The Cost and Cost-Effectiveness of an Integrated Wasting Prevention and Screening Intervention Package in Burkina Faso and Mali.

BACKGROUND: Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting. OBJECTIVES: This study's objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC). METHODS: Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child-contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage. RESULTS: In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali. CONCLUSIONS: Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal.

Background: The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements. Objective: This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Methods: We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60. Results: In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%). Conclusions: The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

Effects of an integrated poultry value chain, nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial.

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2-4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15-49 years with an index child aged 2-4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04-0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03-0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

Stories of change in nutrition in Burkina Faso 1992-2018: a macro-level perspective.

Looking back at the development of successful enabling environments for nutrition may inform policymakers on how to accelerate progress to end all forms of malnutrition by 2030. As under-five stunting declined substantially in Burkina Faso, from a peak at 45% in 1998/99 to 25% in 2018, we analyzed through a stories of change approach the actors, ideas, initiatives, policies and capacities which enabled wide-scale nutrition progress. We triangulated findings from policy analysis, stakeholder mapping, and national-level semi-structured interviews (n = 20). We found that since 2002, nutrition has been anchored in the Ministry of Health, where leadership advocated for the creation of coordination bodies, enabling a coherent defining of nutrition and laying groundwork for better integration of nutrition into and prioritization of nutrition by the health and tangential ministries. Under the leadership of the Ministry of Health and its partners, horizontal and vertical coherence in nutrition action increased, through effective cooperation between nutrition actors; increasing intersectoral collaboration, particularly with the influential agriculture sector; and increasing funding to support nutrition-sensitive programming and build the capacity of nutrition staff. Nevertheless, sustainably organizing funding and human resources at the decentralized level remained challenging, in a context of emerging threats such as climate change and insecurity. Burkina Faso's health sector's success in creating an enabling environment for nutrition may have contributed to improvements in child nutrition alongside other sectoral improvements. Enhancing accountability of the Health, Agriculture, WASH, Education and Social Protection sectors and empowering decentralized bodies to take nutrition-relevant decisions may help accelerating progress in nutrition.

Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe.

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition's upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.

Stories of change in nutrition in Burkina Faso 1992-2018: a micro-level perspective.

Looking back at what has effectively improved nutrition may inform policy makers on how to accelerate progress to end all forms of malnutrition by 2030. As under-five stunting declined substantially in Burkina Faso, we analyzed its nutrition story at the micro-level. We conducted a regression-decomposition analysis to identify demographic and health drivers associated with change in height-for-age using longitudinal, secondary, nationally-representative data. We triangulated results with findings from semi-structured community interviews (n = 91) in two "model communities" with a history of large stunting reduction. We found that improvement in immunization coverage, assets accumulation and reduction in open defecation were associated with 23%, 10% and 6.1% of the improvement in height-for-age, respectively. Associations were also found with other education, family planning, health and WASH indicators. Model communities acknowledged progress in the coverage and quality of nutrition-specific and nutrition-sensitive sectoral programs co-located at the community level, especially those delivered through the health and food security sectors, though delivery challenges remained in a context of systemic poverty and persistent food insecurity. Burkina Faso's health sector's success in improving coverage of nutrition and healthcare programs may have contributed to improvements in child nutrition alongside other programmatic improvements in the food security, WASH and education sectors. Burkina Faso should continue to operationalize sectoral nutrition-sensitive policies into higher-quality programs at scale, building on its success stories such as vaccination. Community leverage gaps and data gaps need to be filled urgently to pressure for and monitor high coverage, quality delivery, and nutrition impact of agriculture, education, and WASH interventions. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01274-z.

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.

Four-Year Effects of a 2-Year Nutrition and Gender Sensitive Agricultural Program on Women's Nutritional Status, Knowledge, and Empowerment in Rural Burkina Faso.

BACKGROUND: Little is known about the sustained effects of nutrition- and gender-sensitive agricultural programs (NSAPs) after they end. OBJECTIVES: To examine the 4-year effects (2010-2014) of a 2-year NSAP (2010-2012) on women's outcomes in rural Burkina Faso. METHODS: We used baseline (2010) and endline (2012) data from a cluster-randomized controlled trial of Helen Keller International's Enhanced Homestead Food Production (EHFP) program and baseline (2014) data from a new program. We included 134 women: 82 who participated in the 2-year EHFP program (treatment) and 52 who did not (control). We examined program (2010-2012), post-program (2012-2014), and overall 4-year effects (2010-2014) using difference-in-difference analysis (DID). RESULTS: We found significant positive program effects (2010-2012) on women's underweight prevalence (DID: 16.44 percentage points [pp]; P = .09) and on women's knowledge about appropriate age to introduce liquids (DID: 28.40 pp; P = .01). Although there were no significant postprogram effects (2012-2014), differences found in 2012 between the treatment and control group were sustained resulting in an overall 4-year (2010-2014) reduction in women's underweight prevalence (DID: 18.26 pp; P = .02) and an improvement in women's knowledge about appropriate age to introduce liquids (DID: 31.29 pp; P = .02). We observed no postprogram or overall 4-year effects on women's knowledge of child feeding and handwashing practices or women's empowerment. CONCLUSIONS: Nutrition- and gender-sensitive agricultural programs demonstrate potential for sustained improvements in women's nutritional status and nutritional knowledge. Postprogram assessments of NSAPs should be embedded in program evaluations to help further understand the potential of NSAPs to generate sustainable impacts on women's outcomes.

