Epigenetic studies in children at risk of stunting and their parents in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: In 2020, an estimated 150 million children under the age of 5 years were stunted. Stunting results from early-life adversity and it is associated with significant physical and cognitive deficit, lifelong socioeconomic disadvantage and reduced life expectancy. There is a need to understand the causes of stunting and its effects in order to develop strategies to avoid it and to mitigate the consequences once stunting has occurred. Epigenetics is an important mechanism through which early-life factors are thought to influence biological function, with long-term consequences. We describe a series of epigenetic studies designed to understand how early-life adversity results in stunting and to inform the development of practical tools such as predictive markers and therapeutic targets. This work is part of the UKRI GCRF Action Against Stunting Hub. METHODS AND ANALYSIS: The project-in India, Indonesia and Senegal-comprises an observational study of mothers, fathers, and offspring (n=500) spanning the first 1000 days of life, and an intervention study in each country. Epigenetic status (DNA methylation) is determined in saliva from babies collected within 1 month of birth and again at 18 months of age, and from mothers and fathers around the time of birth. Epigenome-wide analysis is carried out using the Illumina EPIC array, augmented by high-definition sequencing approaches. Statistical analysis is carried out at the level of candidate genes/regions, higher dimensional epigenetic states and epigenome-wide association. Data analysis focuses on the determinants of stunting, the effectiveness of interventions, population comparisons and the link between epigenetics and other thematic areas, which include anthropometry, microbiome, gut health, parasitology, cognition, nutrition, food hygiene and water sanitation, food systems and the home environment. ETHICS AND DISSEMINATION: This study has been approved by the relevant Ethics Committees in Indonesia, India and Senegal, and the UK. Research data will be published and posted in public repositories.

Understanding the role of household hygiene practices and foodborne disease risks in child stunting: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: Environmental hygiene and food safety are important determinants of child stunting. This research aims to explore the relationship between child stunting and household hygiene practices and behaviours, including the availability of water, sanitation and hygiene (WASH) facilities; the use of safe food and good quality drinking water (especially when used for complementary feeding); hygienic practices in food transport, storage and preparation and the control of cross-contamination from animals, their produce and waste. METHODS AND ANALYSIS: This study is part of a wider observational study which aims to investigate the interdisciplinary factors contributing to child stunting using a 'whole child' paradigm. The observational study recruits women during pregnancy in Hyderabad, India, Lombok, Indonesia and Kaffrine, Senegal, and dyads (ie, 500 mother-infant pairs per country) are followed longitudinally up to 24 months after birth. Within the interdisciplinary niche, the study here has developed tools to investigate the potential exposure pathways to environmental pathogen contamination of foods and water. Holistic WASH and food safety data collection tools have been developed to explore exposure pathways at the household level, including: (1) survey questionnaires; (2) spot-checks; (3) biological sampling of drinking water, food and domestic surfaces and (4) direct observation. An integrated analytical approach will be used to triangulate the evidence in order to examine the relationships between child stunting, WASH and food safety behaviours. ETHICS AND DISSEMINATION: Ethical approval of the study was granted by the ethics committee of the LSHTM, RVC, ILRI, ICMR, IIPHG, SEAMEO-RECFON, University of Cheikh Anta Diop. Findings of the study will be disseminated through publication in peer-reviewed journals, relevant international conferences, public engagement events, and policy-maker and stakeholder events.

Assessment of the role of gut health in childhood stunting in a multisite, longitudinal study in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol.

INTRODUCTION: Childhood stunting has a complex aetiology, with poor gut health being an important contributor. This study will assess inter-relationships between maternal and infant gut health indices and infant linear growth. Inter-relationships between gut health indices, systemic inflammation and growth hormones in early childhood will also be assessed. METHODS AND ANALYSIS: A longitudinal observational study of cohorts of 600 newborns and their mothers in India, Indonesia and Senegal will be conducted. Women will be recruited during pregnancy and their children followed up to age 24 months. Stool, urine and blood samples will be collected from the women and children for assessments of helminthic and protozoal parasites, bacterial pathogens, faecal microbiota taxa, biomarkers of environmental enteric dysfunction, systemic inflammation and growth hormones. Child anthropometric measurements will be collected at birth and at ages 3, 6, 9, 12, 18 and 24 months. The gut health indices will be integrated with cohort data from other Action Against Stunting Hub (AASH) workstreams for interdisciplinary analyses of childhood stunting and the development of a new typology of stunting. DISCUSSION: This study will advance scientific understanding of the role of gut health in childhood stunting and will contribute to a broader knowledge of the complex aetiology of this condition as part of the interdisciplinary AASH research to reduce the global burden of childhood stunting. ETHICS AND DISSEMINATION: This study has been approved by the relevant Ethics Committees in Senegal, India, and Indonesia and LSHTM. The results will be submitted for publication in peer-reviewed journals.

