Contribution of Food from Market Purchases and Home Production to Child Nutrient Intake: Evidence from the EFFECTS Study Baseline Data.

BACKGROUND: Child undernutrition is prevalent in Tanzania, and households rely primarily on local markets and home production as food sources. However, little is known about the contribution of food market purchases to nutrient intakes among children consuming complementary foods. OBJECTIVES: To quantify the relationships between diversity of foods purchased and produced by households and adequate child nutrient intake in Mara, Tanzania. METHODS: Cross-sectional baseline dietary and household food source data from the Engaging Fathers for Effective Child Nutrition and Development in Tanzania study were collected from mothers of 586 children aged 9-23 mo clustered in 80 villages in Mara, Tanzania. We conducted mixed effects linear regressions to quantify the association between the diversity of foods consumed at home, from market purchases and home production, and nutrient intake adequacy (based on 24-h food recalls). RESULTS: Children had inadequate diets, with fewer than half of children consuming adequate amounts of vitamin A, vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B9 (folate), calcium, iron, and zinc. Breastfeeding was associated with higher overall mean adequacy (b = 0.15-0.19 across models, P < 0.001). Diversity of foods purchased was positively associated with the intake of vitamin B12 and calcium (both P < 0.001); this effect was attenuated among breastfed children. Among nonbreastfed children, production diversity was positively associated with vitamin A intake (b=0.04; P < .05) but not with intake of other nutrients. CONCLUSIONS: Both household food purchase and food production diversities were positively associated with children's nutrient intake in rural Mara, Tanzania. Nutrition programming should consider the role of food markets in addition to home food production to improve child diets. This trial was registered at clinicaltrials.gov as NCT03759821, https://clinicaltrials.gov/study/NCT03759821.

Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial.

BACKGROUND: Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes. METHODS: We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being. RESULTS: Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (ß = .18 [95% CI: 0.01, 0.36]) and receptive language development (ß = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (ß = .21 [0.04, 0.38]) and availability of home learning materials (ß = .25 [0.07-0.43]) and reduced paternal parenting distress (ß = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (ß = .45 [0.27, 0.63]). CONCLUSIONS: Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

Effects of engaging fathers and bundling nutrition and parenting interventions on household gender equality and women's empowerment in rural Tanzania: Results from EFFECTS, a five-arm cluster-randomized controlled trial.

Advancing gender equality and women's empowerment (GE/WE) may contribute to better child nutrition and development in low-resource settings. However, few empirical studies have generated evidence on GE/WE and examined the potential of engaging men to transform gender norms and power relations in the context of nutrition and parenting programs. We tested the independent and combined effects of engaging couples and bundling nutrition and parenting interventions on GE/WE in Mara, Tanzania. EFFECTS (ClinicalTrials.gov, NCT03759821) was a cluster-randomized 2 × 2 factorial trial plus control. Eighty village clusters were randomly assigned to one of five intervention conditions: standard of care, mothers nutrition, couples nutrition, mothers bundled nutrition and parenting, or couples bundled nutrition and parenting. Between October 2018-May 2019, 960 households were enrolled with children under 18 months of age residing with their mother and father. Community health workers (CHWs) delivered a bi-weekly 24-session hybrid peer group/home visit gender-transformative behavior change program to either mothers or couples. GE/WE outcomes were analyzed as intention-to-treat and included time use, gender attitudes, social support, couples' communication frequency and quality, decision-making power, intimate partner violence (IPV), and women's dietary diversity (WDD). Data were collected from 957 to 815 mothers and 913 and 733 fathers at baseline and endline, respectively. Engaging couples compared to mothers only significantly increased paternal and maternal gender-equitable attitudes, paternal time spent on domestic chores, and maternal decision-making power. Bundling increased maternal leisure time, decreased maternal exposure to any IPV, and increased WDD over 7 days. A combination of engaging couples and bundling was most effective for paternal gender attitudes, couples communication frequency, and WDD over 24 h and 7 days. Our findings generate novel evidence that CHWs can deliver bundled nutrition and parenting interventions to couples in low-resource community settings that advance GE/WE more than nutrition interventions targeting only women.

