no effect of season on the associations between preformed VA and pro-VA carotenoids intake and serum retinol and carotenoid concentrations. CONCLUSIONS: This study shows that dietary intakes of preformed VA and pro-VA carotenoids based on 24-h dietary recall method cannot be used as proxy of serum retinol and carotenoid concentrations in this population. TRIAL REGISTRATION: The study was registered retrospectively (22 March 2018) as a clinical trial with the Pan African Clinical Trials Registry (Cochrane South Africa; PACTR201803002999356).

Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe District, South Ethiopia: A qualitative study.

Evidence about innovative methods to facilitate nutrition education counseling and promote the intended behavior change at scale is limited. We assessed the acceptability and feasibility of a video-based health education intervention aiming to promote community care for pregnant women, mothers, and infants in the Dirashe District, Ethiopia. Using a phenomenological study design, the experiences of study participants in a trial testing the effectiveness of video-based health education on birth outcomes and nutritional status of mothers and their infants six months postpartum were assessed. Focus group discussions (FGDs) and key informant interviews (KIIs) were used to collect the data. The study was conducted in the Dirashe District, South Ethiopia. Five FGDs and 41 KII were conducted among video implementers, mothers, nurses, and health extension workers (HEWs) in eight intervention villages. All data were collected with a tape recorder. The tape-recorded data were transcribed and then translated into English. Data were analyzed using thematic content analysis. The videos delivered messages about nine themes on health, nutrition, and hygiene related to mothers and infants. Overall, the video-based health education interventions was acceptable and feasible. Messages delivered were found to be clear, easily understandable, culturally acceptable, and relevant to the needs of the mothers. Feasibility was affected by the nature of the work, lack of help, and overlapping duties of the HEWs. The video-based health education intervention was acceptable and feasible. It was suggested that determining a common location/venue to show the videos, involving husbands, and involving HEWs could improve the intervention. Trial registration: The effectiveness "parent" study was registered as a clinical trial with the U.S. National Institute of Health (www.ClinicalTrials.gov; NCT04414527). The qualitative study included recipients from the same cohort (participating mothers from the intervention group), in addition to video implementers, health extension workers the Health Development Army, and nurses from the intervention communities.

Effects of iron supplementation on cognitive development in school-age children: Systematic review and meta-analysis.

BACKGROUND: Iron deficiency is negatively associated with children's cognitive development. Evidence showed that iron supplementation improves cognitive development. Nearly 50% of anemia is caused by iron deficiency. Anemia affects more school-age children, at an age where their brain development continues. The aim of this systematic review and meta-analysis is to review the evidence from published randomized controlled trials to evaluate the effects of iron supplementation on cognitive development and function among school-age children. METHOD: Five databases including MEDLINE, EMBASE, Scopus, Web of Science and CENTRAL were used to search for articles on April 20th, 2021. The search was reconducted on October 13th, 2022 to retrieve new records. Studies were eligible if they included school children 6-12 years of age, were randomized controlled trials, and if they tested iron supplementation and measured cognitive development. RESULT: Thirteen articles were included in the systematic review. Overall, iron supplementation significantly improved intelligence (standardized mean difference, 95% confidence interval) (SMD 0.46, 95%CI: 0.19, 0.73, P<0.001), attention and concentration (SMD 0.44, 95%CI: 0.07, 0.81, P = 0.02) and memory (SMD 0.44, 95%CI: 0.21, 0.67, P <0.001) of school-age children. There was no significant effect of iron supplementation on school achievement of school-age children (SMD 0.06, 95%CI: -0.15, 0.26, P = 0.56). In a subgroup analysis, iron-supplemented children who were anemic at baseline had had better outcomes of intelligence (SMD 0.79, 95%CI: 0.41, 1.16, P = 0.001) and memory (SMD 0.47, 95%CI: 0.13, 0.81; P = 0.006). CONCLUSION: Iron supplementation has a significant positive effect on the intelligence, attention and concentration, and the memory of school-age children but there was no evidence on the effect of iron supplementation on their school achievement.

Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting. OBJECTIVES: We aimed to identify the effect of SQ-LNSs on prevalence of severe wasting (weight-for-length z score < -3) and severe stunting (length-for-age z score < -3). METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS: SQ-LNS provision led to a relative reduction of 31% in severe wasting [prevalence ratio (PR): 0.69; 95% CI: 0.55, 0.86; n = 34,373] and 17% in severe stunting (PR: 0.83; 95% CI: 0.78, 0.90; n = 36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded (PR: 0.74; 95% CI: 0.57, 0.96; n = 26,327 for severe wasting and PR: 0.88; 95% CI: 0.81, 0.95; n = 28,742 for severe stunting). Study-level characteristics generally did not significantly modify the effects of SQ-LNSs, but results suggested greater effects of SQ-LNSs in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation. CONCLUSIONS: Including SQ-LNSs in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. This meta-analysis was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Small-quantity lipid-based nutrient supplements, with or without added zinc, do not cause excessive fat deposition in Burkinabe children: results from a cluster-randomized community trial.

PURPOSE: Public health interventions to address stunting and wasting should be evaluated for possibly contributing to obesity risk. The present study tested the hypothesis that small-quantity lipid-based nutrient supplements (SQ-LNS) might increase fat deposition, and that additional zinc provided via SQ-LNS or in the form of dispersible tablets would increase fat-free mass (FFM) accretion. METHODS: Using a two-stage, cluster-randomized trial design, 34 communities were randomly assigned to the intervention cohort (IC) or non-intervention cohort (NIC), and family compounds within the IC were randomly assigned to receive different amounts of zinc (0, 5 or 10 mg zinc) incorporated in SQ-LNS or 5 mg zinc in the form of dispersible tablets along with treatment for diarrhea, malaria and fever. Body composition was assessed in a subset of IC (n = 201) and NIC (n = 74) children at 9 and 18 months using the deuterium dilution method. A mixed linear model was used to examine average change in FFM and % fat mass (%FM) among intervention groups and by cohort. RESULTS: Children in the IC had significantly greater change in FFM (Mean (95% Confidence Interval)) (1.57 (1.49, 1.64) kg) compared to the NIC (1.35 (1.23, 1.46) kg; p = 0.005). There were no significant differences in the change in %FM between the NIC and IC or among the intervention groups. CONCLUSION: SQ-LNS, along with morbidity treatment increased weight gain and FFM in young children from 9 to 18 months of age without increasing FM deposition. Additional zinc supplementation did not affect changes in FFM or %FM. TRIAL REGISTRATION: The study was registered as a clinical trial with the US National Institute of Health ( www. CLINICALTRIALS: gov ; NCT00944281).

The Effects of Modified Intermittent Fasting in Psoriasis (MANGO): Protocol for a Two-Arm Pilot Randomized Controlled Open Cross-over Study.

