Simplifying dietary assessment: The nutrient specific semi quantitative food frequency questionnaire

Wirth JP, Petry N, Friesen VM, Rohner F, Mbuya MNN

June 2020 – GAIN Working Paper Series

Dietary intake data are required to design, monitor, and evaluate nutrition programmes and policies; however, current dietary assessment methods are complex, time consuming, and costly. Recently, GAIN developed a semi-quantitative food frequency questionnaire (SQ-FFQ) that can be used in coverage surveys to estimate the amount of fortified and biofortified foods consumed and their contributions to nutrient intakes. However, this method is limited in that it does not account for nutrient intakes from other sources in the diet, and thus cannot estimate the extent to which the nutrient gap in the diet is being filled through these programmes. As such, we developed a nutrient-specific SQ-FFQ (NS-SQ-FFQ) module that estimates intakes of key nutrients of interest from fortified and/or biofortified foods, as well as other sources in the diet using simplified dietary assessment methods. This working paper outlines the steps required to develop and implement the module and analyse the resulting data across three phases: preparation, fieldwork, and data cleaning and analyses. We show that the NS-SQ-FFQ can yield individual-level data on intake of key nutrients, which can be used by programme planners to determine the extent to which the nutrient gap in the diet is being filled through consumption of fortified and/or biofortified foods. Further testing and refinement of the method in field settings is needed.

National Prevalence of Micronutrient Deficiencies, Anaemia, Genetic Blood Disorders and Over- and Undernutrition in Omani Women of Reproductive Age and Preschool Children

Petry N, Al-Maamary SA, Woodruff BA, Alghannami S, Al-Shammakhi SM, Al-Ghammari IK, Tyler V, Rohner F, Wirth JP

May 2020 – Sultan Qaboos University Medical Journal

A national cross-sectional survey was conducted to estimate the prevalence of anaemia, micronutrient deficiencies, haemoglobin disorders and over- and undernutrition in children and women of reproductive age in Oman. Wasting and stunting were found in 9.3% and 11.4% of children aged 0–59 months, respectively, while 4.2% were overweight or obese. In addition, 23.8% were anaemic and 10.2%, 9.5% and 10.6% had iron, vitamin A and vitamin D deficiencies, respectively. Sickle cell and β-thalassaemia genetic traits were present in 5.3% and 4.2% of children and 4.7% and 2.8% of women, respectively. Overall, 9.1% of Omani women were underweight and 59.2% were overweight or obese. The prevalence of anaemia was 27.8%, while iron, folate, vitamin B12 and vitamin D deficiencies affected 24.8%, 11.6%, 8.9% and 16.2%, respectively. Anaemia among both children and women and the prevalence of overweight and obesity in women are the most concerning nutritional problems in Oman.

Household Coverage with Adequately Iodized Salt and Iodine Status of Nonpregnant and Pregnant Women in Uzbekistan

Rohner F, Nizamov F, Petry N, Yuldasheva F, Ismailov R, Wegmüller R, Guo S, Wirth JP, Woodruff BA

March 2020 – Thyroid

We conducted a cross-sectional household survey to produce region-specific estimates of the household coverage with adequately iodized salt and iodine status among women for each of the 14 regions in Uzbekistan. Overall, 36% of 3413 households had adequately iodized salt (iodine concentration >15 ppm [parts per million (mg I/kg salt)]), 20% had inadequately iodized salt (5–14 ppm), and 44% had salt without detectable iodine (<5 ppm). Adequate iodization was found in 33.2% of the 2626 salt samples taken from retail packages labeled as ‘‘iodized,’’ 36.5% of the 96 samples taken from retail packages without mention of iodization, and 50.5% of the 674 samples without the original packaging ( p < 0.001). The median urinary iodine concentration (UIC) of 140.9 lg/L in non-pregnant non-lactating women indicated adequate iodine status, while for non-pregnant lactating and pregnant women, the median UIC of 112.9 ug/L [CI 99.3–128.4] and 117.3 ug/L [CI 101.8–139.9], respectively, indicated borderline adequacy. Significant differences in UIC ( p < 0.001) were found between non-pregnant non-lactating women living in households with adequately iodized salt (UIC 208.9 ug/L), inadequately iodized salt (UIC 139.1 ug/L), and non-iodized salt (UIC 89.9 ug/L). Coverage with adequately iodized salt is low in Uzbekistan, and women in households with poorly iodized salt have substantially worse iodine status; claims on packaging about salt iodization do not reflect salt iodine content.

Risk Factors for Anemia and Micronutrient Deficiencies among Women of Reproductive Age—The Impact of the Wheat Flour Fortification Program in Uzbekistan

Petry N, Nizamov F, Woodruff BA, Ishmakova R, Komilov J, Wegmüller R, Wirth JP, Arifdjanova D, Guo S, Rohner F

March 2020 – Nutrients

Food fortification can be effective in reducing the prevalence of anemia and micronutrient deficiencies. This study assessed risk factors for—and the impact of the wheat flour program in Uzbekistan on—anemia, and iron and folate deficiency (FD) in non-pregnant women (NPW) of reproductive age. National data were analyzed for risk factors using multivariable regression. Additional iron intake from fortified flour was not associated with iron deficiency (ID) and did not result in a significantly different prevalence of anemia regardless of the levels, whereas women with additional folic acid intake had a lower relative risk (RR) of FD (RR: 0.67 [95% CI: 0.53, 0.85]). RR for anemia was greater in women with ID (RR: 4.7; 95% CI: 3.5, 6.5) and vitamin A insufficiency (VAI; RR 1.5; 95% CI: 1.3, 1.9). VAI (RR: 1.4 [95% CI: 1.3, 1.6]) and breastfeeding (RR: 1.1 [95% CI: 0.99, 1.2]) were associated with increased risk of ID, while being underweight reduced the risk (RR: 0.74 [95% CI: 0.58, 0.96]). Breastfeeding (RR: 1.2 [95% CI: 1.1, 1.4]) and inflammation (RR: 1.2 [95% CI: 1.0, 1.3]) increased risk of FD. FD results indicate that the fortification program had potential for impact, but requires higher coverage of adequately fortified wheat flour and a more bioavailable iron fortificant.

Anemia, micronutrient deficiencies, malaria, hemoglobinopathies and malnutrition in young children and non-pregnant women in Ghana: Findings from a national survey

Wegmüller R, Bentil H, Wirth JP, Petry N, Tanumihardjo SA, Allen L, Williams TN, Selenje L, Mahama A, Amoaful E, Steiner-Asiedu M, Adu-Afarwuah S, Rohner F

January 2020 – PLOS ONE

The 2017 Ghana Micronutrient Survey (GMS) was conducted to document the current national prevalence of micronutrient deficiencies, anemia, malaria, inflammation, α-thalassemia, sickle cell disease and trait, and under- and over-nutrition. The GMS was a two-stage cross-sectional survey that enrolled pre-school children (6–59 months) and non-pregnant women (15–49 years) from three strata in Ghana: Northern, Middle and Southern Belt. Nationally, 35.6% of children had anemia, 21.5% had iron deficiency, 12.2% had iron deficiency anemia, and 20.8% had vitamin A deficiency; 20.3% tested positive for malaria, 13.9% for sickle trait plus disease, and 30.7% for α-thalassemia. Anemia and micronutrient deficiencies were more prevalent in rural areas, poor households and in the Northern Belt. Stunting and wasting affected 21.4% and 7.0% of children, respectively. Stunting was more common in rural areas and in poor households. Among non-pregnant women, 21.7% were anemic, 13.7% iron deficient, 8.9% had iron deficiency anemia, and 1.5% (0.8,2.9) were vitamin A deficient, 53.8% were folate deficient, and 6.9% were vitamin B12 deficient. Overweight (24.7%) and obesity (14.3%) were more common in wealthier, older, and urban women. Our findings demonstrate that anemia and several micronutrient deficiencies are highly present in Ghana calling for the strengthening of Ghana’s food fortification program while overweight and obesity in women are constantly increasing and need to be addressed urgently through governmental policies and programs.

Deworming children for soil-transmitted helminths in low and middle-income countries: systematic review and individual participant data network meta-analysis

Welch VA, Hossain A, Ghogomu E, Riddle A, Cousens S, Gaffey M, Arora P, Black R, Bundy D, Castro MC, Chen L, Dewidar O, Elliott A,Friis H, Hollingsworth TD, Horton S, King CH, Thi HL, Liu C, Rohner F, Rousham EK, Salam R, Sartono E, Steinmann P, Supali T, Tugwell P, Webb E, Wieringa F, Winnichagoon P, Yazdanbakhsh M, Bhutta ZA, Wells GA

December 2019 – Journal of Development Effectiveness

Intestinal parasites affect millions of children globally. We aimed to assess effects of deworming children on nutritional and cognitive outcomes across potential effect modifiers using individual participant data (IPD). We searched multiple databases to 27 March 2018, grey literature, and other sources. We included randomised and quasi randomised trials of deworming compared to placebo or other nutritional interventions with data on baseline infection. We used a random-effects network meta-analysis with IPD and assessed overall quality, following a pre-specified protocol. We received IPD from 19 trials of STH deworming. Overall risk of bias was low. There were no statistically significant subgroup effects across age, sex, nutritional status or infection intensity for each type of STH. These analyses showed that children with moderate or heavy intensity infections, deworming for STH may increase weight gain (very low certainty). The added value of this review is an exploration of effects on growth and cognition in children with moderate to heavy infections as well as replicating prior systematic review results of small effects at the population level. Policy implications are that complementary public health strategies need to be assessed and considered to achieve growth and cognition benefits for children in helminth endemic areas.

Mass deworming for improving health and cognition of children in endemic helminth areas: A systematic review and individual participant data network meta‐analysis

Welch VA, Ghogomu E, Hossain A, Riddle A, Gaffey M, Arora P, Dewidar O, Salam R, Cousens S, Black R, Hollingsworth TD, Horton S, Tugwell P, Bundy D, Castro MC, Elliott A, Friis H, Le HT, Liu C, Rousham EK, Rohner F, King C, Sartono E, Supali T, Steinmann P, Webb E, Wieringa F, Winnichagoon P, Yazdanbakhsh M, Bhutta YA, Wells G

November 2019 – Campbell Systematic Reviews

Soil transmitted (or intestinal) helminths and schistosomes affect millions of children worldwide. We used individual participant data network meta‐analysis (NMA) to explore the effects of different types and frequency of deworming drugs on anaemia, cognition and growth across potential effect modifiers. Our study included randomised and quasirandomised deworming trials in children for deworming compared to placebo or other interventions with data on baseline infection. The covariates were: age, sex, weight, height, haemoglobin and infection intensity. The effect estimate chosen was the mean difference for the continuous outcome of interest. We received data from 19 randomized controlled trials with 31,945 participants. Overall risk of bias was low. There were no statistically significant subgroup effects across any of the potential effect modifiers. However, analyses showed that there may be greater effects on weight for moderate to heavily infected children (very low certainty evidence). This analysis reinforces the case against mass deworming at a population‐level, finding little effect on nutritional status or cognition. However, children with heavier intensity infections may benefit more. We urge the global community to adopt calls to make data available in open repositories to facilitate individual participant data analyses such as this, which aim to assess effects for the most vulnerable individuals.