Exploring drivers of food choice among PLHIV and their families in a peri-urban Dar es Salaam, Tanzania.

BACKGROUND: A nutritious diet is critical to minimizing disease progression of human immunodeficiency virus (HIV) and maximizing treatment efficacy. In low resource settings, meeting the food preference needs of people living with the HIV (PLHIV) can be achieved with a supportive food environment when HIV status is disclosed. However, less is known about family-level strategies related to building a supportive food environment. The Diet, Environment, and Choices of positive living (DECIDE), a mixed-methods observational study conducted in peri-urban Dar es Salaam, Tanzania, explored food preferences as influenced by the personal, family, and external food domains. METHODS: We completed a qualitative analysis of data generated from 40 interviews (n = 20 PLHIV and n = 20 family members) aimed at exploring the dynamics of food choice for using a family perspective. We expanded on Turner's food environment framework and drew on Giddens' structuration theory to guide our data collection and analysis. Interviews were audio recorded, transcribed, translated from Kiswahili to English, coded, and organized into themes. RESULTS: We found PLHIV personal food preferences were influenced by organoleptic properties, medications, disease stage, and gender norms. Family members were knowledgeable about the importance of nutritious food for HIV treatment and prioritized these needs to avoid HIV-related stigma and fulfill family obligations. With high prices of nutritious foods (animal source foods, fruits), family members strategized to secure preferred foods for the PLHIV by, 1) forgoing their own food preferences; 2) reallocating food within the household; 3)making food substitutions; and 4) leveraging external networks. These strategies were increasingly employed as the disease progressed. CONCLUSION: The use of this expanded framework that included a family perspective on PLHIV food choice illuminated the various households decision-making dynamics that took place in this low resource community. Family members of PLHIV tried to buffer the limitations imposed by the external food environment, especially as the disease progressed. In the context of HIV status disclosure, integrating a family perspective into HIV nutrition interventions and programs has the potential to influence health outcomes and slow disease progression.

Gender and Age Differences in Meal Structures, Food Away from Home, Chrono-Nutrition, and Nutrition Intakes among Adults and Children in Tanzania Using a Newly Developed Tablet-Based 24-Hour Recall Tool.

Background: In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive. Objectives: We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings. Methods: Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes. Results: Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0-18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes. Conclusions: The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.

Caregivers Systematically Overestimate Their Child's Height-for-Age Relative to Other Children in Rural Ethiopia.

BACKGROUND: Stunting affects one-quarter of children <5 y of age, yet little is known about the accuracy of caregivers' perceptions regarding their child's linear growth. Most existing quantitative research on this topic has been conducted in high-income countries and has examined perceptions of children's weight rather than height. OBJECTIVES: In rural Ethiopia where linear growth faltering is highly prevalent, this study aimed to better understand how caregivers perceive their child's growth. The objectives of this analysis were to 1) assess caregivers' perceptions of their child's height; 2) investigate whether there is a discrepancy between a child's actual height and caregivers' perceptions of their child's height; and 3) examine the factors that influence discrepancies in estimating a child's height (secondary outcomes), including the role of the average height in the community (primary outcome). METHODS: We conducted a cross-sectional analysis using data from 808 woman caregivers of children ages 6-35 mo in the Oromia region of Ethiopia. We assessed caregivers' rankings (from 1 to 10) of their child's height relative to other children their age in their village. We then converted these rankings to z scores based on an age- and region-specific distribution in order to calculate their difference with the child's actual height-for-age z score and to determine the degree of overestimation. Lastly, we used multivariate log Poisson regressions to determine factors associated with overestimating a child's height. RESULTS: Forty-three percent of caregivers scored their child's height as the median; 37% overestimated their child's height relative to other children. Regression results showed caregivers who were poorer, and had children who were female, older, and stunted, were more likely to overestimate. CONCLUSIONS: Our findings suggest that caregivers of young children in Oromia systematically overestimated their children's height, which could adversely affect child health if these misperceptions translate to insufficient care-seeking behavior or feeding choices for children.