Anthropometric, biochemical, dietary, morbidity and well-being assessments in women and children in Indonesia, India and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: Child stunting has a complex aetiology, especially in the first 1000 days of life. Nutrition interventions alone have not produced expected impacts in reducing/preventing child stunting, indicating the importance of understanding the complex interplay between environmental, physiological and psychological factors influencing child nutritional status. This study will investigate maternal and child nutrition, health and well-being status and associated factors through the assessment of: (1) anthropometry, (2) biomarkers of nutrition and health status, (3) dietary intakes, (4) fetal growth and development, (5) infant morbidity, (6) infant and young child feeding (IYCF) and (7) perinatal maternal stress, depression and social support. METHODS: This study will be conducted in a prospective pregnancy cohort in India, Indonesia and Senegal. Pregnant women will be recruited in the second (Indonesia, Senegal) and third (India) trimester of pregnancy, and the mother and infant dyads followed until the infant is 24 months of age. During pregnancy, anthropometric measures will be taken, venous blood samples will be collected for biochemical assessment of nutrition and health status, dietary intakes will be assessed using a 4-pass-24-hour dietary recall method (MP24HR), fetal ultrasound for assessment of fetal growth. After birth, anthropometry measurements will be taken, venous blood samples will be collected, MP24HR will be conducted, infant morbidity and IYCF practices will be assessed and a sample of breastmilk will be collected for nutrient composition analyses. Perinatal maternal stress, depression, social support and hair cortisol levels (stress) will be measured. The results from this study will be integrated in an interdisciplinary analysis to examine factors influencing infant growth and inform global efforts in reducing child stunting. ETHICS AND DISSEMINATION: Ethical approval was granted by the Ethics Committee of the London School of Hygiene and Tropical Medicine (17915/RR/17513); National Institute of Nutrition (ICMR)-Ministry of Health and Family Welfare, Government of India (CR/04/I/2021); Health Research Ethics Committee, University of Indonesia and Cipto Mangunkusumo Hospital (KET-887/UN2.F1/ETIK/PPM.00.02/2019); and the Comité National d'Ethique pour la Recherche en Santé, Senegal (Protocole SEN19/78); the Royal Veterinary College (URN SR2020-0197) and the International Livestock Research Institute Institutional Research Ethics Committee (ILRI-IREC2020-33). Results will be published in peer-reviewed journals and disseminated to policy-makers and participating communities.

Mother's Dietary Diversity and Underweight among Under-five Rural Children in Three Major Agro-climatic Zones, Myanmar.

Background: Children's growth is essential to nutritional status and population health. In 2015, 18.9% of under-five children in Myanmar were underweight, and only 25% of 6-23-month-old children had the minimum dietary diversity (MDD). Objectives: We conducted this study to assess the association between mother's dietary diversity score (DDS) and underweight among under-five children. Materials and Methods: This study analyzed data from the "Livelihood and Food Security Survey," a cross-sectional study conducted in 2016 in rural areas in Chin State, Magway, and Ayeyarwady regions. It included 2029 under-five children and used underweight as an outcome variable. We calculated DDSs for mothers of under-five children using the MDD-women methodology. The prevalence of underweight and MDD were estimated. A multivariable binary logistic regression analysis estimated odds ratios and 95% confidence intervals (CIs). Results: The overall prevalence of underweight was 26.3% (95% CI: 23.4, 29.3), and that of the mother with a MDD score was 29.2% (95% CI: 26.0, 32.8). Multivariable binary logistic regression analysis showed that the prevalence of underweight in children was higher if maternal MDD was not met (adjusted odds ratio = 1.41; 95% CI: 1.05, 1.89). Conclusions: The children's age, types of toilets, and region were independent predictors of being underweight. Underweight among under-five children and diverse food consumption among their mothers are critical public health challenges in rural Myanmar that require urgent action. Nutrition education for rural communities should focus on feeding children with locally available diverse foods.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017).