A Poultry Value Chain Intervention Promoting Diversified Diets Has Limited Impact on Maternal and Child Diet Adequacy during the Lean Season in a Cluster Randomized Controlled Trial.

BACKGROUND: Soutenir l'Exploitation Familiale pour Lancer l'Élevage des Volailles et Valoriser l'Économie Rurale (SELEVER) is a nutrition- and gender-sensitive poultry value chain project designed and implemented by international nongovernmental organization Tanager, which consists of poultry market facilitation and behavior change activities aiming at increasing poultry production and improving diets without free inputs transfer. OBJECTIVES: The study aimed at assessing the impact of SELEVER on diets of women and children during the lean season. METHODS: Within a cluster randomized controlled trial, 45 communes were assigned to 1 of 3 arms, including 1) SELEVER interventions, 2) SELEVER with an intensive hygiene and sanitation component (SELEVER + WASH), and 3) a control group without intervention. Two rounds of survey were conducted 2 y apart during the lean season. Primary dietary outcomes were the probability of adequacy (PA) of iron, zinc, and vitamin A intakes; mean PA of 11 micronutrients and individual dietary diversity score collected through quantitative 24-h recall in longitudinal samples of women and index children (2-4 y old) in 1054 households; and minimum acceptable diet in the repeated cross-sectional sample of their younger sibling aged 6-23 mo. Impacts were assessed by intention-to-treat ANCOVA. RESULTS: Relative to control, SELEVER interventions (groups 1 + 2) increased the PA of iron intakes in women by 1.8 percentage points (pp) (P = 0.030). We found no further impact on primary outcomes, although egg consumption increased in index children (+0.73 pp, P = 0.010; +0.69 kcal/d, P = 0.036). Across the 3 groups, we observed negative effects of SELEVER on the PA of zinc intakes in women relative to SELEVER + WASH (-4.1 pp, P = 0.038) and on a variety of secondary dietary outcomes relative to both other groups. The study was registered on the ISCRCTN registry (ISRCTN16686478). CONCLUSIONS: Information-only-based value chain interventions may not have meaningful positive effects on diets of women and children in the lean season in settings with largely inadequate diets. We found suggestive evidence that synergies between intervention components may have introduced heterogeneity in effects on diet.

Fortified Balanced Energy-Protein Supplements Increase Nutrient Adequacy without Displacing Food Intake in Pregnant Women in Rural Burkina Faso.

BACKGROUND: In many low- and middle-income countries, the prevalence of energy and nutrient deficiencies is high among pregnant women. Balanced energy-protein (BEP) supplements are a promising strategy to cover nutritional requirements during pregnancy and improve birth outcomes. However, the displacement of nutrient-dense foods by BEP might attenuate the efficacy of supplementation. OBJECTIVE: This cross-sectional study of participants in a randomized controlled trial evaluated the difference in energy and macro- and micronutrient intakes, food groups, and nutrient adequacy between a control and intervention group receiving either a daily iron-folic acid (IFA) tablet or IFA and BEP supplement during pregnancy, respectively. METHODS: We collected a single multiple-pass 24-h recall from 470 pregnant women from the MIcronutriments pour la SAnté de la Mère et de l'Enfant (MISAME) III study that investigates the efficacy of BEP supplementation on birth outcomes and infant growth. Dietary intake (median and IQR) and nutrient adequacy were assessed using individual recipes and preparation methods of mixed dishes for each participant. Linear regression models were fitted to compare energy and nutrient intakes. RESULTS: Dietary energy, and macro- and micronutrient intakes were significantly higher among women in the intervention group when including BEP [2329 kcal/d (1855, 3008 kcal/d) compared with 1942 kcal/d (1575, 2405 kcal/d) in the control group (all P < 0.001)]. The difference in median energy intake (448 kcal/d; 95% CI: 291, 605 kcal/d) was approximately equivalent to a daily dose of the BEP supplement (393 kcal). Nutrient adequacy ratios for both groups were low for all micronutrients (between 0.02 and 0.66), when excluding BEP (except iron and folic acid, due to standard supplemental doses) from analysis. However, nutrient intakes increased to the Estimated Average Requirement for pregnant women when including BEP supplements. CONCLUSIONS: BEP supplementation increases energy and macro- and micronutrient intakes among pregnant women and fills nutrient gaps without displacing food intake. This trial was registered at clinicaltrials.gov as NCT03533712 (https://clinicaltrials.gov/ct2/show/NCT03533712).