Nutrition trends in the past fifteen years in Guinea: Secondary analysis of cross-sectional data on children, adolescent girls and women

Wirth JP, Woodruff BA, Mamady D, Beauliere JM, Ayoya M, Rohner F, Teta IN

November 2019 – African Journal of Food, Agriculture, Nutrition, and Development

This study investigated the nutrition trends in children <5 years of age, adolescent girls 15-19 years of age, and non-pregnant women 15-49 years of age over the past 15 years in Guinea. Data from nationally-representative DHS and SMART surveys conducted from 1999 to 2015 were used to examine trends in the aforementioned population groups. The analysis found that prevalence of stunting in children decreased consistently from 39% in 2005 to 25% in 2015, with the most rapid decline between 2012 and 2015 – the period when the Ebola outbreak occurred. Despite this decline, the prevalence of anemia remained elevated between 2005 and 2012, with more than 70% of children found anemic in both surveys. Among adolescent girls, the national prevalence of underweight increased from 12% in 1999 to 19% in 2012, with the largest increase among girls with no education and those residing in rural areas and households in the lowest wealth quintile. Among all women 15 and 49 years of age, there was a steady increase in the combined prevalence of overweight and obesity, from 12% in 1999 to 19% in 2012. Increases in prevalence were pronounced in urban areas and among women with no education, >30 years of age, and among women residing in wealthy households. This trend analysis suggests that if Guinea’s stunting reduction trends are maintained for the next decade, it can likely meet international stunting targets. In women, efforts to reduce underweight should be targeted at adolescent girls and research is needed to identify the determinants of overweight and obesity in Guinean women.

Uzbekistan Nutrition Survey Report 2017

Ministry of Health-Uzbekistan, UNICEF, GroundWork

October 2019 – Report Release, Tashkent, Uzbekistan

The 2017 Uzbekistan Nutrition Survey (UNS) is national nutrition and micronutrient survey that collected data on anemia and micronutrient deficiencies (i.e. iron, vitamin A, folate, vitamin B12, iodine) in children 6-59 months of age, and non-pregnant women 15-49 years of age, and pregnant women. The UNS also collected anthropometric measurements to estimate the prevalence of stunting and wasting in children, and overweight and obesity in non-pregnant women. The information collected by the UNS will enable the government and international agencies to monitor the current status of national nutrition programs (e.g. wheat fortification and salt iodization) and to plan future nutrition and health interventions. The UNS was conducted by the Ministry of Health, UNICEF, and GroundWork.

Hepcidin-guided screen-and-treat interventions against iron-defciency anaemia in pregnancy: a randomised controlled trial in The Gambia

Bah A, Muhammad AK, Wegmüller R, Verhoef H, Goheen MM, Sanyang S, Danso E, Sise EA, Pasricha SR, Armitage AE, Drakesmith H, Cross JH, Moore SE, Cerami C, Prentice AM

October 2019 – Lancet Global Health

WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the The Gambia among pregnant women aged 18–45 years at between 14 and 22 weeks of gestation. Women were randomly allocated women to either WHO’s recommended regimen, a 60 mg screen-and-treat approach, or a 30 mg screen-and-treat approach. Compared with WHO’s recommended regimen, the two screen-and-treat approaches did not result in significantly different hemoglobin concentrations. The hepcidin-guided screen-and-treat approaches had no advantages over WHO’s recommended regimen in terms of adherence, side-effects, or safety outcomes. Our results suggest that the current WHO policy for iron administration to pregnant women should remain unchanged while more effective approaches continue to be sought.

Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia

Tumilowicz A, Habicht JP, Mbuya MNN, Beal T, Ntozini R, Rohner F, Pelto GH, Fisseha T, Haidar J, Assefa N, Wodajo HY, Wolde TT, Neufeld LM

October 2019 – Maternal & Child Nutrition

A theory‐driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross‐sectional survey data of caregivers of children 6–23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12–17 months were 32% (P < 0.001) and children 18–23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6–11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.

Micronutrient Deficiencies, Nutritional Status and the Determinants of Anemia in Children 0–59 Months of Age and Non-Pregnant Women of Reproductive Age in The Gambia

Petry N, Jallow B, Sawo Y, Darboe MK, Barrow S, Sarr A, Ceesay PO, Fofana MN, Prentice AM, Wegmüller R, Rohner F, Phall MC, and Wirth JP

September 2019 – Nutrients

Data on micronutrient deficiency prevalence, nutrition status, and risk factors of anemia in The Gambia is scanty. To fill this data gap, a nationally representative cross-sectional survey was conducted on 1354 children (0–59 months), 1703 non-pregnant women (NPW; 15–49 years), and 158 pregnant women (PW). The survey assessed the prevalence of under and overnutrition, anemia, iron deficiency (ID), iron deficiency anemia (IDA), vitamin A deficiency (VAD), and urinary iodine concentration (UIC). Multivariate analysis was used to assess risk factors of anemia. Among children, prevalence of anemia, ID, IDA, and VAD was 50.4%, 59.0%, 38.2%, and 18.3%, respectively. Nearly 40% of anemia was attributable to ID. Prevalence of stunting, underweight, wasting, and small head circumference was 15.7%, 10.6%, 5.8%, and 7.4%, respectively. Among NPW, prevalence of anemia, ID, IDA and VAD was 50.9%, 41.4%, 28.0% and 1.8%, respectively. Anemia was significantly associated with ID and vitamin A insufficiency. Median UIC in NPW and PW was 143.1 µg/L and 113.5 ug/L, respectively. Overall, 18.3% of NPW were overweight, 11.1% obese, and 15.4% underweight. Anemia is mainly caused by ID and poses a severe public health problem. To tackle both anemia and ID, programs such as fortification or supplementation should be intensified.

A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone: A food value-chain framework for improving future response strategies

Kodish SR, Bio F, Oemcke R, Conteh J, Beauliere JM, Pyne-Bailey S, Rohner F, Ngnie-Teta I, Jalloh MB, Wirth JP

September 2019 – PLOS Neglected Tropical Diseases

This study sought understand how the 2014–2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude. This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. During the humanitarian response,nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition sensitive interventions were not central to the initial response as EVD containment and survival took priority. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters.

Respiratory infections drive hepcidin-mediated blockade of iron absorption leading to iron deficiency anemia in African children

Prentice AM, Bah A, Jallow MW, Jallow AT, Sanyang S, Sise EA, Ceesay K, Danso E, Armitage AE, Pasricha S, Drakesmith H, Wathuo M, Kessler N, Cerami C, Wegmuller R

March 2019 – Science Advances

Iron deficiency anemia (IDA) is the most prevalent nutritional condition worldwide. We studied the contribution of hepcidin-mediated iron blockade to IDA in African children. We measured hepcidin and hemoglobin weekly, and hematological, inflammatory, and iron biomarkers at baseline, 7 weeks, and 12 weeks in 407 anemic (hemoglobin < 11 g/dL), otherwise healthy Gambian children (6 to 27 months). Each child maintained remarkably constant hepcidin levels (P < 0.0001 for between-child variance), with half consistently maintaining levels that indicate physiological blockade of iron absorption. Hepcidin was strongly predicted by nurse-ascribed adverse events with dominant signals from respiratory infections and fevers (all P < 0.0001). Diarrhea and fecal calprotectin were not associated with hepcidin. In multivariate analysis, C-reactive protein was the dominant predictor of hepcidin and contributed to iron blockade even at very low levels. We conclude that even low-grade inflammation, especially associated with respiratory infections, contributes to IDA in African children.

The Gambia Micronutrient Survey 2018

National Nutrition Agency (NaNA)-Gambia, UNICEF, Gambia Bureau of Statistics (GBOS), GroundWork

March 2019 – Report Release, Banjul, The Gambia

The 2018 Gambia Micronutrient Survey (GMNS) is national and comprehensive micronutrient survey that was implemented in tandem with The Gambia’s 2018 Multiple Indicator Cluster Survey (MICS). The GMNS collected data on micronutrient deficiencies, anemia, and malaria in children 6-59 months of age, and non-pregnant women 15-49 years of age, and pregnant women. The GMNS also measured the prevalence of diet-related non-communicable diseases and conditions in non-pregnant women (e.g. overweight, obesity, diabetes, hypertension) and stunting, wasting, and underweight in children. The information generated by the GMNS will enable the government and international agencies to enhance existing national programs, such as vitamin A supplementation, and commercial fortification of wheat flour, rice, and vegetable oil. In addition, GMNS results will help nutrition stakeholders in The Gambia plan future nutrition and health interventions, in particular related to the double burden of malnutrition. The GMNS was conducted by the Gambia’s National Nutrition Agency (NaNA), UNICEF, GBOS, and GroundWork.

Measurement and interpretation of hemoglobin concentration in clinical and field settings: a narrative review

Karakochuk CD, Hess SY, Moorthy D, Namaste S, Parker ME, Rappaport AI, Wegmuller R, Dary O, & the HEmoglobin MEasurement (HEME) Working Group

February 2019 – Annals of the New York Academy of Sciences

Anemia affects over 800 million women and children globally. Defined as a limited or insufficient functional red blood cell supply in peripheral blood, anemia causes a reduced oxygen supply to tissues and can have serious health consequences for women and children. Hemoglobin (Hb) concentration is most commonly measured for anemia diagnosis. Methods to measure Hb are usually invasive (requiring a blood sample); however, advances in diagnostic and clinical chemistry over the past decade have led to the development of new noninvasive methods. Accurate diagnosis at the individual level is important to identify individuals who require treatment. At the population level, anemia prevalence estimates are often the impetus for national nutrition policies or programs. Thus, it is essential that methods for Hb measurement are sensitive, specific, accurate, and reproducible. The objective of our narrative review is to describe the basic principles, advantages, limitations, and quality control issues related to methods of Hb measurement in clinical and field settings. We also discuss other biomarkers and tests that can help to determine the severity and underlying causes of anemia. In conclusion, there are many established and emerging methods to measure Hb concentration, each with their own advantages, limitations, and factors to consider before use.

Consensus building around nutrition lessons from the 2014 – 16 Ebola virus disease outbreak in Guinea and Sierra Leone

Kodish SR, Simen-Kapeu A, Beauliere JM, Ngnie-Teta I, Jalloh MB, Pyne-Bailey S, Schwartz H, Wirth JP

February 2019 – Health Policy and Planning

To understand the nutrition challenges faced during the Ebola virus disease outbreak in West Africa, participatory workshops in Guinea and Sierra Leone were conducted in February 2017. Workshops followed the Nominal Group Technique, which is a methodological approach for idea generation and consensus building among diverse participants. Those findings were triangulated with qualitative interview data from participants representing government, United Nations bodies, civil society, nongovernmental organizations and local communities in both Guinea and Sierra Leone. In both countries, this research identified five key nutrition challenges, including reduced access and utilization of the health system, poor caretaking and infant and young child feeding practices, implementation challenges during nutrition response, household food insecurity and changing breastfeeding practices. (2) In Sierra Leone, organizational factors that facilitated this response included the use of standard operating procedures and psychosocial counselling. In contrast, in Guinea, hygiene assistance was distinctly important. Political will, Increased funding, food assistance and to a lesser extent, enhanced coordination, were deemed ‘most important’ response factors. Disease outbreaks pose widespread nutrition challenges to populations in resource-constrained settings where global health security is not a guarantee. These findings should be considered for emergency nutrition preparedness and inform evidence-based priority setting in the post-Ebola virus context of Guinea and Sierra Leone.

Growth Status, Inflammation, and Enteropathy in Young Children in Northern Tanzania

Wirth JP, Kitilya B, Petry N, PrayGod G, Veryser S, Mngara J, Zwahlen C, Wieringa F, Berger J, de Onis M, Rohner F and Becquey E

November 2018 – The American Journal of Tropical Medicine and Hygiene

Recent evidence suggests that enteropathy of the gut due to environmental conditions (i.e., environmental enteropathy [EE]) in young children is negatively associated with linear growth. Using a case–control study design, we examined the potential determinants of stunting in stunted and non-stunted children 22–28 months of age. Potential determinants included inflammation biomarkers C-reactive protein, alpha-1-acid glycoprotein (AGP), and endotoxin-core antibody (EndoCAb) measured in serum samples; enteropathy markers alpha-1-antitrypsin, neopterin, myeloperoxidase (MPO) measured in stools samples; and demographic, health, feeding, and household characteristics. We also explored the determinants of EE by testing associations of composite EE scores and individual biomarkers with potential risk factors. Fifty-two percent of children (n = 310) were found to be stunted, and mean height-for-age Z scores (HAZ) were −1.22 (SD ± 0.56) among non-stunted (control) children and −2.82 (SD ± 0.61) among stunted (case) children. Child HAZ was significantly (P < 0.05) and inversely associated with AGP, and child stunting was significantly associated (P < 0.05) with low dietary diversity, severe household hunger, and absence of soap in the household. Alpha-1-acid glycoprotein and EndoCAb concentrations were also significantly higher (P < 0.05) among children in households with no soap. Our study documented a seemingly localized cultural practice of young children (25%) being fed their dirty bathwater, which was associated with significantly higher concentrations of MPO (P < 0.05).