Systematic Review and Meta-Analysis on the Effect of Portion Size and Ingestive Frequency on Energy Intake and Body Weight among Adults in Randomized Controlled Feeding Trials.

Energy intake is the product of portion size (PS)-the energy content of an ingestive event-and ingestive frequency (IF)-the number of ingestive events per unit time. An uncompensated alteration in either PS or IF would result in a change in energy intake and body weight if maintained over time. The objective of this meta-analysis was to assess the independent effects of PS and IF on energy intake and body weight among healthy adults in randomized controlled trials (RCTs). A total of 9708 articles were identified in PubMed, Web of Science, Cochrane, and CINAHL databases. The articles were divided among 10 researchers; each article was screened for eligibility by 2-3 independent reviewers. Exclusion criteria included: populations <19 y and >65 y, unhealthy populations (i.e. participants with an acute or chronic disease), assessments <24 h and <4 wk in duration for trials investigating energy intake or body weight, respectively. Controlled feeding trials (i.e. fixed energy intake) that manipulated IF and PS in the same study intervention (IF/PS) were evaluated separately and for the body weight outcome only. Twenty-two studies (IF = 4, PS = 14, IF/PS = 4) met the inclusion criteria. There was an insufficient number of studies to assess the effect of IF, PS, or IF/PS on body weight. There was heterogeneity in the effect sizes among all comparisons (I2 ≥75%). Consuming larger portion sizes was associated with higher daily energy intake [295 kcal (202, 388), n = 24; weighted mean differences (WMD) (95% CI), n = comparisons], and increased frequency of ingestive events was associated with higher energy intake [203 kcal (76, 330), n = 10]. Results from RCTs support that larger PS and greater IF are both associated with higher energy consumption. However, there is insufficient information to determine chronic effects on body weight. This protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42018104757.

The role of chicken management practices in children's exposure to environmental contamination: a mixed-methods analysis.

BACKGROUND: Household chicken production presents an opportunity to promote child nutrition, but the benefits might be offset by increased environmental contamination. Using household surveys, direct observations, and in-depth interviews with woman caregivers, we sought to describe the relationship between chicken management practices and household exposure to environmental contamination, and assess barriers to adopting improved husbandry practices. METHODS: First, we analyzed baseline data from 973 households raising chickens in the two interventions arms from the Agriculture-to-Nutrition (ATONU) study in Ethiopia to assess the relationship between animal management practices and environmental exposures. Second, we conducted six-hour direct observations of children's environmental exposures in 18 households. Among these households, we analyzed in-depth interviews with child caregivers. RESULTS: Quantitative analyses showed that households raised approximately 11 chickens, had animal feces visible on the property 67% of the time, and children's hands were visibly dirty 38% of the time. Households with more chickens had lower exposure to animal feces. Having a chicken coop increased the risk of observing animal feces on the property by 30%, but among those with a coop, having an enclosed coop reduced that risk by 83%. Coops that were enclosed, had fencing, and were located further from homes were associated with a reduced risk of observing animal feces and an increased likelihood of children having clean hands. Direct observations showed that chicken coops were often poorly designed or not used. On average, 3 to 5 chickens were inside homes at a time, and livestock and domestic animals were frequently inside of houses and interacting with young children. In-depth interviews revealed that protection of animals, maintenance of household cleanliness and health, type of chicken (local versus improved) and resource constraints influenced management decisions. CONCLUSIONS: Improvements in chicken management practices could mitigate the exposure of household members to environmental contamination. Our findings highlight the need for training and resources to promote safe animal husbandry practices and optimal child health in nutrition-sensitive livestock projects. TRIAL REGISTRATION: Clinical trials number: NCT03152227 ; Retrospectively registered at ClinicalTrials.gov on May 12, 2012.

Soil zinc, serum zinc, and the potential for agronomic biofortification to reduce human zinc deficiency in Ethiopia.