OBJECTIVE: The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar. DESIGN: Repeated cross-sectional surveys in three states of Myanmar. SETTING: Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta). PARTICIPANTS: From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations. RESULTS: Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting. CONCLUSIONS: Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Increased vegetable intake improves glycaemic control in adults with type 2 diabetes mellitus: a clustered randomised clinical trial among Indonesian white-collar workers.

Dietary patterns high in fibre and green leafy vegetables have shown an inverse association with lower risks of type 2 diabetes mellitus and improved glycaemic control. The study aimed to investigate the effects of increased vegetable intake and conventional diabetes diet on glycaemic control among type 2 diabetic patients. White-collar workers from one telecommunication company with type 2 diabetes were assigned to two treatment groups by cluster randomisation. Individuals with known type 2 diabetes and poor glycaemic control (HbA1c ≥8 g%) were eligible and a total of 84 subjects were recruited. Subjects in the intervention group (n 41) were offered to attend seminars and intensive coaching weekly to encourage them to increase raw vegetable intake. The control group (n 40) followed the conventional diet according to the guidelines of the Indonesian Society of Endocrinology. Glycated haemoglobin (HbA1c), plasma lipids, blood pressure, vegetable intake and anthropometric measurements were assessed at baseline and end line of 12 weeks intervention. A regression analysis was conducted using differences in HbA1C between baseline and 12 weeks as the dependent variable. Student's t test was conducted for the changes of biochemical indicators from baseline to end line during the period of 12 weeks intervention. Glycaemic control improved in the intervention group and mean HbA1C, fasting blood glucose and post-prandial blood glucose in the intervention group decreased significantly along with body weight, waist circumference and total cholesterol. The finding suggested that the intervention which emphasised raw vegetable intake contributed to improved glycaemic control among Indonesian adults with type 2 diabetes mellitus.

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province, Indonesia.

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster-randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0-23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age-appropriate breastfeeding and bottle-feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35-2.53) and age-appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07-1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41-0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.

Effect of an Integrated Package of Nutrition Behavior Change Interventions on Infant and Young Child Feeding Practices and Child Growth from Birth to 18 Months: Cohort Evaluation of the Baduta Cluster Randomized Controlled Trial in East Java, Indonesia.

The need for a multisectoral approach to tackle stunting has gained attention in recent years. Baduta project aims to address undernutrition among children during their first 1000 days of life using integrated nutrition-specific and nutrition-sensitive interventions. We undertook this cohort study to evaluate the Baduta project's effectiveness on growth among children under 2 years of age in two districts (Sidoarjo and Malang Districts) in East Java. Six subdistricts were randomly selected, in which three were from the intervention areas, and three were from the control areas. We recruited 340 pregnant women per treatment group during the third trimester of pregnancy and followed up until 18 months postpartum. The assessment of breastfeeding and complementary feeding practices used standard infant and young child feeding (IYCF) indicators in a tablet-based application. We measured weight and length at birth and every three-months after that. The enumerators met precision and accuracy criteria following an anthropometry standardization procedure. Among the breastfed children, the percentage of children who achieved the minimum dietary diversity score (DDS) and minimum acceptable diet (MAD) was higher for the intervention group than the comparison group across all age groups. The odd ratios were 3.49 (95% CI: 2.2-5.5) and 2.79 (95% CI: 1.7-4.4) for DDS and 3.49 (95% CI: 2.2-5.5) and 2.74 (95% CI: 1.8-5.2) for MAD in the 9-11 month and 16-18-month age groups, respectively. However, there was no significant improvement in growth or reduction in the prevalence of anemia. The intervention was effective in improving the feeding practices of children although it failed to show significant improvement in linear growth of children at 18 months of age.

Evaluation of a Package of Behaviour Change Interventions (Baduta Program) to Improve Maternal and Child Nutrition in East Java, Indonesia: Protocol for an Impact Study.