Micronutrient Deficiencies, Over- and Undernutrition, and Their Contribution to Anemia in Azerbaijani Preschool Children and Non-Pregnant Women of Reproductive Age

Wirth JP, Rajabov T, Petry N, Woodruff BA, Shafique NB, Mustafa R, Tyler VQ, Rohner F

October 2018 – Nutrients

A nationally representative cross-sectional survey was conducted to assess the prevalence of micronutrient deficiencies, over- and undernutrition, and to disentangle determinants of anemia in children and women in Azerbaijan. The survey generated estimates of micronutrient deficiency and growth indicators for children aged 0–59 months of age (6–59 months for blood biomarkers) and non-pregnant women 15–49 years of age. In total, 3926 household interviews were successfully completed with a response rate of 80.6%. In the 1455 children, the prevalence of wasting and stunting were 3.1% and 18.0%, respectively; and 14.1% of children were overweight or obese. In children, the prevalence of anemia, iron deficiency, and iron deficiency anemia was 24.2%, 15.0%, and 6.5%, respectively. Vitamin A and zinc deficiencies were found in 8.0% and 10.7% of children. Data from 3089 non-pregnant women showed that while undernutrition was scarce, 53% were overweight or obese, with increasing prevalence with increasing age. Anemia affected 38.2% of the women, iron deficiency 34.1% and iron deficiency anemia 23.8%. Vitamin A insufficiency was found in 10.5% of women. Folate and vitamin B12 deficiency were somewhat more common, with prevalence rates of 35.0% and 19.7%, respectively. The main risk factors for anemia in children were recent lower respiratory infection, inflammation and iron deficiency. In women, the main risk factors for anemia were iron deficiency and vitamin A insufficiency. Anemia is a public health problem in Azerbaijani children and women, and additional efforts are needed to reduce anemia in both groups.

Implications of the Ebola virus disease outbreak in Guinea: Qualitative findings to inform future health and nutrition-related responses

Kodish SR, Rohner F, Beaulière JM, Mamady D, Ayoya MA, Wirth JP, Ngnie-Teta I

August 2018 – PLOS ONE

Due to the close relationship between EVD and nutrition, the humanitarian community implemented various nutrition-specific and -sensitive interventions to stem the Ebola Virus Disease (EVD) outbreak in West Africa. To understand stakeholder and community members’ perspectives toward this response in Guinea, we aimed to firstly understand how EVD may have influenced the nutrition situation; and secondly to assess the perceived acceptability and effectiveness of the nutrition response. Using 27 in-depth interviews conducted in April and May 2016, this descriptive, qualitative study had three iterative phases in an emergent design. Overall, several plausible pathways through an interrelated network of bio-social factors help describe EVD impacts on the nutrition situation of Guinea. At a basic level, complex social dimensions of health, response unpreparedness, and market disruptions were perceived to be major determinants affecting the nutrition situation, especially among IYC. At an underlying level, household food security was negatively impacted, along with weakened care-seeking practices, IYC feeding practices, and coping strategies. Consequently, treatment coverage for childhood illnesses and IYC diets were negatively impacted during the outbreak. In hindsight, most participants had positive perceptions toward the overall EVD response, but described salient considerations for improving upon this nutrition response during future outbreaks.

Ghana Micronutrient Survey Report

University of Ghana, GroundWork, University of Wisconsin, KEMRI-Wellcome Trust, & UNICEF

June 2018 – Report Release, Accra, Ghana

The 2017 Ghana Micronutrient Survey (GMS) is national and comprehensive micronutrient survey that collected data on micronutrient deficiencies, anemia, malaria, and blood disorders (e.g. sickle cell, alpha-thalassemia) in children 6-59 months of age, and non-pregnant women 15-49 years of age, and pregnant women. The GMS also collected anthropometric measurements to estimate the prevalence of stunting and wasting in children, and overweight and obesity in non-pregnant women. The information collected by the GMS will enable the government and international agencies to monitor the current status of national nutrition programs (e.g. wheat and vegetable oil fortification and vitamin A supplementation) and to plan future nutrition and health interventions. The GMS was conducted by the University of Ghana and GroundWork and their nutrition partners (e.g. University of Wisconsin, Kemri-Wellcome Trust, UNICEF, Ghana Health Service, and others). Funding was provided by UNICEF and the Canadian Government.

Affordable Nutritious Food for Women (ANF4W) product availability and consumption study

GroundWork, University of Ghana

March 2018 – Report Release, Accra, Ghana

Women of reproductive age, particularly during pregnancy and lactation, have increased nutrient needs and are therefore more vulnerable to nutritional deficiencies. In Ghana, despite two decades of sustained economic growth and reductions in some forms of malnutrition, progress on eliminating micronutrient deficiency has been slow. The “Affordable Nutritious Foods for Women” (ANF4W) program thus aimed to increase the local supply of and demand for affordable nutritious foods for women of reproductive age in developing countries. The ANF4W evaluation included two cross‐sectional surveys, and this report presents the situation after a 6 months branded and unbranded marketing campaign, which followed the product launch in March 2017.

Comparison of a New Multiplex Immunoassay for Measurement of Ferritin, Soluble Transferrin Receptor, Retinol-Binding Protein, C-Reactive Protein and α1-Acid-glycoprotein Concentrations against a Widely-Used s-ELISA Method

Karakochuk CD, Henderson AM, Samson KLI, Aljaadi AM, Devlin AM, Becquey E, Wirth JP, Rohner F

February 2018 – Diagnostics

Recently, a multiplex ELISA (Quansys Biosciences) was developed that measures ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), C-reactive protein (CRP), α1-acid glycoprotein (AGP), thyroglobulin, and histidine-rich protein 2. Our primary aim was to conduct a method-comparison study to compare five biomarkers (ferritin, sTfR, RBP, CRP, and AGP) measured with the Quansys assay and a widely-used s-ELISA (VitMin Lab, Willstaett, Germany) with use of serum samples from 180 women and children from Burkina Faso, Cambodia, and Malaysia. Bias and concordance were used to describe the agreement in values measured by the two methods. We observed poor overall agreement between the methods, both with regard to biomarker concentrations and deficiency prevalence estimates. Several measurements were outside of the limit of detection with use of the Quansys ELISA (total n = 42 for ferritin, n = 2 for sTfR, n = 0 for AGP, n = 5 for CRP, n = 22 for RBP), limiting our ability to interpret assay findings. Although the Quansys ELISA has great potential to simplify laboratory analysis of key nutritional and inflammation biomarkers, there are some weaknesses in the procedures. Overall, we found poor comparability of results between methods. Besides addressing procedural issues, additional validation of the Quansys against a gold standard method is warranted for future research.

Thyroid Function and Growth – The Mechanisms of Iodine

Farebrother J, Rohner F

February 2018 – The Biology of the First 1,000 days

Iodine deficiency used to be highly prevalent in many parts of the world until salt iodization programs and other prevention strategies were implemented and scaled up, beginning in the 1980s in most countries. Great progress toward reducing iodine deficiency and its consequences has been achieved since; however, large numbers of people continue to be affected. This chapter examines mechanisms of iodine, thyroid hormones, and growth during the « 1,000-day window », the period between conception and when a child is 2 years of age.

Association between sickle cell and β-thalassemia genes and hemoglobin concentration and anemia in children and non-pregnant women in Sierra Leone: ancillary analysis of data from Sierra Leone’s 2013 National Micronutrient Survey

Wirth JP, Ansumana R, Woodruff BA, Koroma AS, Hodges MH

January 2018 – BMC Research Notes

By measuring the associations between the presence of sickle cell and β-thalassemia genes, we assessed the extent to which these hemoglobinopathies contribute to the high prevalence of anemia observed in preschool-aged children and women of reproductive age in Sierra Leone. The prevalence of anemia was statistically significantly higher in children with homozygous sickle cell genes (HbSS) than in children with normal hemoglobin genes (HbAA or HbAC), but there was no difference in anemia prevalence in those with heterozygous sickle cell trait (HbAS or HbSC) compared with those with normal hemoglobin genes. In women, there was no difference in anemia prevalence by sickle cell status. In both children and women, there was no difference in the anemia prevalence for individuals with or without the β-thalassemia gene. For both sickle cell and β-thalassemia, there was no significant difference in hemoglobin concentrations by sickle cell or β-thalassemia status. Anemia prevalence was higher in children and women with homozygous sickle cell (HbSS). However, as the prevalence of HbSS children (5.4%) and women (1.6%) was quite small, it is unlikely that these hemoglobinopathies substantially contributed to the high anemia prevalence found in the 2013 national micronutrient survey.

Determinants of Stunting, Wasting, and Anemia in Guinean Preschool-Age Children: An Analysis of DHS Data From 1999, 2005, and 2012

Woodruff BA, Wirth JP, Ngnie-Teta I, Beaulière JM, Mamady D, Ayoya MA, Rohner F

January 2018 – Food and Nutrition Bulletin

Wasting, stunting, and anemia are persistent and important forms of malnutrition in preschool-age children in the less developed world, in particular the Republic of Guinea, which was the site of a large outbreak of Ebola virus disease in 2014 to 2015. We analyzed data from 3 Demographic and Health Surveys done in Guinea in 1999, 2005, and 2012 to identify possible determinants of wasting, stunting, and anemia. All analyses, both bivariate and multivariate, were carried out separately for each of 3 age groups: less than 6 months, 6 to 23 months, and 24 to 59 months. Variables found statistically significantly associated with stunting, wasting, or anemia in bivariate analysis were placed in an age-specific logistic regression model for that outcome. Overall, anthropometric indices were available for 9228 children and hemoglobin concentrations were available for 5681 children. Logistic regression found relatively few variables associated with nutrition outcomes in children younger than 6 months. More variables were associated with nutrition outcomes in children aged 6 to 23 months. Such variables measured a wide variety of conditions, including estimated birth size, child health and nutritional status, child caring practices, mother’s nutritional and health status, and household water source and sanitation. A similarly broad ranges of variables were statistically significantly associated with one or more nutrition outcomes in children aged 24 to 59 months. Few of the standard infant and young child feeding indicators were associated with any nutrition outcome. Improvement in the nutritional status of young children in Guinea may require a broad range of nutrition and health interventions.

Adjusting retinol-binding protein concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Larson LM, Namaste SML, Williams AM, Engle-Stone R, Addo OY, Suchdev PS, Wirth JP, Temple V, Serdula M, Northrop-Clewes CA

June 2017 – American Journal of Clinical Nutrition

Retinol-binding protein (RBP) is often used in population surveys to measure vitamin A status, but its interpretation is challenging in settings where inflammation is common because RBP concentrations decrease during the acute-phase response. We assessed the relation between RBP concentrations and inflammation and malaria in preschool children (PSC) (age range: 6–59 mo) and women of reproductive age (WRA) (age range: 15–49 y) and to investigate adjustment algorithms to account for these effects. Several approaches were explored to adjust RBP concentrations in PSC in inflammation and malaria settings as follows: 1) the exclusion of subjects with C-reactive protein (CRP) concentrations >5 mg/L or a-1-acid glycoprotein (AGP) concentrations >1 g/L, 2) the application of arithmetic correction factors, and 3) the use of a regression correction approach. The impact of adjustment on the estimated prevalence of VAD (defined as <0.7 mmol/L) was examined in PSC. The relation between estimated VAD and CRP and AGP deciles followed a linear pattern in PSC. In women, the correlations between RBP and CRP and AGP were too weak to justify adjustments for inflammation. Depending on the approach used to adjust for inflammation (CRP+AGP), the estimated prevalence of VAD decreased by a median of 11–18 percentage points in PSC compared with unadjusted values. There was no added effect of adjusting for malaria on the estimated VAD after adjusting for CRP and AGP.