Human zinc deficiency is a global public health problem. Many African soils are zinc deficient (ZnD), indicating fertilizers could increase crop yields and grain Zn levels, thereby increasing Zn in the food supply and alleviating human Zn deficiency. To analyze associations among soil Zn, human Zn deficiency, and child nutritional status, we combined the Ethiopian soil Zn map and the Ethiopian National Micronutrient Survey (ENMS). ENMS provides representative, georeferenced data on child nutritional status using anthropometry of children under five years old (CU5) and on human Zn deficiency among CU5 and women of reproductive age (WRA) using the recommended biomarker, serum Zn. ZnD soils mostly occur in lower altitudes, which are less populated and outside the main crop-producing areas. Serum Zn deficiencies were high, and correlated to soil Zn for children, but not for WRA. About 4 million Ethiopian CU5 are ZnD, and, of these, about 1.5 million live on low-Zn soils (< 2.5 mg/kg), while 0.3 million live on ZnD soils (< 1.5 mg/kg). Therefore, if Zn fertilizers are only applied on ZnD soils, their impact on child Zn deficiency may be limited. Greater impact is possible if Zn fertilizers are applied to soils with sufficient Zn for plant growth and if this results in increased grain Zn. Optimal soil Zn levels for plant and human nutrition may be different, and context-specific optimal levels for the latter must be determined to develop nutrition-sensitive fertilizer policies and recommendations.

Informal food environment is associated with household vegetable purchase patterns and dietary intake in the DECIDE study: Empirical evidence from food vendor mapping in peri-urban Dar es Salaam, Tanzania.

We study the relationship between the food environment (FE) and the food purchase patterns, dietary intakes, and nutritional status of individuals in peri-urban Tanzania. In Africa, the prevailing high density of informal vendors creates challenges to characterizing the FE. We present a protocol and tool developed as part of the Diet, Environment, and Choices of positive living (DECIDE) study to measure characteristics of the FE. We mapped 6627 food vendors in a peri-urban settlement of Dar es Salaam, of which over 60% were semi-formal and informal (mobile) vendors. We compute and compare four FE metrics inspired by landscape ecology-density, dispersion, diversity, and dominance-to better understand how the informal food environment relates to food purchase patterns, diets, and nutritional status among households with persons living with human immunodeficiency virus (PLHIV).

Exposure to aflatoxins and fumonisins and linear growth of children in rural Ethiopia: a longitudinal study.

OBJECTIVE: We hypothesise that exposure to aflatoxins and fumonisins, measured in serum, alters protein synthesis, reducing serum protein and insulin-like growth factor 1 (IGF-1), increasing inflammation and infection, leading to child's linear growth failure. DESIGN: Children 6-35 months, stratified by baseline stunting, were subsampled from an intervention trial on quality protein maize consumption and evaluated at two time-points. SETTING: Blood samples and anthropometric data were collected in the pre-harvest (August-September 2015) and post-harvest (February 2016) seasons in rural Ethiopia. PARTICIPANTS: 102 children (50 stunted and 52 non-stunted). RESULTS: Proportions of children exposed to aflatoxin G1, aflatoxin G2 and aflatoxin M1 were higher in the pre-harvest (8, 33 and 7, respectively) compared to post-harvest season (4, 28 and 4, respectively). The proportion of children exposed to any aflatoxin was higher in the pre-harvest than post-harvest season (51 % v. 41 %). Fumonisin exposure ranged from 0 % to 11 %. In joint statistical tests, aflatoxin exposure was associated with serum biomarkers of inflammation (C-reactive protein, α-1-glycoprotein) and protein status (transthyretin, lysine, tryptophan), IGF-1 and linear growth (all P < 0·01). However, exposure to specific aflatoxins was not significantly associated with any biomarkers or outcomes (all P > 0·05). CONCLUSIONS: Aflatoxin exposure among rural Ethiopian children was high, with large variation between seasons and individual aflatoxins. Fumonisin exposure was low. There was no clear association between aflatoxin exposure and protein status, inflammation or linear growth. A larger study may be needed to examine the potential biological interactions, and the assessment of aflatoxins in food is needed to determine sources of high exposure.