BACKGROUND: Over the past decade, the prevalence of stunting has been close to 37% in children aged <5 years in Indonesia. The Baduta program, a multicomponent package of interventions developed by the Global Alliance for Improved Nutrition, aims to improve maternal and infant nutrition in Indonesia. OBJECTIVE: This study aims to assess the impact of the Baduta program, a package of health system strengthening and behavior change interventions, compared with the standard village health services on maternal and child nutrition. METHODS: The impact evaluation uses a cluster randomized controlled trial design with 2 outcome assessments. The first uses cross-sectional surveys of mothers of children aged 0-23 months and pregnant women before and after the interventions. The second is a cohort study of pregnant women followed until their child is 18 months from a subset of clusters. We will also conduct a process evaluation guided by the program impact pathway to assess coverage, fidelity, and acceptance. The study will be conducted in the Malang and Sidoarjo districts of East Java, Indonesia. The unit of randomization is the subdistricts. As random allocation of interventions to only 6 subdistricts is feasible, we will use constrained randomization to ensure balance of baseline covariates. The first intervention will be health system strengthening, including the Baby-Friendly Hospital Initiative, and training on counseling for appropriate infant and young child feeding (IYCF). The second intervention will be nutrition behavior change that includes Emo-Demos; a national television (TV) advertising campaign; local screening TV spots; a free, text message service; and promotion of low-cost water filters and hygiene practices. The primary study outcome is child stunting (low length-for-age), and secondary outcomes include length-for-age Z scores, wasting (low weight-for-length), anemia, child morbidity, IYCF indicators, and maternal and child nutrient intakes. The sample size for each cross-sectional survey is 1400 mothers and their children aged <2 years and 200 pregnant women in each treatment group. The cohort evaluation requires a sample size of 340 mother-infant pairs in each treatment group. We will seek Gatekeeper consent and written informed consent from the participants. The intention-to-treat principle will guide our data analysis, and we will apply Consolidated Standards of Reporting Trials guidelines for clustered randomized trials in the analysis. RESULTS: In February 2015, we conducted a baseline cross-sectional survey on 2435 women with children aged <2 years and 409 pregnant women. In February 2017, we conducted an end-line survey on 2740 mothers with children aged <2 years and 642 pregnant women. The cohort evaluation began in February 2015, with 729 pregnant women, and was completed in December 2016. CONCLUSIONS: The results of the program evaluation will help guide policies to support effective packages of behavior change interventions to prevent child stunting in Indonesia. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/18521.

The Use of Tablet-Based Multiple-Pass 24-Hour Dietary Recall Application (MP24Diet) to Collect Dietary Intake of Children under Two Years Old in the Prospective Cohort Study in Indonesia.

Dietary intake data are crucial for developing or evaluating nutrition interventions to improve the nutritional status of populations. The collection of accurate and reliable dietary data in developing countries, however, remains challenging. The emergence of new technologies, which facilitate electronic data capture, might address some of these challenges. This paper aims to describe an application developed to collect a multiple-pass 24-h dietary recall, using electronic data capture, and compare the results to those estimated using a paper-based method. In this study, a tablet-based application was developed, in the CommCare platform, to evaluate the effectiveness, for improving dietary adequacy, of a package of behavior change interventions to reduce stunting and anemia among 6-23-month-old children in East Java, Indonesia (Baduta project). Dietary intakes of energy and nutrients were estimated using electronic data capture in the cohort study of the Baduta project (n = 680). We compared these results with those estimated using paper-based data capture in the project's end-line cross-sectional study (n = 2740). We found a higher percentage of children classified as acceptable energy reporters (reported energy intake within the 95% CI of Total Energy Expenditure) with the electronic data capture compared with paper-based data capture (i.e., 60.8%, 72.4% and 80.7% for 6-8-, 9-11- and 12-23-month-old children, respectively, vs. 40.9%, 56.9%, and 54.3%, respectively). The estimated mean energy and nutrient intakes were not significantly different between these dietary data capture methods. These results suggest dietary data collection, using a tablet-based application, is feasible and can improve the quality of dietary data collected in developing countries.

The Association of TMPRSS6 Gene Polymorphism and Iron Intake with Iron Status among Under-Two-Year-Old Children in Lombok, Indonesia.