Predictors of anemia in women of reproductive age: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Wirth JP, Woodruff BA, Engle-Stone R, Namaste SML, Temple V, Petry N, Macdonald B, Suchdev PS, Rohner F, Aaron GJ

June 2017 – American Journal of Clinical Nutrition

Anemia in women of reproductive age (WRA) (age range: 15–49 y) is a global public health problem, and reducing anemia in women by 50% by 2025 is a goal of the World Health Assembly. Using cross-sectional, nationally representative data from 10 surveys (n = 27,018) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA), we examined the associations between anemia and proximal risk factors (e.g., iron and vitamin A deficiencies, inflammation, malaria, and body mass index) and distal risk factors (e.g., education status, household sanitation and hygiene, and urban or rural residence). Analyses were conducted separately and pooled by category of infection burden. Multivariate logistic regression models were constructed for each infection-burden category to identify independent determinants of anemia (hemoglobin concertation <120 g/L). Iron deficiency was consistently associated with anemia in multivariate models, but the proportion of anemic women who were iron deficient was considerably lower in the high-infection group (35%) than in the moderate- and lowinfection groups (65% and 71%, respectively). In the multivariate analysis, inflammation, vitamin A insufficiency, socioeconomic status, and age were also significantly associated with anemia, but malaria and vitamin B-12 and folate deficiencies were not. Anemia-reduction programs for WRA can be improved by considering the underlying infection burden of the population and by assessing the overlap of micronutrient deficiencies and anemia.

Predictors of anemia in preschool children: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Engle-Stone R, Aaron GJ, Huang J, Wirth JP, Namaste SML, Williams AM, Peerson JM, Rohner F, Varadhan R, Addo OY, Temple V, Rayco-Solon P, Macdonald B, Suchdev PS

June 2017 – American Journal of Clinical Nutrition

Due to a lack of information on the etiology of anemia, we evaluated predictors of anemia in preschool children (PSC) (age range: 6–59 mo) by country and infection-burden category. Cross-sectional data from 16 surveys (n = 29,293) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed separately and pooled by category of infection burden. We assessed relations between anemia (hemoglobin concentration <110 g/L) and severe anemia (hemoglobin concentration <70 g/L) and individual-level (age, anthropometric measures, micronutrient deficiencies, malaria, and inflammation) and household-level predictors; we also examined the proportion of anemia with concomitant iron deficiency (defined as an inflammation-adjusted ferritin concentration <12 μg/L). In multivariable pooled models, child age, iron deficiency, and stunting independently predicted anemia and severe anemia. Inflammation was generally associated with anemia in the high- and very high–infection groups but not in the low- and medium-infection groups. In PSC with anemia, 50%, 30%, 55%, and 58% of children had concomitant iron deficiency in low-, medium-, high-, and very high–infection categories, respectively. Results suggest anemia-control programs should address both iron deficiency and infections. The relative importance of factors that are associated with anemia varies by setting, and thus, country-specific data are needed to guide programs.

Adjusting soluble transferrin receptor concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Rohner F, Namaste SML, Larson LM, Addo OY, Mei Z, Suchdev PS, Williams AM, Sakr Ashour FA, Rawat R, Raiten DJ, Northrop-Clewes CA

June 2017 – American Journal of Clinical Nutrition

Iron deficiency is thought to be one of the most prevalent micronutrient deficiencies globally, but an accurate assessment in populations who are frequently exposed to infections is impeded by the inflammatory response, which causes iron-biomarker alterations. We assessed the relation between soluble transferrin receptor (sTfR) concentrations and inflammation and malaria in preschool children (PSC) and women of reproductive age (WRA) and investigated adjustment algorithms to account for these effects using cross-sectional data from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. The following 3 adjustment approaches were compared with estimated iron-deficient erythropoiesis (sTfR concentration >8.3 mg/L): 1) the exclusion of individuals with C-reactive protein (CRP) concentrations >5 mg/L or α-1-acid glycoprotein (AGP) concentrations >1 g/L, 2) the application of arithmetic correction factors, and 3) the use of regression approaches. The prevalence of elevated sTfR concentrations incrementally decreased as CRP and AGP deciles decreased for PSC and WRA, but the effect was more pronounced for AGP than for CRP. Depending on the approach used to adjust for inflammation, the estimated prevalence of iron-deficient erythropoiesis decreased by 4.4-14.6 and 0.3-9.5 percentage points in PSC and WRA, respectively, compared with unadjusted values. The correction-factor approach yielded a more modest reduction in the estimated prevalence of iron-deficient erythropoiesis than did the regression approach.

Adjusting total body iron for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.

Mei Z, Namaste SML, Serdula M, Suchdev PS, Rohner F, Flores-Ayala R, Addo OY, Raiten DJ

June 2017 – American Journal of Clinical Nutrition

Total body iron (TBI) that is calculated from ferritin and soluble transferrin receptor (sTfR) allows for the evaluation of the full range of iron status from deficiency to excess. However, both ferritin and sTfR are affected by inflammation and malaria, which may require a statistical adjustment. TBI has been used to assess iron status in the United States, but its use worldwide and in settings with inflammation has been limited. We examine whether inflammation-adjusted ferritin and sTfR concentrations affect TBI values and the prevalence of low TBI (<0 mg/kg) in preschool children (PSC) and women of reproductive age (WRA) using cross-sectional data from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. TBI and the prevalence of low TBI were compared following 3 adjustment approaches for ferritin and sTfR: 1) the exclusion of individuals with inflammation (C-reactive protein concentration >5 mg/L or α-1-acid glycoprotein concentration >1 g/L), 2) the application of arithmetic correction factors, and 3) the use of regression correction. Regardless of the method that was used to adjust ferritin and sTfR for inflammation, the adjusted mean TBI decreased in both PSC and WRA compared with unadjusted values. Subsequently, inflammation-adjusted TBI increased the prevalence of low TBI by a median of 4-14 percentage points (pps) in PSC and 1-3 pps in WRA compared with unadjusted TBI. The regression approach resulted in a greater median increase than was achieved with the exclusion or correction-factor approaches, and accounting for malaria in addition to inflammation did not have an added effect on the prevalence estimates.

Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Namaste SML, Rohner F, Huang J, Bhushan NL, Flores-Ayala R, Kupka R, Mei Z, Rawat R, Williams AM, Raiten DJ, Northrop-Clewes CA, Suchdev PS

June 2017 – American Journal of Clinical Nutrition

The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation. We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PSC) (age range: 6–59 mo) and women of reproductive age (WRA) (age range: 15–49 y) and investigated adjustment algorithms to account for these effects using cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Several approaches were explored to estimate depleted iron stores, including a regression correction approach. Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7–25 and 2–8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.

Identification of a Hemolysis Threshold That Increases Plasma and Serum Zinc Concentration

Killilea DW, Rohner F, Ghosh S, Otoo GE, Smith L, Siekmann JH, King JC

May 2017 – Journal of Nutrition

Plasma or serum zinc concentration (PZC or SZC) is the primary measure of zinc status, but it is not established how much hemolysis can occur without changing PZC/SZC concentrations. To estimate the effect of hemolysis on PZC/SZC concentrations, this study calculated a hemolysis threshold and then compared it with results from an in vitro study and a population survey. This study found a 5% increase in PZC/SZC was calculated to result from the lysis of 1.15% of the erythrocytes in whole blood, corresponding to ~1 g hemoglobin/L added into the plasma or serum. Similarly, the addition of simulated hemolysate to control plasma in vitro caused a 5% increase in PZC when hemoglobin concentrations reached 1.1860.10 g/L. In addition, serum samples from a population nutritional survey were scored for hemolysis and analyzed for changes in SZC; samples with hemolysis in the range of 1–2.5 g hemoglobin/L showed an estimated increase in SZC of 6% compared with non-hemolyzed samples. Each approach indicated that a 5% increase in PZC/SZC occurs at ~1 g hemoglobin/L in plasma or serum. This concentration of hemoglobin can be readily identified directly by chemical hemoglobin assays or indirectly by direct spectrophotometry or matching to a color scale. A threshold of 1 g hemoglobin/L is recommended for PZC/SZC measurements to avoid increases in zinc caused by hemolysis. The use of this threshold may improve zinc assessment for monitoring zinc status and nutritional interventions.

Efficacy of iron-biofortified crops

Boy E, Haas JD, Petry N, Cercamondi CI, Gahutu JB, Mehta S, Finkelstein JL,Hurrell RF

April 2017 – African Journal of Food, Agriculture, Nutrition, and Development

Biofortification aims to increase the content of micronutrients in staple crops without sacrificing agronomic yield, making the new varieties attractive to farmers. Food staples that provide a major energy supply in low- and middle-income populations are the primary focus. The low genetic variability of iron in the germplasm of most cereal grains is a major obstacle on the path towards nutritional impact with these crops, which is solvable only by turning to transgenic approaches. However, biofortified varieties of common beans and pearl millet have been developed successfully and made available with iron contents as high as 100 mg/kg and 80 mg/kg, respectively, two to five times greater than the levels in the regular varieties. This brief review summarizes the research to date on the bioavailability and efficacy of iron-biofortified crops, highlights their potential and limitations, and discusses the way forward with multiple biofortified crop approaches suitable for diverse cultures and socio-economic milieu. Like post-harvest iron fortification, these biofortified combinations might provide enough iron to meet the additional iron needs of many iron deficient women and children that are not covered at present by their traditional diets.

Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency

Wirth JP, Petry N, Tanumihardjo, SA, Rogers LM, McLean E, Greig A, Garrett GS, Klemm RDW, Rohner F

February 2017 – Nutrients

Vitamin A supplementation (VAS) programs targeted at children aged 6–59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.

Accelerating salt iodization in Angola

Wirth JP, Jooste P, Costa C, Nsalambi CA, Futi M, Agbo S

December 2016 – IDD Newsletter

Over the past decade, Angola has made continuous efforts to enhance its salt iodization program. Salt iodization was made mandatory in 2008, and according to the existing survey and monitoring data, the majority of salt in Angola is iodized (although the adequacy of iodized salt is unknown). Despite these advances, there has not been a comprehensive and recent assessment of iodine status in children and women nor of the iodine content of table salt at the production sites or in the households. To address this information gap, a situation analysis of Angola’s salt iodization program was conducted in July 2016, and provides detailed recommendations to enhance the program moving forward. This situation analysis was followed by a workshop of salt producers and public health stakeholders in September 2016, and advocacy activities promoting the benefits of iodized salt were conducted in October 2016.