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia.

In an effort to address undernutrition among women and children in rural areas of low-income countries, nutrition-sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56-66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, 'dietary' and 'vitamin' knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men's engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.

Behavioural insights to support increased consumption of quality protein maize by young children: a cluster randomised trial in Ethiopia.

INTRODUCTION: Biofortified crops have tremendous potential to improve child nutrition. We tested whether complementing the distribution of quality protein maize (QPM) with a package of interventions informed by behavioural insights could support greater consumption of QPM by young children and translate into improved growth. METHODS: We conducted a cluster-randomised trial in Oromia, Ethiopia. Clusters of households with a child between 6 and 35 months were randomised into an arm receiving QPM seed only (320 households, 203 clusters) or an arm receiving QPM seed and a child consumption targeting intervention (290 households, 183 clusters). The intervention package included tools to help caregivers keep QPM separate from conventional maize and to earmark QPM specifically for child consumption, as well as encouragement regarding cooking QPM specifically for young children. We analysed the impact of the intervention on food storage, cooking and consumption behaviours and on anthropometric measures (weight-for-age, height-for-age z scores). RESULTS: The consumption targeting intervention increased the probability of child consumption of QPM in the past week by 17.3 percentage points (pp) (95% CI 9.4 pp to 25.1 pp; p<0.01), increased the probability that QPM flour was stored separately from conventional maize by 46.5 pp (95% CI 38.3 pp to 54.7 pp; p<0.01) and increased the probability that caregivers cooked QPM specifically for young children in the past week by 14.4 pp (95% CI 7.9 pp to 20.9 pp; p<0.01). These effects persisted, but were attenuated, 10 months postintervention. No significant effects on anthropometric outcomes were found. CONCLUSIONS: Enhancing the distribution of new, biofortified crop varieties with a consumption targeting campaign can change storage, cooking and consumption behaviours. However, these improved behaviours did not translate into increased growth in this setting. TRIAL REGISTRATION NUMBER: NCT02710760 and AEARCTR0000786.

Mining maize diversity and improving its nutritional aspects within agro-food systems.

Agro-food systems are undergoing rapid innovation in the world and the system's continuum is promoted at different scales with one of the main outcomes to improve nutrition of consumers. Consumer knowledge through educational outreach is important to food and nutrition security and consumer demands guide breeding efforts. Maize is an important part of food systems. It is a staple food and together with rice and wheat, they provide 60% of the world's caloric intake. In addition to being a major contributor to global food and nutrition security, maize forms an important part of the culinary culture in many areas of Africa, the Americas, and Asia. Maize genetics are being exploited to improve human nutrition with the ultimate outcome of improving overall health. By impacting the health of maize consumers, market opportunities will be opened for maize producers with unique genotypes. Although maize is a great source of macronutrients, it is also a source of many micronutrients and phytochemicals purported to confer health benefits. The process of biofortification through traditional plant breeding has increased the protein, provitamin A carotenoid, and zinc contents of maize. The objective of this paper is to review the innovations developed and promoted to improve the nutritional profiles of maize and outcomes of the maize agro-food system.

A Chicken Production Intervention and Additional Nutrition Behavior Change Component Increased Child Growth in Ethiopia: A Cluster-Randomized Trial.