Multiple common variants in transmembrane protease serine 6 (TMPRSS6) were associated with the plasma iron concentration in genome-wide association studies, but their effect in young children where anemia and iron deficiency (ID) were prevalent has not been reported, particularly taking account of iron intake. This study aims to investigate whether TMPRSS6 SNPs (rs855791 and rs4820268) and iron intake are associated with a low iron and hemoglobin concentration in under-two-year-old children. The study analyzed the baseline of a randomized trial (NUPICO, ClinicalTrials.gov NCT01504633) in East Lombok, Indonesia. Children aged 6-17 months (n = 121) were included in this study. The multiple linear regressions showed that TMPRSS6 decreased serum ferritin (SF) by 4.50 g/L per copy minor allele (A) of rs855791 (p = 0.08) and by 5.00 µg/L per copy minor allele (G) of rs4820268 (p = 0.044). There were no associations between rs855791 and rs4820268 with soluble transferrin receptor (sTfR) and hemoglobin (Hb) concentration (rs855791; p = 0.38 and p = 0.13, rs4820268; p = 0.17 and p = 0.33). The finding suggests the need for further studies to explore whether the nutrient recommendation for iron should be based on genetic characteristics, particularly for children who have mutation in TMPRSS6.

Is Iron Supplementation Influenced by Sub-Clinical Inflammation?: A Randomized Controlled Trial Among Adolescent Schoolgirls in Myanmar.

Iron absorption was impaired in the presence of sub-clinical inflammation (SCI) and might hamper the effect of iron supplementation. The purpose of the study was to identify the influence of SCI on iron supplementation. A randomized, double-blinded, placebo-controlled experimental study was conducted among anaemic adolescent schoolgirls in Ayeyarwady region, Myanmar. A total of 402 schoolgirls were recruited from six schools screened from 1269 girls who were assigned into one of four groups: Folate group (2.5 mg of folate), Vitamin A group (15,000 IU of vitamin), Iron folate group (60 mg elemental iron and folate) and Iron, and vitamin A and folate group. Supplementation was done once a week for 12 weeks. Iron, vitamin A and inflammation were measured at the baseline, middle and endline. Changes in serum ferritin and body iron were significantly higher in the IFA and IFA + vitA among those without SCI. There was interaction between vitamin A and SCI on Hb changes. Analysis of GLM repeated measure showed interactions between treatment and SCI for hemoglobin and serum transferrin receptor. Those treated with vitamin A had better outcomes when there was SCI. Inflammation accompanied a negative effect on iron supplementation and vitamin A improved efficacy of iron supplementation in the presence of SCI.

Chronic low grade inflammation measured by dietary inflammatory index and its association with obesity among school teachers in Yangon, Myanmar.

BACKGROUND AND OBJECTIVES: This study was aimed to investigate the association between obesity and chronic low grade inflammation (CLGI) measured by Dietary Inflammatory Index (DII) as a proxy indicator of CLGI among obese and non-obese teachers. METHODS AND STUDY DESIGN: We conducted a cross sectional study among 128 non-obese (BMI <25) and 116 obese (BMI >=25) female teachers aged 25-60 years from six urban schools in Yangon, Myanmar between January and March 2015. Usual dietary intake was collected by 3-day nonconsecutive estimated 24 hour's dietary records and semi-quantitative Food Frequency Questionnaires. Adapted DII was calculated by standardized methods using literature-derived population-based dietary inflammatory weights of 31 food parameters. C-reactive protein (CRP) was analysed by a sandwich Enzyme-Linked Immunosorbent Assay (ELISA) technique. Mean DII between obese and non-obese was compared by independent t test. The association between obesity indices and high DII (DII >=1.1) and high CRP (>3 mg/L) were investigated by logistic regression. RESULTS: Obese teachers had lower intakes of anti-inflammatory nutrients (vitamin B-6, vitamin A and zinc)/food (onion) compared with non-obese teachers (p<0.05) and obesity was significantly associated with CRP (Odd ratio (OR)=5.5, 95% Confidence interval (CI) 1.2-24.1, p=0.02). However, there was no significant association between obesity and DII (OR=1.4, 95% CI -0.8-2.3, p=0.23). CONCLUSIONS: Role of antiinflammatory foods should be promoted for prevention of obesity and related diseases. Further use of DII among Myanmar general population for prevention of obesity and its related diseases should be explored with longitudinal studies.

Folate and vitamin B12 status and dietary intake of anaemic adolescent schoolgirls in the delta region of Myanmar.