The Effect of Low Dose Iron and Zinc Intake on Child Micronutrient Status and Development during the First 1000 Days of Life: A Systematic Review and Meta-Analysis

Petry N, Olofin I, Boy E, Angel MD, Rohner F

December 2016 – Nutrients

Adequate supply of micronutrients during the first 1000 days is essential for normal development and healthy life. To investigate if interventions administering dietary doses of iron and zinc from conception to age 2 years have the potential to influence nutritional status and development of children, we conducted a systematic review and meta-analysis of randomized and quasi-randomized fortification, biofortification, and supplementation trials in women (pregnant and lactating) and children (6–23 months) delivering iron or zinc in doses up to the recommended nutrient intake (RNI) levels. Supplying iron or zinc during pregnancy had no effects on birth outcomes. There were limited or no data on the effects of iron/zinc during pregnancy and lactation on child iron/zinc status, growth, morbidity, and psychomotor and mental development. Delivering up to 15 mg iron/day during infancy increased mean hemoglobin by 4 g/L (p < 0.001) and mean serum ferritin concentration by 17.6 µg/L (p < 0.001) and reduced the risk for anemia by 41% (p < 0.001), iron deficiency by 78% (ID; p < 0.001) and iron deficiency anemia by 80% (IDA; p < 0.001), but had no effect on growth or psychomotor development. Providing up to 10 mg of additional zinc during infancy increased plasma zinc concentration by 2.03 µmol/L (p < 0.001) and reduced the risk of zinc deficiency by 47% (p < 0.001). Further, we observed positive effects on child weight for age z-score (WAZ) (p < 0.05), weight for height z-score (WHZ) (p < 0.05), but not on height for age z-score (HAZ) or the risk for stunting, wasting, and underweight.

High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan, Coˆte d’Ivoire: Findings from a Cross-Sectional Survey

Leyvraz M, Rohner F, Konan AG, Esso LJCE, Woodruff BA, Norte A, Adiko AF, Bonfoh B, & Aaron GJ

November 2016 – PLOS ONE

As part of a broad effort to address poor complementary feeding practices among infants and young children in Côte d’Ivoire, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d’Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d’Ivoire. Four measures of coverage were assessed: “message coverage” (i.e., has the caregiver ever heard of the product?), “contact coverage” (i.e., has the caregiver ever fed the child the product?), “partial coverage” (i.e., has the caregiver fed the child the product in the previous month?), and “effective coverage” (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. The results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand.

The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys

Petry N, Olofin I, Hurrell RF, Boy E, Wirth JP, Moursi M, Angel MD, Rohner F

November 2016 – Nutrients

Iron deficiency is commonly assumed to cause half of all cases of anemia, with hereditary blood disorders and infections such as hookworm and malaria being the other major causes. In countries ranked as low, medium, and high by the Human Development Index, we conducted a systematic review of nationally representative surveys that reported the prevalence of iron deficiency, iron deficiency anemia, and anemia among pre-school children and non-pregnant women of reproductive age. Using random effects meta-analyses techniques, data from 23 countries for pre-school children and non-pregnant women of reproductive age was pooled, and the proportion of anemia attributable to iron deficiency was estimated by region, inflammation exposure, anemia prevalence, and urban/rural setting. For pre-school children and non-pregnant women of reproductive age, the proportion of anemia associated with iron deficiency was 25.0% (95% CI: 18.0, 32.0) and 37.0% (95% CI: 28.0, 46.0), respectively. The proportion of anemia associated with iron deficiency was lower in countries where anemia prevalence was >40%, especially in rural populations (14% for pre-school children; 16% for non-pregnant women of reproductive age), and in countries with very high inflammation exposure (20% for pre-school children; 25% for non-pregnant women of reproductive age). Despite large heterogeneity, our analyses suggest that the proportion of anemia associated with iron deficiency is lower than the previously assumed 50% in countries with low, medium, or high Human Development Index ranking.

High Coverage and Utilization of Fortified Take-Home Rations among Children 6–35 Months of Age Provided through the Integrated Child Development Services Program: Findings from a Cross-Sectional Survey in Telangana, India

Leyvraz M, Wirth JP, Woodruff BA, Sankar R, Sodani PR, Sharma ND, Aaron GJ

October 2016 – PLOS ONE

The Integrated Child Development Services (ICDS) in the State of Telangana, India, freely provides a fortified complementary food product, Bal Amrutham, as a take-home ration to children 6–35 months of age. To assess the coverage, utilization, barriers, and drivers of the program, a two-stage, stratified cross-sectional cluster survey was conducted in randomly selected catchment areas of ICDS centers in Telangana. A total of 1,077 children 0-35 months were randomly selected and enrolled in the survey. The coverage of the fortified take-home ration was found to be high among the target population. Nearly all caregivers (93.7%) had heard of Bal Amrutham and 86.8% had already received the product for the target child. Among the children surveyed, 57.2% consumed the product regularly. The ICDS program’s services were not found to be a barrier to product coverage. In fact, the ICDS program was found to be widely available, accessible, accepted, and utilized by the population in both urban and rural catchment areas, as well as among poor and non-poor households. However, two barriers to optimal coverage were found: the irregular supply of the product to the beneficiaries and the intra-household sharing of the product. Although sharing was common, the product was estimated to provide the target children with significant proportions of the daily requirements of macro- and micronutrients.

Situation analysis of salt iodization and iodine status in Angola

Iodine Global Network and GroundWork

September 2016 – Report Release, Luanda, Angola

The Iodine Global Network (IGN) has classified Angola’s iodine status as « insufficient » and has estimated that approximately 520,000 Angolan infants are at risk of iodine deficiency. Though the existing data sources indicate that iodine is a severe public health problem in Angola, there has not been a comprehensive and recent assessment of iodine status nor of the iodized salt sector. In order to compile all available data related to salt iodization program and iodine nutrition in Angola, IGN and GroundWork have collaborated undertaken a situation analysis. As documented in the report, the salt iodization program in Angola has made considerable strides over the past decade. Angola has established legislation and standards, a coordinating body, and promotional and awareness raising materials. Moreover, according to the existing survey and monitoring data, the majority of salt in Angola is iodized, although the adequacy of iodized salt is unknown. To build upon and sustain recent advances in Angola’s salt iodization program and expand the supply and coverage of adequately iodized salt, efforts are needed to review and strengthen the salt supply chain and generate updated evidence on the status of iodine nutrition in the population. Through these efforts, Angola can further its efforts to grow its domestic salt iodization industry and reduce iodine deficiency and its disorders.

Coverage of Adequately Iodized Salt Is Suboptimal and Rice Fortification Using Public Distribution Channels Could Reach Low-Income Households: Findings from a Cross-Sectional Survey of Anganwadi Center Catchment Areas in Telangana, India

Wirth JP, Leyvraz M, Sodani PR, Aaron GJ, Sharma ND, Woodruff BA

July 2016 – PLOS ONE

To assess the coverage of adequately iodized salt and the potential for rice fortification, we conducted a cross-sectional survey of children 0–35 months of age residing in the catchment areas of anganwadi centers in the state of Telangana, India. Iodine concentration of salt samples was tested using iodometric titration, and information on household rice consumption and Telangana’s rice sector was collected and interpreted. In households of selected children, 79% of salt samples were found to be adequately iodized. Salt brand and district were significant predictors of inadequately iodized salt. Daily rice consumption among children and women averaged 122 grams and 321 grams per day, respectively. Approximately 28% of households reported consuming rice produced themselves or purchased from a local farmer, 65% purchased rice from a market or shop, 6% got rice from a public distribution system site, and 2% obtained it from a rice mill. Due to the significant variation in the coverage of adequately iodized salt by district and brand, increasing the adequacy of iodization of smaller salt manufacturers will help achieve universal salt iodization in Telangana. Despite high consumption of rice, our findings suggest that large-scale market-based rice fortification is not feasible in Telangana. Distributing fortified rice via Telangana’s public distribution system may be a viable approach to target low-income households, but would only reach a small proportion of the population.

The Potential of Food Fortification to Add Micronutrients in Young Children and Women of Reproductive Age – Findings from a Cross-Sectional Survey in Abidjan, Côte d’Ivoire

Rohner F, Leyvraz M, Konan AG, Esso LJCE, Wirth JP, Norte A, Adiko AF, Bonfoh B, Aaron GJ

July 2016 – PLOS ONE

Large-scale food fortification is considered a cost-effective approach to deliver micronutrients, and fortification of salt (iodine), wheat flour (iron and folic acid), and vegetable oil (vitamin A) is mandatory in Côte d’Ivoire. A cross-sectional survey on households with at least one child 6–23 months was conducted to update coverage figures with adequately fortified food vehicles in Abidjan, the capital of and largest urban community in Côte d’Ivoire, and to evaluate whether additional iron and vitamin A intake is sufficient to bear the potential to reduce micronutrient malnutrition. Information on demographics and food consumption was collected, along with samples of salt and oil. Wheat flour was sampled from bakeries and retailers residing in the selected clusters. In Abidjan, 86% and 97% of salt and vegetable oil samples, respectively, were adequately fortified, while only 32% of wheat flour samples were adequately fortified, but all samples contained some added iron. There were no major differences in additional vitamin A and iron intake between poor and non-poor households. For vitamin A in oil, the additional percentage of the recommended nutrient intake was 27% and 40% for children 6–23 months and women of reproductive age, respectively, while for iron from wheat flour, only 13% and 19% could be covered. Fortification of vegetable oil clearly provides a meaningful additional amount of vitamin A. This is not currently the case for iron, due to the low fortification levels. Iron levels in wheat flour should be increased and monitored, and additional vehicles should be explored to add iron to the Ivorian diet.

Scale up of nutrition and health programs in Ethiopia and their overlap with reductions in child stunting

Wirth JP, Matji J, Woodruff BA, Chamois S, Getahun Z, White JM, Rohner F

May 2016 – Maternal & Child Nutrition

In Ethiopia, the national stunting prevalence and number of stunted children have decreased consistently since 2000. We compare regional differences and temporal patterns in stunting with large-scale program coverage to identify where and when programs may have led to reductions in stunting. Data from three national demographic and health surveys and population statistics illustrate, at the regional level, where andwhen the prevalence and number of stunted children changed since 2000.Reports from large-scale nutrition and health programs were used to identify ecologic associations between geographic program coverage and reductions in stunting. From 2000 to 2005, the decline in the national stunting prevalence was mainly a result of reductions in Oromiya, SNNP and Tigray. Few nutrition programs had high coverage during this time, and economic growth may have contributed to stunting reduction by increasing household wealth and investments in sanitation. From 2005 to 2011, declines in stunting prevalence in Amhara, SNNP, Somali and Oromiya were largely responsible for national reductions. Numerous programs were implemented at scale and could have plausibly improved stunting. While ecologic relationships suggest that economic growth and large-scale programs may have contributed to the reduction in stunting in Ethiopia, stunting did not decrease in all regions despite increased program coverage expansion of the health system.

Assessment of the WHO Stunting Framework using Ethiopia as a case study

Wirth JP, Rohner F Petry N Onyango AW, Matji J, Bailes A, de Onis M, Woodruff BA

May 2016 – Maternal & Child Nutrition

Poor linear growth in children <5 years old, or stunting, is a serious public health problem particularly in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) released a conceptual framework on the Context, Causes and Consequences of Childhood Stunting (the ‘WHO framework’) that identifies specific and general factors associated with stunting. The framework is based upon a global review of data, and we have applied it to a country level analysis where health and nutrition policies are made and public health and nutrition data are collected. We reviewed the literature related to sub-optimal linear growth, stunting and birth outcomes in Ethiopia as a case study. We found consistent associations between poor linear growth and indicators of birth size, recent illness (e.g. diarrhoea and fever), maternal height and education. Other factors listed as causes in the framework such as inflammation, exposure to mycotoxins and inadequate feeding during and after illness have not been examined in Ethiopia, and the existing literature suggests that these are clear data gaps. Some factors associated with poor linear growth in Ethiopia are missing in the framework, such as household characteristics (e.g. exposure to indoor smoke). Examination of the factors included in the WHO framework in a country setting helps identifying data gaps helping to target further data collection and research efforts.