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.

Standard Minimum Dietary Diversity Indicators for Women or Infants and Young Children Are Good Predictors of Adequate Micronutrient Intakes in 24-59-Month-Old Children and Their Nonpregnant Nonbreastfeeding Mothers in Rural Burkina Faso.

BACKGROUND: Simple proxy indicators are needed to assess and monitor micronutrient intake adequacy of vulnerable populations. Standard dichotomous indicators exist for nonpregnant women of reproductive age and 6-23-mo-old children in low-income countries, but not for 24-59-mo-old children or pregnant or breastfeeding women. OBJECTIVES: This study aimed to evaluate the performance of 2 standard food group scores (FGSs) and related dichotomous indicators to predict micronutrient adequacy of the diet of rural Burkinabe 24-59-mo-old children and women of reproductive age by physiological status. METHODS: A 24-h recall survey was conducted at dry season among 1066 pairs of children and caregivers. Micronutrient adequacy was evaluated by the mean probability of adequacy (MPA) of intake over 11 micronutrients. Proxy indicators were FGS-10 [10 food groups based on the FAO/FHI360 minimum dietary diversity for women (MDD-W) guidelines] and related MDD-W (FGS-10 ≥5); and FGS-7 [7 groups based on the WHO infant and young child (IYC) feeding MDD guidelines] and related MDD-IYC (FGS-7 ≥4). RESULTS: FGS-10 and FGS-7 were similar across children and women (∼3 groups). FGS-10 performed better than FGS-7 to predict MPA in children (Spearman rank correlation = 0.59 compared with 0.50) and women of all 3 physiological statuses (Spearman rank correlation = 0.53-0.55 compared with 0.42-0.52). MDD-W and MDD-IYC performed well in predicting MPA >0.75 in children and MPA >0.6 in nonpregnant nonbreastfeeding (NPNB) women, but a 4-group cutoff for FGS-10 allowed a better balance between sensitivity, specificity, and proportion of correct classification. MPA levels for pregnant and breastfeeding women were too low to assess best cutoff points. CONCLUSIONS: MDD-IYC or an adapted MDD-W (FGS-10 ≥4 instead of FGS-10 ≥5) can be extended to 24-59-mo-old children and NPNB women in similar-diet settings. The inadequacy of micronutrient intakes in pregnant and breastfeeding women warrants urgent action. Micronutrient adequacy predictors should be validated in populations where a higher proportion of these women do meet dietary requirements.

Validation of 24-h dietary recall for estimating nutrient intakes and adequacy in adolescents in Burkina Faso.

Data on dietary nutrient intakes of adolescents in low- and middle-income countries (LMIC) is lacking partly due to the absence of validation studies of the 24-h recall method in adolescents. We conducted a validation study of 24-h recall (24HR) compared with observed weighed records (OWR) in adolescents (n = 132, 10-11 years; n = 105, 12-14 years). Dietary data were collected for the same day by both methods by conducting the 24HR the day after the OWR. For OWR, all foods consumed by adolescents from the first to last meal of the day were weighed; for 24HR adolescents reported foods consumed using portion aids. Food intakes were converted to nutrients. Nutrient intakes by both methods were tested for equivalence by comparing the ratios (24HR/OWR) with equivalence margins of within ±10%, 15% and 20% of the ratio. Prevalences of inadequacy (POIs) were obtained using the NCI method. Mean ratios for energy were 0.88 and 0.92, for younger and older adolescents, respectively, and other nutrients ranged between 0.84 and 1.02. Energy intakes were equivalent within the 15% bound, and most nutrients fell within the 20% bound. POI was overestimated by 24HR, but differences were less than 25 percentage points for most nutrients. Half of adolescents omitted foods in recalls, mainly sweet or savoury snacks, fruits and beverages. Our study showed that adolescents underestimated intakes by 24HR; however, the degree of underestimation was generally acceptable for 12-14-year-olds within a bound of 15%. Errors could possibly be reduced with further training and targeted probing.

Using structural equation modelling to understand the contributors to anaemia among young Burkinabe children.