BACKGROUND: Psoriasis is a complex disease associated with multiple comorbidities, including metabolic syndrome and leaky gut syndrome. Dietary lifestyle interventions have been reported to affect the disease in terms of lesional severity. It remains unclear how diets affect these comorbidities and the general health in psoriasis patients. Modified intermittent fasting (MIF) on 2 nonconsecutive days has shown beneficial effects on metabolic parameters. A significant advantage of MIF over the currently investigated dietary changes is its feasibility. OBJECTIVE: Here, we aim to study the effects of MIF on skin, gut, and metabolic health in psoriasis patients. METHODS: A 2-arm pilot randomized controlled open cross-over study will be performed in 24 patients with psoriasis. Patients will be randomized 1:1 to either start with 12 weeks of MIF and go on a subsequent regular diet for another 12 weeks or start with 12 weeks of regular diet and do subsequent MIF for 12 weeks. The following parameters will be assessed: demographics, disease phenotype, medical and familial history, psoriasis severity, dermatology-specific and general quality of life, nutritional and physical habits, mental and intestinal health, intestinal and cutaneous integrity, inflammatory and metabolic markers, and satisfaction. RESULTS: A total of 24 participants have been enrolled in the study. The final visit is foreseen for June 2021. CONCLUSIONS: The aim is to uncover the effects of MIF on psoriasis severity and gut health integrity through clinical and molecular investigation. More precisely, we want to map the evolution of the different markers, such as psoriasis severity, permeability, and inflammation, in response to MIF as compared to a regular diet,. Understanding how dietary lifestyles can affect epithelial lineages, such as the skin and gut, will greatly improve our understanding of the development of psoriasis and may offer a nonpharmacological venue for treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT04418791; https://clinicaltrials.gov/ct2/show/NCT04418791. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26405.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child anemia and micronutrient status: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Small-quantity lipid-based nutrient supplements (SQ-LNSs) have been shown to reduce the prevalence of child anemia and iron deficiency, but effects on other micronutrients are less well known. Identifying subgroups who benefit most from SQ-LNSs could support improved program design. OBJECTIVES: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child hemoglobin (Hb), anemia, and inflammation-adjusted micronutrient status outcomes. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 13 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 15,946). We generated study-specific and subgroup estimates of SQ-LNSs compared with control, and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine potential study-level effect modifiers. RESULTS: SQ-LNS provision decreased the prevalence of anemia (Hb < 110 g/L) by 16% (relative reduction), iron deficiency (plasma ferritin < 12 µg/L) by 56%, and iron deficiency anemia (IDA; Hb < 110 g/L and plasma ferritin <12 µg/L) by 64%. We observed positive effects of SQ-LNSs on hematological and iron status outcomes within all subgroups of the study- and individual-level effect modifiers, but effects were larger in certain subgroups. For example, effects of SQ-LNSs on anemia and iron status were greater in trials that provided SQ-LNSs for >12 mo and provided 9 (as opposed to <9) mg Fe/d, and among later-born (than among first-born) children. There was no effect of SQ-LNSs on plasma zinc or retinol, but there was a 7% increase in plasma retinol-binding protein (RBP) and a 56% reduction in vitamin A deficiency (RBP < 0.70 µmol/L), with little evidence of effect modification by individual-level characteristics. CONCLUSIONS: SQ-LNSs can substantially reduce the prevalence of anemia, iron deficiency, and IDA among children across a range of individual, population, and study design characteristics. Policy-makers and program planners should consider SQ-LNSs within intervention packages to prevent anemia and iron deficiency.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020156663.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers.

BACKGROUND: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS: In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS: SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS: The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Mycotoxin exposure assessments in a multi-center European validation study by 24-hour dietary recall and biological fluid sampling.

The European Food Consumption Validation (EFCOVAL) project includes 600 men and women from Belgium, the Czech Republic, France, the Netherlands, and Norway, who had given serum and 24-hour urine samples, and completed 24-hour dietary recall (24-HDR) interviews. Consumption, according to 24-HDR, was matched against the European Food Safety Authority (EFSA) databases of mycotoxin contaminations, via the FoodEx1 standard classifications, producing an indirect external estimate of dietary mycotoxin exposure. Direct, internal measurements of dietary mycotoxin exposure were made in serum and urine by ultra-performance liquid chromatography coupled to tandem mass spectrometry. For the first time, mycotoxin exposures were thoroughly compared between two 24-HDRs, and two 24-hour urine samples collected during the same days covered by the 24-HDRs. These measurements were compared to a single-time point serum measurement to investigate evidence of chronic mycotoxin exposure. According to 24-HDR data, all 600 individuals were exposed to between 4 and 34 mycotoxins, whereof 10 found to exceed the tolerable daily intake. Correlations were observed between two time points, and significant correlations were observed between concentrations in serum and urine. However, only acetyldeoxynivalenol, ochratoxin A, and sterigmatocystin were found to have significant positive correlations between 24-HDR exposures and serum, while aflatoxin G1 and G2, HT-2 toxin, and deoxynivalenol were associated between concurrent 24-HDR and 24-hour urine. Substantial agreements on quantitative levels between serum and urine were observed for the groups Type B Trichothecenes and Zearalenone. Further research is required to bridge the interpretation of external and internal exposure estimates of the individual on a time scale of hours. Additionally, metabolomic profiling of dietary mycotoxin exposures could help with a comprehensive assessment of single time-point exposures, but also with the identification of chronic exposure biomarkers. Such detailed characterization informs population exposure assessments, and aids in the interpretation of epidemiological health outcomes related to multi-mycotoxin exposure.