Determinants of stunting reduction in Ethiopia 2000 – 2011

Woodruff BA, Wirth JP, Bailes A, Matji J, Timmer A, Rohner F

May 2016 – Maternal & Child Nutrition

The prevalence of stunting in Ethiopia declined from 57% in 2000 to 44% in 2011, yet the factors producing this change are not fully understood. Data on 23,999 children 0–59 months of age from three Demographic and Health Surveys (DHS) from 2000, 2005, and 2011 were analyzed to assess the trends in stunting prevalence, mean height-for-age z-scores (HAZ) and the associations between potential factors and HAZ. Associations were determined separately using three separate generalized linear models for children age less than 6months, 6–23 months, and 24–59 months of age. Significant variables were then analyzed to determine if they showed an overall trend between the 2000 and 2011 surveys. In children<6months of age, only mother’s height was both a significant predictor of HAZ and showed a progressive, albeit non-significant, increase from 2000 to 2011. In children 6–23 months of age, only mother’s use of modern contraception showed substantial changes in a direction consistent with improving HAZ, but improvements in maternal nutrition status were observed from 2000 to 2005. For children 24–59 months of age a consistent and progressive change is seen in child’s diarrhea, fever, mother’s education, and the occurrence of open defecation. Our analysis demonstrated that factors associated with HAZ vary by child’s age and the dominant livelihood practice in the community. Variables that could have contributed to the decline of stunting in Ethiopia in children less than 5 years of age include markers of child health, mother’s nutritional status, mother’s educational level, and environmental hygiene.

Anemia, Micronutrient Deficiencies, and Malaria in Children and Women in Sierra Leone Prior to the Ebola Outbreak – Findings of a Cross-Sectional Study

Wirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, Russel F, Sesay F, Dominguez E, Petry N, Shahab-Ferdows S, de Onis M, Hodges MH

May 2016 – PLOS ONE

To identify the factors associated with anemia and to document the severity of micronutrient deficiencies, a nationally representative cross-sectional survey was conducted in rural and urban areas of Sierra Leone. Household and individual data were collected, and blood samples from children and women were used to measure the prevalence of malaria, inflammation, and deficiencies of iron, vitamin A, folate, and vitamin B12. 839 children and 945 non-pregnant women were included in the survey. In children, the prevalence of anemia (76.3%), malaria (52.6%), and acute and chronic inflammation (72.6%) was high. However, the prevalence of vitamin A deficiency (17.4%) was moderate, and the prevalence of iron deficiency (5.2%) and iron-deficiency anemia (3.8%) were low. Malaria and inflammation were associated with anemia, yet they explained only 25% of the population-attributable risk. In women, 44.8%, 35.1%, and 23.6% were affected by anemia, malaria, or inflammation, respectively. The prevalence of iron deficiency (8.3%), iron-deficiency anemia (6.1%), vitamin A deficiency (2.1%) and vitamin B12 deficiency (0.5%) were low, while folate deficiency was high (79.2%). Iron deficiency, malaria, and inflammation were significantly associated with anemia, but explained only 25% of cases of anemia. Anemia in children and women is a severe public health problem in Sierra Leone, and other causes of anemia, such as hemoglobinopathies, should also be explored.

In Rwandese Women with Low Iron Status, Iron Absorption from Low-Phytic Acid Beans and Biofortified Beans Is Comparable, but Low-Phytic Acid Beans Cause Adverse Gastrointestinal Symptoms

Petry N, Rohner F, Gahutu JB, Campion B, Boy E, Tugirimana PL, Zimmerman MB, Zwahlen C, Wirth JP, and Moretti D.

March 2016 – Journal of Nutrition

Phytic acid (PA) is a major inhibitor of iron bioavailability from beans, and high PA concentrations might limit the positive effect of biofortified beans (BBs) on iron status. As low-phytic acid (lpa) bean varieties could increase iron bioavailability, we tested whether lpa beans provide more bioavailable iron than a BBs and control beans (CBs) (regular iron and PA concentrations) by comparing iron absorption in 25 nonpregnant young women with low iron status with the use of a multiple-meal crossover design. Iron absorption was measured with stable iron isotopes. The total amount of iron absorbed from lpa beans and BBs was 421 μg (95% CI: 234, 756 μg) and 431 μg (95% CI: 237, 786 μg), respectively, and did not significantly differ, but was >50% higher (P < 0.005) than from CBs (278 μg; 95% CI: 150, 499 μg). In our trial, the lpa beans were hard to cook, and their consumption caused transient adverse digestive side effects in ∼95% of participants. Gel electrophoresis analysis showed phytohemagglutinin L (PHA-L) residues in cooked lpa beans. In conclusion, BBs and lpa beans provided more bioavailable iron than control beans and could reduce dietary iron deficiency. Digestive side effects of lpa beans were likely caused by PHA-L, but it is unclear to what extent the associated digestive problems reduced iron bioavailability.

The Effects of an Oil and Wheat Flour Fortification Program on Pre-School Children and Women of Reproductive Age Living in Côte d’Ivoire, a Malaria-Endemic Area

Rohner F, Raso G, Aké-Tano SOP, Tschannen AB, Mascie-Taylor CGN, Northrop-Clewes CA

March 2016 – Nutrients

Anemia and micronutrient deficiencies are widespread in sub-Saharan Africa, but the impact of food fortification is still debated. The objective of this study was to estimate the iron and vitamin A status of preschool children (PSC) and women of reproductive age (WRA) in households consuming fortified oil and wheat flour. The survey was cross-sectional in a rural and an urban area. Data on demographics, socioeconomic status, and fortified foods were collected at households. Hemoglobin (Hb), retinol binding protein (RBP), ferritin, soluble transferrin receptors (sTfR), subclinical inflammation, and Plasmodium spp. infection data were collected. In PSC, vitamin A deficiency (VAD) was prevalent, but for each 1 mg retinol equivalents (RE)/kg of oil consumed, RBP increased by 0.37 µmol/L (p = 0.03). In WRA, there was no significant VAD in the population (0.7%). Anemia was found in 92.2% of rural and 56.3% of urban PSC (p < 0.001). PSC with access to adequately fortified flour had Hb concentrations 15.7 g/L higher than those who did not (p < 0.001). Hb levels increased by +0.238 g/L per mg/kg increase in iron fortification levels (p < 0.001). The national program fortifying vegetable oil with vitamin A and wheat flour with iron and folic acid may have contributed to improved micronutrient status of PSC from two areas in Côte d’Ivoire.

Iodine Status of Women of Reproductive Age in Sierra Leone and Its Association with Household Coverage with Adequately Iodized Salt

Rohner F, Wirth JP, Woodruff BA, Chiwile F, Yankson H, Sesay F, Koroma AS, Petry N, Pyne-Bailey S, Dominguez E, Kupka R, Hodges MH, & de Onis M.

February 2016 – Nutrients

Salt iodization programs are a public health success in tackling iodine deficiency. Yet, a large proportion of the world’s population remains at risk for iodine deficiency. In a nationally representative cross-sectional survey in Sierra Leone, household salt samples and women’s urine samples were quantitatively analyzed for iodine content. Salt was collected from 1123 households, and urine samples from 817 non-pregnant and 154 pregnant women. Household coverage with adequately iodized salt (ě15 mg/kg iodine) was 80.7%. The median urinary iodine concentration (UIC) of pregnant women was 175.8 µg/L and of non-pregnant women 190.8 µg/L. Women living in households with adequately iodized salt had higher median UIC (for pregnant women: 180.6 µg/L vs. 100.8 µg/L, respectively, p < 0.05; and for non-pregnant women: 211.3 µg/L vs. 97.8 µg/L, p < 0.001). Differences in UIC by residence, region, household wealth, and women’s education were much smaller in women living in households with adequately iodized salt than in households without. Despite the high household coverage of iodized salt in Sierra Leone, it is important to reach the 20% of households not consuming adequately iodized salt. Salt iodization has the potential for increasing equity in iodine status even with the persistence of other risk factors for deficiency.

Implementation of Multiple Irish Aid-Funded Orange Flesh Sweet Potato Projects

Petry N, Wirth JP, Siddle, B, Gaynor, M.

December 2015 – Sight and Life

Biofortification of sweet potatoes is a promising and sustainable agricultural approach to reduce vitamin A deficiency (VAD), particularly in remote areas where individuals have limited access to commercial markets and mainly rely on household-produced crops. Due to its large genetic variability, its favorable growing characteristics, and the high consumption in remote areas, the orange flesh sweet potato (OFSP) is one of the major targeted crops of biofortification initiatives. OFSP have high concentrations of provitamin A and are the most advanced biofortified crop in terms of research studies demonstrating bioavailability, efficacy, and effectiveness. Irish Aid has provided funding to five projects in Sub-Saharan Africa promoting and disseminating OFSP, a review was undertaken to better understand the common accomplishments and challenges of these five projects in order to identify common factors for success. The review found that the three following components of decentralized vine multiplication systems were indispensable for the successful OFSP projects: 1) growing large quantities of OFSP vines for dissemination by trained decentralized vine multipliers; 2) distributing vines to project farmers; and 3) teaching project farmers in OFSP growing techniques.

Sierra Leone Micronutrient Survey Report

Ministry of Health and Sanitation, UNICEF, WHO, HKI, GroundWork LLC

December 2015 – Report Release, Freetown, Sierra Leone

The 2013 Sierra Leone Micronutrient Survey (SLMS) is the first nationally-representative comprehensive micronutrient survey in Sierra Leone. Conducted by the Ministry of Health and Sanitation and nutrition partners (e.g. UNICEF, WHO, Helen Keller International, and others), the SLMS collected data on micronutrient deficiencies, anemia, and malaria of children <5 years of age, and non-pregnant women 15-49 years of age, and pregnant women. The SLMS was conducted prior to the Ebola outbreak in Sierra Leone, and the information collected by the SLMS will enable the government and international agencies to monitor the current status of national nutrition programs (e.g. salt iodization and vitamin A supplementation) and to plan future nutrition interventions. GroundWork supported the SLMS by designing the survey protocol, developing the questionnaires, training survey staff, analyzing data, and writing the report.

RAIN+ Baseline Survey Report 2015

Concern Worldwide-Zambia, GroundWork LLC

October 2015 – Report Release, Lusaka, Zambia

Concern Worldwide is conducting a second phase of its Realigning Agriculture for Improved Nutrition (RAIN) project in Zambia’s Mumbwa District. This second phase (referred to as RAIN+) aims to improve nutrition and health outcomes for women and young children by providing integrated agriculture, nutrition, health, and women’s empowerment interventions. The objective of the baseline survey was to collect information on priority outcome and output indicators of the RAIN+ project related to agriculture, maternal, infant and young child feeding practices (MIYCF), gender equality, and water, sanitation, and hygiene (WASH). GroundWork supported the RAIN+ baseline survey by designing the survey protocol, training interviewers and supervisors, analyzing the data, and writing the report.

Comparative Validation of Five Quantitative Rapid Test Kits for the Analysis of Salt Iodine Content: Laboratory Performance, User- and Field-Friendliness

Rohner F, Kangambèga MO, Khan N, Kargougou R, Garnier D, Sanou I, Ouaro BD, Petry N, Wirth JP, & Jooste P.

September 2015 – PLOS ONE

To render national salt iodization programs sustainable and ensure adequate iodization levels, simple methods to quantitatively assess whether salt is adequately iodized are required. Several methods claim to be simple and reliable, and are available on the market or are in development. This work has validated the currently available quantitative rapid test kits (quantRTK) in a comparative manner for both their laboratory performance and ease of use in field settings. Laboratory performance parameters (linearity, detection and quantification limit, intra- and inter-assay imprecision) were conducted on 5 quantRTK. We assessed inter-operator imprecision using salt of different quality along with the comparison of 59 salt samples from across the globe; measurements were made both in a laboratory and a field setting by technicians and non-technicians. Most of the devices showed acceptable laboratory performance, but for some of the devices, use by non-technicians revealed poorer performance when working in a routine manner. Of the quantRTK tested, the iCheck1 and I-Reader1 showed most consistent performance and ease of use, and a newly developed paper-based method (saltPAD) holds promise if further developed.