The aim of the present study was to assess the prevalence of deficiency of folate and vitamin B12 and, simultaneously, the nutrient intake adequacy of folate, vitamin B12, iron, vitamin A, vitamin C, vitamin B6 and calcium in 391 adolescent anaemic (Hb<120 g/l) schoolgirls living in the delta region of Myanmar (Burma). Dietary intakes were assessed using a 3 d estimated food record. The distribution of observed intakes calculated from the food records were adjusted for usual intakes, and the prevalence of inadequacy was estimated using the estimated average requirement cut-point method. Median (first, third quartile) serum folate and vitamin B12 concentrations were 6·5 (4·6, 8·5) nmol/l and 612·8 (443·2, 795·2) pmol/l, respectively. The prevalence of folate deficiency defined as <6·8 nmol/l was 54 %; however, vitamin B12 deficiency defined as <148 pmol/l was negligible (<1 %). The prevalence of inadequate intake of folate was high (100 %) as was the prevalence of inadequate intakes of vitamin A, vitamin C, vitamin B6 and calcium, ranging from 60 to 100 %. Red meat or poultry was rarely consumed, but fish was consumed on a daily basis. Green leafy vegetables were also consumed frequently but consumption of dairy products was uncommon. Folate deficiency was high, and the prevalence of inadequate intake of folate among other key micronutrients was relatively common in this sample of anaemic adolescent schoolgirls. Appropriate strategies such as food fortification and dietary diversification are needed to improve the micronutrient status of these young women to ensure optimal health and future reproductive success.

Local food-based complementary feeding recommendations developed by the linear programming approach to improve the intake of problem nutrients among 12-23-month-old Myanmar children.

Poor feeding practices result in inadequate nutrient intakes in young children in developing countries. To improve practices, local food-based complementary feeding recommendations (CFR) are needed. This cross-sectional survey aimed to describe current food consumption patterns of 12-23-month-old Myanmar children (n 106) from Ayeyarwady region in order to identify nutrient requirements that are difficult to achieve using local foods and to formulate affordable and realistic CFR to improve dietary adequacy. Weekly food consumption patterns were assessed using a 12-h weighed dietary record, single 24-h recall and a 5-d food record. Food costs were estimated by market surveys. CFR were formulated by linear programming analysis using WHO Optifood software and evaluated among mothers (n 20) using trial of improved practices (TIP). Findings showed that Ca, Zn, niacin, folate and Fe were 'problem nutrients': nutrients that did not achieve 100 % recommended nutrient intake even when the diet was optimised. Chicken liver, anchovy and roselle leaves were locally available nutrient-dense foods that would fill these nutrient gaps. The final set of six CFR would ensure dietary adequacy for five of twelve nutrients at a minimal cost of 271 kyats/d (based on the exchange rate of 900 kyats/USD at the time of data collection: 3rd quarter of 2012), but inadequacies remained for niacin, folate, thiamin, Fe, Zn, Ca and vitamin B6. TIP showed that mothers believed liver and vegetables would cause worms and diarrhoea, but these beliefs could be overcome to successfully promote liver consumption. Therefore, an acceptable set of CFR were developed to improve the dietary practices of 12-23-month-old Myanmar children using locally available foods. Alternative interventions such as fortification, however, are still needed to ensure dietary adequacy of all nutrients.

Genetic variants of FADS gene cluster, plasma LC-PUFA levels and the association with cognitive function of under-two-year-old Sasaknese Indonesian children.

BACKGROUND/AIMS: Long-chain polyunsaturated fatty acids (LC-PUFA) are regarded as essential for child cognition. Genetic variation in fatty acid (FA) desaturase enzyme (FADS) has been recognized as an important effect modifier in the relation between LC-PUFA and child cognitive function. This study aimed to identify the distribution of genetic variant (genotype) SNP rs174468 and to assess plasma FA and developmental outcome by the genotype among under-2 year old Sasaknese Indonesian children. METHODS: Data was collected at baseline of a randomized trial (NUPICO, clinicaltrials.gov NCT01504633) in East Lombok district, Indonesia. Breastfed, 12- 17 month old children were recruited and 240 subjects were included in the study. Child cognition was assessed as Bayley Mental Developmental Index (MDI). RESULTS: From 206 subjects whose blood samples can be collected, only two genotypes were found (90.3% GG homozygotes, 9.7% AG heterozygotes), and minor allele AG was significantly associated with higher level of arachidonic acid (20:4 n-6), n-6 LC-PUFA and FADS1 index. MDI score was associated with a FADS2 index (DHA:EPA ratio) but not genotype (Adjusted R-square= 0.043). CONCLUSIONS: FADS2 index was associated with cognitive function. No difference was found between children with GG and AG genotypes who were all breastfed and not low birth weight.