Path analyses of risk factors for linear growth faltering in four prospective cohorts of young children in Ghana, Malawi and Burkina Faso.

Stunting prevalence is an indicator of a country's progress towards United Nations' Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%-62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.

Serum Carotenoids Reveal Poor Fruit and Vegetable Intake among Schoolchildren in Burkina Faso.

The health benefits of fruits and vegetables are well-documented. Those rich in provitamin A carotenoids are good sources of vitamin A. This cross-sectional study indirectly assessed fruit and vegetable intakes using serum carotenoids in 193 schoolchildren aged 7 to 12 years in the Western part of Burkina Faso. The mean total serum carotenoid concentration was 0.23 ± 0.29 µmol/L, which included α- and ß-carotene, lutein, and ß-cryptoxanthin, and determined with serum retinol concentrations in a single analysis with high performance liquid chromatography. Serum retinol concentration was 0.80 ± 0.35 µmol/L with 46% of children (n = 88) having low values <0.7 µmol/L. Total serum carotene (the sum of α- and ß-carotene) concentration was 0.13 ± 0.24 µmol/L, well below the reference range of 0.9⁻3.7 µmol carotene/L used to assess habitual intake of fruits and vegetables. Individual carotenoid concentrations were determined for α-carotene (0.01 ± 0.05 µmol/L), ß-carotene (0.17 ± 0.24 µmol/L), ß-cryptoxanthin (0.07 ± 0.06 µmol/L), and lutein (0.06 ± 0.05 µmol/L). These results confirm the previously measured high prevalence of low serum vitamin A concentrations and adds information about low serum carotenoids among schoolchildren suggesting that they have low intakes of provitamin A-rich fruits and vegetables.

Differing growth responses to nutritional supplements in neighboring health districts of Burkina Faso are likely due to benefits of small-quantity lipid-based nutrient supplements (LNS).

BACKGROUND: Of two community-based trials among young children in neighboring health districts of Burkina Faso, one found that small-quantity lipid-based nutrient supplements (LNS) increased child growth compared with a non-intervention control group, but zinc supplementation did not in the second study. OBJECTIVES: We explored whether the disparate growth outcomes were associated with differences in intervention components, household demographic variables, and/or children's morbidity. METHODS: Children in the LNS study received 20g LNS daily containing different amounts of zinc (LNS). Children in the zinc supplementation study received different zinc supplementation regimens (Z-Suppl). Children in both studies were visited weekly for morbidity surveillance. Free malaria and diarrhea treatment was provided by the field worker in the LNS study, and by a village-based community-health worker in the zinc study. Anthropometric assessments were repeated every 13-16 weeks. For the present analyses, study intervals of the two studies were matched by child age and month of enrollment. The changes in length-for-age z-score (LAZ) per interval were compared between LNS and Z-Suppl groups using mixed model ANOVA or ANCOVA. Covariates were added to the model in blocks, and adjusted differences between group means were estimated. RESULTS: Mean ages at enrollment of LNS (n = 1716) and Z-Suppl (n = 1720) were 9.4±0.4 and 10.1±2.7 months, respectively. The age-adjusted change in mean LAZ per interval declined less with LNS (-0.07±0.44) versus Z-Suppl (-0.21±0.43; p<0.0001). There was a significant group by interval interaction with the greatest difference found in 9-12 month old children (p<0.0001). Adjusting for demographic characteristics and morbidity did not reduce the observed differences by type of intervention, even though the morbidity burden was greater in the LNS group. CONCLUSIONS: Greater average physical growth in children who received LNS could not be explained by known cross-trial differences in baseline characteristics or morbidity burden, implying that the observed difference in growth response was partly due to LNS.