Inflammatory and metabolic responses to high-fat meals with and without dairy products in men

Schmid A, Petry N, Walther B, Bütikofer U, Luginbühl W, Gille D, Chollet M, McTernan PG, Gijs MAM, Vionnet N, Pralong FP, Laederach K, Vergères G

May 2015 – British Journal of Nutrition

Postprandial inflammation is an important factor for human health since chronic low-grade inflammation is associated with chronic diseases. Dairy products have a weak but significant anti-inflammatory effect on postprandial inflammation. The objective of the present study was to compare the effect of a high-fat dairy meal (HFD meal), a high-fat non-dairy meal supplemented with milk (HFM meal) and a high-fat non-dairy
control meal (HFC meal) on postprandial inflammatory and metabolic responses in healthy men. A cross-over study was conducted in nineteen male subjects. Blood samples were collected before and 1, 2, 4 and 6 h after consumption of the test meals. Plasma concentrations of insulin, glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol, TAG and C-reactive protein (CRP) were measured at each time point. IL-6, TNF-a and endotoxin concentrations were assessed at baseline and endpoint (6 h). Time-dependent curves of these metabolic parameters were plotted, and the net incremental AUC were found to be significantly higher for TAG and lower for CRP after consumption of the HFM meal compared with the HFD meal; however, the HFM and HFD meals were not different from the HFC meal. Alterations in IL-6, TNF-a and endotoxin concentrations were not significantly different between the test meals. The results suggest that full-fat milk and dairy products (cheese and butter) have no significant impact on the inflammatory response to a high-fat meal.

Azerbaijan Nutrition Survey Report

UNICEF, Ministry of Health, State Statistical Committee, GroundWork LLC

April 2015 – Report Launch, Baku, Azerbaijan

The 2013 AzNS is the first nationally-representative micronutrient assessment survey in Azerbaijan. Conducted by the Ministry of Health of the Republic of Azerbaijan, the State Statistical Committee of Azerbaijan, and the Azerbaijan office of the United Nations Children’s Fund (UNICEF), the AzNS collected data on anthropometric and micronutrient status of children < 5 years, non-pregnant women 15-49 years, and pregnant women. The AzNS 2013 will provide a baseline assessment for Azerbaijan's national food fortification programme and other future nutrition programs. GroundWork LLC supported the AzNS by designing the survey protocol, developing the survey questionnaires, training phlebotomists, analyzing data and drafting the report.

The Potential of the Common Bean (Phaseolus vulgaris) as a Vehicle for Iron Biofortification

Petry N, Boy E, Wirth JP, Hurrell RF

February 2015 – Nutrients

Common beans are a staple food and the major source of iron for populations in Eastern Africa and Latin America. Bean iron concentration is high and can be further increased by biofortification. A major constraint to bean iron biofortification is low iron absorption, attributed to inhibitory compounds such as phytic acid (PA) and polyphenol(s) (PP). We have evaluated the usefulness of the common bean as a vehicle for iron biofortification. High iron concentrations and wide genetic variability have enabled plant breeders to develop high iron bean varieties (up to 10 mg/100 g). PA concentrations in beans are high and tend to increase with iron biofortification. Short-term human isotope studies indicate that iron absorption from beans is low, PA is the major inhibitor, and bean PP play a minor role. Multiple composite meal studies indicate that decreasing the PA level in the biofortified varieties substantially increases iron absorption. Fractional iron absorption from composite meals was 4%–7% in iron deficient women; thus the consumption of 100 g biofortified beans/day would provide about 30%–50% of their daily iron requirement. Beans are a good vehicle for iron biofortification, and regular high consumption would be expected to help combat iron deficiency (ID).

Phytic Acid Concentration Influences Iron Bioavailability from Biofortified Beans in Rwandese Women with Low Iron Status

Petry N, Egli I, Gahutu JB, Tugirimana PL, Boy E, Hurrell RF

September 2014 – Journal of Nutrition

The common bean is a staple crop in many African and Latin American countries and is the focus of biofortification initiatives. Bean iron concentration has been doubled by selective plant breeding, but the additional iron is reported to be of low bioavailability, most likely due to high phytic acid (PA) concentrations. To evaluate the impact of PA on iron bioavailability from iron-biofortified beans, a multiple-meal iron absorption crossover study was conducted in Rwandese women. Iron absorption was based on the erythrocyte incorporation of stable iron isotopes, and meals contained biofortified beans and control beans; beans tested either contained their native PA concentration and were dephytinized at ∼50% and >95%. The quantity of iron absorbed from the biofortified bean meals (406 μg) was 19% higher (P < 0.05) than that from the control bean meals. With ∼50% and >95% dephytinization, the quantity of iron absorbed from the biofortified bean meals increased to 599 and 746 μg, respectively, which was 37% (P < 0.005) and 51% (P < 0.0001) higher than from the control bean meals. PA strongly decreases iron bioavailability from iron-biofortified beans, and a high PA concentration is an important impediment to the optimal effectiveness of bean iron biofortification. Plant breeders should focus on lowering the PA concentration of high-iron beans.

Vitamin D status and associated factors of deficiency among Jordanian children of preschool age

Nichols EK, Khatib IM, Aburto NJ, Serdula MK, Scanlon KS, Wirth JP, Sullivan KM

September 2014 – European Journal of Clinical Nutrition

Vitamin D deficiency in children remains a global concern. Although literature exists on the vitamin D status and its risk factors among children in the Middle East, findings have yielded mixed results, and large, representative community studies are lacking. In a nationally representative survey of 1077 Jordanian children of preschool age (12-59 months) in Spring 2010, we measured 25(OH)D3 concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with various factors. Results showed 19.8% deficiency (<12 ng/ml) and 56.5% insufficiency (<20 ng/ml). In adjusted models, prevalence of deficiency was higher for females compared with males and lower for children 24-35 months of age compared with children 12-23 months of age. In rural areas, there was no difference in prevalence of vitamin D deficiency between those whose mothers had/did not have vitamin D deficiency (P=0.312); however, in urban areas, prevalence of vitamin D deficiency was 3.18 times greater among those whose mothers were vitamin D deficient compared with those whose mothers were not deficient (P=0.000). Vitamin D deficiency and insufficiency pose significant public health problems in Jordanian children with female children disproportionately affected. Strong associations between vitamin D status in children and urban residency and maternal vitamin D status suggest that the behaviors related to sun exposure in urban mothers likely also affect the sun exposure and thus vitamin D status of their children.

Iron Speciation in Beans (Phaseolus vulgaris) Biofortified by Common Breeding

Hoppler M, Egli I, Petry N, Gille D, Zeder C, Walczyk T, Blair MW, and Hurrell RF.

August 2014 – Journal of Food Science

With the aim of evaluating the potential of ferritin iron in plant breeding, we used species-specific isotope dilution mass spectrometry to quantify ferritin iron in bean varieties with a wide range of total iron content. Zinc, phytic acid, and polyphenols were also measured. Total iron concentration in 21 bean varieties ranged from 32 to 115 ppm and was positively correlated with concentrations of zinc (P = 0.001) and nonferritin bound iron (P < 0.001). Ferritin iron ranged from 13% to 35% of total iron and increased only slightly in high iron beans (P = 0.007). Concentrations of nonferritin bound iron and phytic acid were correlated (P = 0.001), although phytic acid:iron molar ratio decreased with increasing iron concentration (P = 0.003). Most iron in high iron beans was present as nonferritin bound iron, which confirms our earlier finding showing that ferritin iron in beans was lower than previously published. As the range of ferritin iron content in beans is relatively narrow, there is less opportunity for breeders to breed for high ferritin. The relevance of these findings to the extent of iron absorption depends on resolving the question of whether ferritin iron is absorbed or not to a greater extent than nonferritin bound iron.

Iodine biomarkers: a new interactive web interface

Raghavan R, Rohner F, Raiten DJ

August 2014 – IDD Newsletter

The Biomarkers of Nutrition for Development (BOND) project began in 2010 to improve data on micronutrient deficiencies and to facilitate the assessments of micronutrient deficiencies globally. One of the important objectives of the BOND project is to translate the existing evidence from expert panels to the wider audience through the BOND website. In an effort to disseminate information to organizations and professionals addressing iodine deficiency, BOND recently released the Iodine Query Based System – an interactive tool that advises users on the most appropriate biomarkers depending on their specific needs. In addition to recommending an iodine biomarker, the QBS informs users of lab methods and cut-off values for a given biomarker. In the future, BOND will launch similar query systems for folate, zinc, iron, vitamin A, and vitamin B12.

Biomarkers of Nutrition for Development—Iodine Review

Rohner F, Zimmermann M, Jooste P, Pandav C, Caldwell K, Raghavan R, Raiten DJ.

August 2014 – Journal of Nutrition

In phase I of the Biomarkers of Nutrition for Development (BOND) project, 6 nutrients (iodine, vitamin A, iron, zinc, folate, and vitamin B-12) were selected for their high public health importance because they typify the challenges faced by users in the selection, use, and interpretation of biomarkers. For each nutrient,an expert panel was constituted and charged with the development of a comprehensive review covering the respective nutrients biology, existing biomarkers, and specific issues of use with particular reference to the needs of the individual user groups. This review represents the first in the series of reviews and covers all relevant aspects of iodine biology and biomarkers. The article is organized to provide the reader with a full appreciation of iodines background history as a public health issue, its biology, and an overview of available biomarkers and specific considerations for the use and interpretation of iodine biomarkers across a range of clinical and population-based uses. The review also includes a detailed research agenda to address priority gaps in our understanding of iodine biology and assessment.

Micronutrient status in Jordan: 2002 and 2010

Serdula M, Nichols EK, Aburto NJ, Masa’d H, Obaid B, Wirth JP, Tarawneh M, Barham R, Hijawi B, Sullivan KM, and the Jordan Fortification Working Group

July 2014 – European Journal of Clinical Nutrition

Two national surveys were conducted in Jordon in 2002 and 2010 to investigate the micronutrient status in women and children. To determine the prevalence of anemia, iron and folate deficiency among women and children in 2010 and compare with the prevalence of anemia and iron deficiency in 2002. Venous blood samples were used to measure hemoglobin, ferritin and red blood cell folate. Among women in 2010, the prevalence of folate deficiency and insufficiency was 13.6% and 82.9%, respectively. Geometric mean serum ferritin was higher in 2010 compared with 2002 (21.3 ng/ml vs 18.3, P=0.01); there was no significant change in the prevalence of iron deficiency (35.1% vs 38.7%, P=0.17), iron deficiency anemia (19.1% vs 20.0%, P=0.61) or anemia (29.2% vs 29.3%, P=0.96). Among children, a significantly lower prevalence was observed in 2010 compared with 2002 for iron deficiency (13.7% vs 26.2% P<0.001) and iron deficiency anemia (4.8% vs 10.1%, P<0.001); a nonsignificant lower prevalence was observed for anemia (16.6% vs 20.2%, P=0.09). In 2010, approximately one of seven women was folate deficient and six out of seven were folate insufficient for the prevention of neural tube defects. Between 2002 and 2010, significant improvement was observed in the prevalence of iron deficiency in children, but not in women.

Polyphenols and Low Iron Bioavailability

Petry N

January 2014 – Polyphenols in Human Health and Disease

The negative impact on iron bioavailability from plant-based foods has largely been demonstrated in humans by iron isotope absorption studies, although their impact on the human iron status is still unclear.High concentrations of polyphenols can be found in numerous vegetables, legumes, fruits and beverages. It is commonly assumed that, depending on their structure, polyphenols form insoluble complexes with iron in the gut and thereby inhibit its absorption. However, the complex formation of polyphenols and iron depends not only on polyphenol structure, but also on pH and the concentration of polyphenols and iron in the solution. Both vitamin C and EDTA (although the latter to a lesser extent) have been shown to protect iron against complex formation with polyphenols and increase its absorption. This chapter studies the negative and positive health aspects of polyphenols on iron absorption and their consequences, by discussing the results of both single and multiple meal studies in an effort to measure the impact of polyphenols on iron absorption.