Effectiveness in improving knowledge, practices, and intakes of "key problem nutrients" of a complementary feeding intervention developed by using linear programming: experience in Lombok, Indonesia.

BACKGROUND: Complementary feeding recommendations (CFRs) with the use of locally available foods can be developed by using linear programming (LP). Although its potential has been shown for planning phases of food-based interventions, the effectiveness in the community setting has not been tested to our knowledge. OBJECTIVE: We aimed to assess effectiveness of promoting optimized CFRs for improving maternal knowledge, feeding practices, and child intakes of key problem nutrients (calcium, iron, niacin, and zinc). DESIGN: A community-intervention trial with a quasi-experimental design was conducted in East Lombok, West Nusa Tenggara Province, Indonesia, on children aged 9-16 mo at baseline. A CFR group (n = 240) was compared with a non-CFR group (n = 215). The CFRs, which were developed using LP, were promoted in an intervention that included monthly cooking sessions and weekly home visits. The mother's nutrition knowledge and her child's feeding practices and the child's nutrient intakes were measured before and after the 6-mo intervention by using a structured interview, 24-h recall, and 1-wk food-frequency questionnaire. RESULTS: The CFR intervention improved mothers' knowledge and children's feeding practices and improved children's intakes of calcium, iron, and zinc. At the end line, median (IQR) nutrient densities were significantly higher in the CFR group than in the non-CFR group for iron [i.e., 0.6 mg/100 kcal (0.4-0.8 mg/100 kcal) compared with 0.5 mg/100 kcal (0.4-0.7 mg/100 kcal)] and niacin [i.e., 0.8 mg/100 kcal (0.5-1.0 mg/100 kcal) compared with 0.6 mg/100 kcal (0.4-0.8 mg/100 kcal)]. However, median nutrient densities for calcium, iron, niacin, and zinc in the CFR group (23, 0.6, 0.7, and 0.5 mg/100 kcal, respectively) were still below desired densities (63, 1.0, 0.9, and 0.6 mg/100 kcal, respectively). CONCLUSIONS: The CFRs significantly increased intakes of calcium, iron, niacin, and zinc, but nutrient densities were still below desired nutrient densities. When the adoption of optimized CFRs is constrained by economic access for or acceptability of nutrient-dense foods, other strategies need to be incorporated into interventions to ensure adequate intakes of these nutrients.

Vitamin A-fortified cooking oil reduces vitamin A deficiency in infants, young children and women: results from a programme evaluation in Indonesia.

OBJECTIVE: To assess oil consumption, vitamin A intake and retinol status before and a year after the fortification of unbranded palm oil with retinyl palmitate. DESIGN: Pre-post evaluation between two surveys. SETTING: Twenty-four villages in West Java. SUBJECTS: Poor households were randomly sampled. Serum retinol (adjusted for subclinical infection) was analysed in cross-sectional samples of lactating mothers (baseline n 324/endline n 349), their infants aged 6-11 months (n 318/n 335) and children aged 12-59 months (n 469/477), and cohorts of children aged 5-9 years (n 186) and women aged 15-29 years (n 171), alongside food and oil consumption from dietary recall. RESULTS: Fortified oil improved vitamin A intakes, contributing on average 26 %, 40 %, 38 %, 29 % and 35 % of the daily Recommended Nutrient Intake for children aged 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women, respectively. Serum retinol was 2-19 % higher at endline than baseline (P<0·001 in infants aged 6-11 months, children aged 5-9 years, lactating and non-lactating women; non-significant in children aged 12-23 months; P=0·057 in children aged 24-59 months). Retinol in breast milk averaged 20·5 µg/dl at baseline and 32·5 µg/dl at endline (P<0·01). Deficiency prevalence (serum retinol <20 µg/dl) was 6·5-18 % across groups at baseline, and 0·6-6 % at endline (P≤0·011). In multivariate regressions adjusting for socio-economic differences, vitamin A intake from fortified oil predicted improved retinol status for children aged 6-59 months (P=0·003) and 5-9 years (P=0·03). CONCLUSIONS: Although this evaluation without a comparison group cannot prove causality, retinyl contents in oil, Recommended Nutrient Intake contributions and relationships between vitamin intake and serum retinol provide strong plausibility of oil fortification impacting vitamin A status in Indonesian women and children.