Anaemia is a persistent problem among young Burkinabe children, yet population-specific information on its determinants is scant. We used baseline data from an evaluation of Helen Keller International's Enhanced Homestead Food Production Program (n=1210 children) to quantify household-, mother-, and child-level factors associated with anaemia in Burkinabe children aged 6-12 months. We used structural equation modelling to assess a theoretical model, which tested four categories of factors: (a) household food security and dietary diversity, (b) household sanitation and hygiene (latrine and poultry access and bednet ownership), (c) maternal factors (anaemia, stress, cleanliness, and health, hygiene and feeding knowledge and practices), and (d) child nutrition and health (iron deficiency (ID), retinol binding protein (RBP), malaria, and inflammation). The model also included household socio-economic status, size, and polygamy; maternal age and education; and child age and sex. Results showed that ID, malaria, and inflammation were the primary direct determinants of anaemia, contributing 15%, 10%, and 10%, respectively. Maternal knowledge directly explained improved child feeding practices and household bednet ownership. Household dietary diversity directly explained 18% of child feeding practices. Additionally, RBP, child age and sex, and maternal anaemia directly predicted child haemoglobin. Our findings suggest that program effectiveness could be increased by addressing the multiple, context-specific contributors of child anaemia. For young Burkinabe children, anaemia control programs that include interventions to reduce ID, malaria, and inflammation should be tested. Other potential intervention entry points suggested by our model include improving maternal knowledge of optimal health, hygiene, and nutrition practices and household dietary diversity.

Lipid-based nutrient supplements and all-cause mortality in children 6-24 months of age: a meta-analysis of randomized controlled trials.

BACKGROUND: Undernutrition is associated with an elevated risk of mortality among children in low- and middle-income countries. Small-quantity lipid-based nutrient supplements (LNS) have been evaluated as a method to prevent undernutrition and improve infant development, but the effects on mortality are unknown. OBJECTIVE: Our objective was to evaluate the effect of LNS on all-cause mortality among children 6-24 mo old. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials of LNS designed to prevent undernutrition, with or without other interventions. Literature was searched in May 2019 and trials were included if they enrolled children between 6 and 24 mo old and the period of supplementation lasted ≥6 mo. We extracted data from participant flow diagrams and contacted study investigators to request data. We conducted a meta-analysis to produce summary RR estimates. RESULTS: We identified 18 trials conducted in 11 countries that enrolled 41,280 children and reported 586 deaths. The risk of mortality was lower in the LNS arms than in the non-LNS comparison arms (RR: 0.73; 95% CI: 0.59, 0.89; 13 trials). Estimates were similar when trials with maternal LNS intervention arms were added or when alternative formulations of LNS were excluded. The results appeared stronger in trials in which LNS were compared with passive control arms. Excluding these contrasts and only comparing multicomponent arms with LNS groups and comparison groups that contained all the same components without LNS attenuated the effect estimate (RR: 0.82; 95% CI: 0.61, 1.10). CONCLUSIONS: LNS provided for the prevention of undernutrition may reduce the risk of mortality, but more trials with appropriate comparison groups allowing isolation of the effect of LNS alone are needed.This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019128718.

Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso.

BACKGROUND: Community management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM. METHODS AND FINDINGS: We used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P < 0.001; longitudinal study: +23 pp, 95% CI 17-29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09-16, P = 0.047; longitudinal study: +7.7 pp, 95% CI -1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75-1.3, P = 0.88), or AM prevalence (cross-sectional study: -0.46 pp, 95% CI -4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage. CONCLUSIONS: Adding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02245152.

Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali.

BACKGROUND: Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. METHODS AND FINDINGS: A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. CONCLUSIONS: Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. TRIAL REGISTRATION: ClinicalTrials.gov NCT02323815.

Poultry husbandry, water, sanitation, and hygiene practices, and child anthropometry in rural Burkina Faso.

Poultry production in low income countries provides households with nutrient-rich meat and egg products, as well as cash income. However, traditional production systems present potential health and nutrition risks because poultry scavenging around household compounds may increase children's exposure to livestock-related pathogens. Data from a cross-sectional survey were analysed to examine associations between poultry, water, sanitation, and hygiene practices, and anthropometric indicators in children (6-59 months; n = 3,230) in Burkina Faso. Multilevel regression was used to account for the hierarchical nature of the data. The prevalence of stunting and wasting in children 6-24 months was 19% and 17%, respectively, compared with a prevalence of 26% and 6%, respectively, in children 25-60 months. Over 90% of households owned poultry, and chicken faeces were visible in 70% of compounds. Caregivers reported that 3% of children consumed eggs during a 24-hr recall. The presence of poultry faeces was associated with poultry flock size, poultry-husbandry and household hygiene practices. Having an improved water source and a child visibly clean was associated with higher height-for-age z scores (HAZ). The presence of chicken faeces was associated with lower weight-for-height z scores, and no associations were found with HAZ. Low levels of poultry flock size and poultry consumption in Burkina Faso suggest there is scope to expand production and improve diets in children, including increasing chicken and egg consumption. However, to minimize potential child health risks associated with expanding informal poultry production, research is required to understand the mechanisms through which cohabitation with poultry adversely affects child health and design interventions to minimize these risks.