BACKGROUND: Chicken production in the context of nutrition-sensitive agriculture may benefit child nutrition in low-income settings. OBJECTIVES: This study evaluated effects of 1) a chicken production intervention [African Chicken Genetic Gains (ACGG)], and 2) the ACGG intervention with nutrition-sensitive behavior change communication (BCC) [ACGG + Agriculture to Nutrition (ATONU)], on child nutrition and health outcomes and hypothesized intermediaries. METHODS: Forty ACGG villages received 25 genetically improved chickens and basic husbandry guidance; of these, 20 ACGG + ATONU villages in addition received a nutrition-sensitive behavior change and homegardening intervention; 20 control clusters received no intervention. We assessed effects of the interventions on height-for-age z scores (HAZ), weight-for-age z scores (WAZ), and weight-for-height z scores (WHZ) at 9 (midline) and 18 mo (endline) through unadjusted and adjusted ordinary least squares (OLS) regressions. We examined the interventions' effects on hypothesized intermediaries including egg production and consumption, dietary diversity, women's empowerment, income, child morbidities, anemia, and chicken management practices through OLS and log binomial models. RESULTS: Data included 829 children aged 0-36 mo at baseline. ACGG + ATONU children had higher midline HAZ [mean difference (MD): 0.28; 95% CI: 0.02, 0.54] than controls. The ACGG group had higher HAZ (MD: 0.28; 95% CI: 0.05, 0.50) and higher WAZ (MD: 0.18; 95% CI: 0.01, 0.36) at endline than controls; after adjusting for potential baseline imbalance, effects were similar but not statistically significant. At endline, differences in ACGG + ATONU children's HAZ and WAZ compared with controls were similar in magnitude to those of ACGG, but not statistically significant. There were no differences in anthropometry between the intervention groups. ACGG + ATONU children had higher dietary diversity and egg consumption than ACGG children at endline. Both interventions showed improvements in chicken management practices. The interventions did not increase anemia, diarrhea, fever, or vomiting, and the ACGG + ATONU group at midline showed reduced risk of fever. CONCLUSIONS: A chicken production intervention with or without nutrition-sensitive BCC may have benefited child nutrition and did not increase morbidity.This trial was registered at clinicaltrials.gov as NCT03152227.

Hemoglobin and hepcidin have good validity and utility for diagnosing iron deficiency anemia among pregnant women.

BACKGROUND/OBJECTIVES: Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. SUBJECTS/METHODS: We pooled data from an iron supplementation trial of 1500 iron-replete pregnant woman and a prospective cohort of 600 iron-deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age <27 weeks) and IDA at delivery. RESULTS: Hemoglobin had the largest AUC for crude ID (0.96), while hepcidin had the largest AUC for corrected ID (0.80). The optimal hepcidin cutoff for the diagnosis of corrected IDA based on maximal sensitivity and specificity was ≤1.6 µg/L. An hepcidin cutoff of <4.3 µg/L had a sensitivity of 95% for regression-corrected ID. Among iron-replete women who did not receive iron, the association of baseline hemoglobin >110 g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin >1.6 µg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). CONCLUSIONS: Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin's high costs may limit its use.

Market food diversity mitigates the effect of environment on women's dietary diversity in the Agriculture to Nutrition (ATONU) study, Ethiopia.

OBJECTIVE: In Ethiopia, women's dietary diversity is low, primarily due to poor food availability and access, both at home and market level. The present study aimed to describe market access using a new definition called market food diversity (MFD) and estimate the impact of MFD, crop and livestock diversity on dietary diversity among women enrolled in the Agriculture to Nutrition (ATONU) trial. DESIGN: Baseline cross-sectional data collected from November 2016 to January 2017 were used for the analysis. Availability of foods in markets was assessed at the village level and categorized into nine food groups similar to the dietary diversity index for women. Bivariate and multivariate mixed-effects regression analyses were conducted, adjusted for clustering at the village level. SETTING: Chicken-producing farmers in rural Ethiopia.ParticipantsWomen (n 2117) aged 15-49 years. RESULTS: Overall, less than 6 % of women met the minimum dietary diversity (≥5 food groups) and the most commonly consumed food groups were staples and legumes. Median MFD was 4 food groups (interquartile range: 2-8). Multivariate models indicated that women's dietary diversity differed by livestock diversity, food crop diversity and agroecology, with significant interaction effects between agroecology and MFD. CONCLUSIONS: Women's dietary diversity is poor in Ethiopia. Local markets are variable in food availability across seasons and agroecological zones. The MFD indicator captures this variability, and women who have access to higher MFD in the highland agroecological zone have better dietary diversity. Thus, MFD has the potential to mitigate the effects of environment on women's dietary diversity.

Biofortified Maize Can Improve Quality Protein Intakes among Young Children in Southern Ethiopia.

Quality protein maize (QPM) varieties are biofortified, or nutritionally improved, to have higher lysine and tryptophan levels to increase quality protein intakes particularly among young children. This study assesses adequacy of children's protein intakes in Ethiopia, where QPM is being promoted, accounting for protein quality and seasonal dietary changes, and estimates potential increases in intakes if QPM replaced conventional maize in diets. Diets of randomly sampled children aged 12⁻36 months in rural southern Ethiopia (n = 218) were assessed after harvest during relative food security and 3⁻4 months later during relative food insecurity using 24-h weighed food records. Diets were analyzed for protein adequacy, accounting for protein quality using the protein digestibility corrected amino acid score (PDCAAS) method, and potential improvements from QPM substitution were estimated. Stunting was prevalent (38%) at the first assessment. Across seasons, 95⁻96% of children consumed maize, which provided 59⁻61% of energy and 51⁻55% of total protein in 24 h. Dietary intakes decreased in the food insecure season, though children were older. Among children no longer breastfeeding, QPM was estimated to reduce inadequacy of utilizable protein intakes from 17% to 13% in the food secure season and from 34% to 19% in the food insecure season. However, breastfed children had only 4⁻6% inadequate intakes of utilizable protein, limiting QPM's potential impact. Due to small farm sizes, maize stores from home production lasted a median of three months. Young Ethiopian children are at risk of inadequate quality protein intakes, particularly after breastfeeding has ceased and during food insecurity. QPM could reduce this risk; however, reliance on access through home production may result in only short-term benefits given the limited quantities of maize produced and stored.

Harnessing University Strengths in Multisectoral Collaborations for Planetary Health.

Although significant achievements in human health have been made globally, progress has been made possible, in part, through unconstrained use of natural resources. As the health of our planet worsens, human health is also endangered. Scholars and policymakers from diverse disciplines highlighted complex, multisectoral approaches for addressing poor dietary intake, over- and undernutrition, and chronic diseases in sub-Saharan Africa at the Agriculture, Nutrition, Health, and the Environment in Africa Conference held at Harvard University on 6-7 November 2017. A planetary health approach to addressing these challenges offers a unique opportunity to advance solutions for environmental and social factors that influence agriculture, nutrition, and overall health in the larger context of rapid population growth and transitions in food systems and livelihoods. This paper outlines 3 key avenues for universities to promote science at the intersection of public health and the environment in sub-Saharan Africa.

Associations among High-Quality Protein and Energy Intake, Serum Transthyretin, Serum Amino Acids and Linear Growth of Children in Ethiopia.

Limited evidence is available on the associations of high-quality protein and energy intake, serum transthyretin (TTR), serum amino acids and serum insulin-like growth factor-1 (IGF-1) with linear growth of young children. Data collected during the baseline of a randomized control trial involving rural Ethiopian children aged 6⁻35 months (n = 873) were analyzed to evaluate the associations among height/length-for-age z-scores, dietary intakes, and these biomarkers (i.e., serum level of TTR, IGF-1, tryptophan and lysine, and inflammation). The prevalence of stunting was higher for children >23 months (38%) than ≤23 months (25%). The prevalence of inflammation was 35% and of intestinal parasites 48%. Three-quarters of the children were energy deficient, and stunted children had lower daily energy intake that non-stunted children (p < 0.05). Intakes of tryptophan, protein, and energy, and serum levels of tryptophan and IGF-1 were positively correlated with the linear growth of children. Controlling for inflammation, intestinal parasites, and sociodemographic characteristics, daily tryptophan (b = 0.01, p = 0.001), protein (b = 0.01, p = 0.01) and energy (b = 0.0003, p = 0.04) intakes and serum TTR (b = 2.58, p = 0.04) and IGF-1 (b = 0.01, p = 0.003) were positively associated with linear growth of children. Linear growth failure in Ethiopian children is likely associated with low quality protein intake and inadequate energy intake. Nutrition programs that emphasize improved protein quantity and quality and energy intake may enhance the linear growth of young children and need to be further investigated in longitudinal and interventional studies.