External Mill Monitoring of Wheat Flour Fortification Programs: An Approach for Program Managers Using Experiences from Jordan

Wirth JP, Nichols E, Masa’d H, Barham R, Johnson QJ, Serdula M.

November 2013 – Nutrients

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. This paper assesses the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention’s Updated Guidelines for Evaluating Public Health Surveillance Systems. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan’s external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.

Prevalence and public health relevance of micronutrient deficiencies and undernutrition in pre-school children and women of reproductive age in Côte d’Ivoire, West Africa

Rohner F, Northrop-Clewes C, Tschannen AB, Bosso PE, Kouassi-Gohou V, Erhardt JG, Bui M, Zimmermann MB, and Mascie-Taylor CGN.

September 2013 – Public Health Nutrition

To understand the prevalence and magnitude of nutritional deficiencies pre-school age children (pre-SAC) and non pregnant women of reproductive age (WRA) in Côte d’Ivoire, a national cross-sectional survey assessing maco/micronutrient status and infection (e.g. malaria) was conducted. In pre-SAC, anaemia was classified as a severe public health problem (72%), and was higher in rural areas (76 %) and the north (87 %). A quarter of pre-SAC suffered from vitamin A deficiency (inflammation-adjusted) and prevalence of undernutrition (assessed by stunting, wasting and underweight) was high. The prevalence of inflammation (67%) and malaria parasites (25%) were also of concern. In WRA, prevalence of malaria parasites (5 %) was low, but inflammation (34 %) was higher. Anaemia was a severe public health problem and prevalence differed by residency and eco-region. Inflammation-adjusted Fe deficiency was highest in urban areas (20 %). Nationally, folate deficiency was 86 %, higher in urban areas and varied by eco-region. Prevalence of vitamin B12 deficiency was low but higher in the rural areas and the north. Inflammation adjusted vitamin A deficiency was very low (1 %). Prevalence of inflammation, malaria parasites and micronutrient deficiencies were high in Côte d’Ivoire, particularly in pre-SAC. Nutritional interventions should be accompanied by strategies to reduce exposure to infections.

Genetic Reduction of Phytate in Common Bean (Phaseolus vulgaris L.) Seeds Increases Iron Absorption in Young Women

Petry N, Egli I, Campion B, Nielsen E, and Hurrell R.

July 2013 – Journal of Nutrition

Iron bioavailability from common beans is negatively influenced by phytic acid and polyphenols. Newly developed low-PA (lpa) beans with 90% less PA and variable PPs might improve iron bioavailability. The aim of this study was to evaluate the influence of lpa beans on iron bioavailability in women (n = 20). We compared iron absorption from 4 different beans using a paired, double meal, crossover design. Iron absorption was measured as erythrocyte incorporation of stable iron isotopes from 2 lpa bean lines, one high in PPs and one low in PPs. The other 2 beans used were their parents with a normal PA concentration, one high in PPs and one low in PPs. Fractional iron absorption from the lpa bean high in PPs was 6.1%, which was 60 and 130% higher compared with the parent high in PPs (P < 0.001) and low in PPs (P < 0.001), respectively. The total amount of iron absorbed per test meal from the lpa bean high in PPs (372 μg) was 60 and 163% higher compared with the parent high in PPs (P < 0.001) and low in PPs (P < 0.001), respectively. Fractional iron absorption from the lpa line low in PPs (4%) was 50% higher and the total amount of iron absorbed per test meal (261 μg) was 85% higher than iron from the parent low in PPs (P < 0.001). There was no difference between the lpa beans high or low in PPs or between the parents high or low in PPs. A 90% reduction in PA leads to an increase in bioavailable iron from beans, independent of the PP concentration. The lpa mutation could be a key tool for improving iron bioavailability from beans.

Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A

Rohner F, Woodruff BA, Aaron GJ, Yakes EA, Lebanan MA, Rayco-Solon P, and Saniel OP.

June 2013 – Food and Nutrition Bulletin

To improve the understanding of contributors associated with the nutritional status of children 6 to 23 months of age living in urban areas of the Philippines, a cross-sectional survey was conducted covering five urban centers in the Philippines. Data on infant and young child feeding and nutritional status (including wasting, stunting, underweight, anemia, iron deficiency, and vitamin A deficiency) were collected for 1,784 children. Among children from urban and predominantly poor and very poor households, 26% were stunted, 18% were underweight, and 5% were wasted. Forty-two percent were anemic, 28% were iron deficient, and 3% were vitamin A deficient. About half of the children were breastfed within an hour after birth, were breastfed at the time of the survey, and had been continuously breastfed up to 1 year of age. Of the factors investigated, low socio-economic status, use of cheaper cooking fuel, and nonuse of multivitamins were all independently associated with stunting. The prevalence of anemia, iron deficiency, and vitamin A deficiency were independently associated with the same factors and poorer sanitation facilities, lower maternal education, current unemployment, and inflammation. These factors merit attention in future programming, and interventions may include promotion of the timely introduction of appropriate fortified complementary foods, the use of affordable multiple micronutrient preparations, and measures to reduce infection.

Anaemia in infancy in rural Bangladesh: contribution of iron deficiency, infections and poor feeding practices

Rawat R, Saha KK, Kennedy A, Rohner F, Ruel M, Menon P.

June 2013 – British Journal of Nutrition

Few data exist on the aetiology of anaemia and iron deficiency (ID) during early infancy in South Asia. The present study aimed to determine the contribution of ID, infections and feeding practices to anaemia in Bangladeshi infants aged 6-11 months. Multivariate logistic regression was used to identify risk factors for anaemia and ID, and population attributable fractions (PAF) were computed to estimate the proportion of anaemia that might be prevented by the elimination of individual risk factors. It was found that 68 % of the infants were anaemic, 56 % were Fe deficient, and one-third had evidence of subclinical infections. ID and subclinical infections were major risk factors for anaemia, in addition to age and male sex. Similarly, subclinical infections, age and male sex were significant risk factors for ID. Previous-day consumption of Fe-rich foods was very low and not associated with anaemia or ID. The PAF of anaemia attributable to ID was 67 % (95 % CI 62, 71) and that of subclinical infections was 16 % (95 % CI 11, 20). These results suggest that a multipronged strategy that combines improvements in dietary Fe intake alongside infection control strategies is needed to prevent anaemia during infancy in Bangladesh.

Are analytical differences the reason for discrepancies between the absolute values of retinol and retinol-binding protein in human serum?

Erhardt JG and Rohner F

March 2013, Poster Presentation – International Congress on Hidden Hunger, Stuttgart, Germany

The WHO estimates that vitamin A (VA) deficiency globally affects over 190 million preschool age children. A reliable measurement of the VA status is thus essential to determine the public health relevance of VA deficiency and to assess the impact of interventions aiming to reduce VA deficiency. The currently most common VA assessment method is serum retinol by HPLC, but the measurement of retinol-binding protein (RBP) is gaining importance. It can be measured much more efficiently and easily combined with indicators for the iron and infectious status. Yet, to date, there is still uncertainty whether the absolute values of both measurements are directly comparable, and varying thresholds for defining VA deficiency are proposed. The results of this study indicate that the often observed differences between the absolute values of RBP and retinol are caused by analytical differences and can be minimized by using the same calibrators for both methods. This calls for caution prior to establishing separate thresholds for RBP and retinol, as this may induce confusion within the program managers implementing VA interventions in developing countries.

Lessons learned from national food fortification projects: Experiences from Morocco, Uzbekistan, and Vietnam

Wirth J, Laillou A, Rohner F, Northrop-Clewes C, Macdonald B, and Moench-Pfanner R

December 2012, Food and Nutrition Bulletin

Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. In this regards, the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam were documented, utilizing independent end-of-project evaluations reports, national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer reviewed articles, were used to document the current responses to challenges and future project plans. All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects’ design to address the challenges faced.

Validation of a user-friendly and rapid method for quantifying iodine content of salt

Rohner F, Garrett G, Laillou A, Frey S, Mothes R, Schweigert F, and Locatelli-Rossi L

December 2012, Food and Nutrition Bulletin

Despite considerable progress made in the past decade through salt iodization programs, over 2 billion people worldwide still have inadequate iodine intake, with devastating consequences for brain development and intellectual capacity. To optimize these programs with regard to salt iodine content, careful monitoring of salt iodine content is essential, but few methods are available to quantitatively measure iodine concentration in a simple, fast, and safe way.  To address this gap, the validation of a newly developed device that quantitatively measures the content of potassium iodate in salt in a simple, safe, and rapid way was assessed by examined independently and in comparison with iodometric titration, using salt samples from several countries. Comparison with the iodometric method showed high agreement between the methods (R2 = 0.978; limits of agreement, –10.5 to 10.0 mg/kg). Therefore, the device offers a field- and user-friendly solution to quantifying potassium iodate salt content reliably. For countries that use potassium iodide in salt iodization programs, further validation is required.

Improvement of the Vietnamese Diet for Women of Reproductive Age by Micronutrient Fortification of Staples Foods and Condiments

Laillou A, Berger J, Le BM, Pham VT, Le TH, Nguyen CK, Panagides D, Rohner F, Wieringa F, Moench-Pfanner R.

November 2012, PLoS One

A micronutrient survey carried out in 2010 among randomly selected Vietnamese women in reproductive age indicated that anemia and micronutrient deficiencies are still prevalent. The objective of this study was thus to analyze the dietary micronutrient intakes of these women, to select the food vehicles to be fortified and to calculate their contributions to meet the recommended nutrient intake (RNI) for iron, zinc, vitamin A and folic acid. Consumption data showed that the median intake was 38.4% of the RNI for iron, 61.1% for vitamin A and 91.8% for zinc. However, more than 50% of the women had daily zinc consumption below the RNI. Rice and vegetable oil were consumed daily in significant amounts (median: 320.4 g/capita/day and 8.6 g/capita/day respectively) by over 90% of the women, making them suitable vehicles for fortification. Based on consumption data, fortified vegetable oil could contribute to an additional vitamin A intake of 27.1% of the RNI and fortified rice could increase the intake of iron by 41.4% of the RNI, zinc by 15.5% and folate by 34.1%. Other food vehicles, such as fish and soy sauces and flavoring powders, consumed respectively by 63% and 90% of the population could contribute to increase micronutrient intakes if they are properly fortified and promoted. Wheat flour was consumed by 39% of the women and by less than 20% women from the lowest socioeconomic strata. Therefore, the fortification of edible vegetable oils with vitamin A and of rice with iron, zinc and folic acid are the most promising fortification strategies to increase micronutrient intakes of women in reproductive age in Vietnam.

Performance of iron spot test with Arabic bread made from fortified white wheat flour.

Nichols E, Aburto N, Masa’d H, Wirth J, Sullivan K, Serdula M.

September 2012, Food and Nutrition Bulletin

The iron spot test (IST) is a simple qualitative technique for determining the presence of added iron in fortified flour. IST performance in bread has never been investigated. If found to perform well, the IST has the potential to provide a field-friendly method for testing bread and thus support the monitoring and evaluation of flour fortification programs. To assess the performance of the IST in Arabic bread made from white wheat flour, bread samples were collected from 1,737 households during a national micronutrient survey in Jordan. A subsample of Arabic bread (n = 44) was systematically selected for testing by both the IST and spectrophotometry (criterion reference). Performance measures (sensitivity, specificity, and positive and negative predictive values) were calculated using five cutoffs to define the presence of added iron, including ≥ 15.0 ppm (approximate level of natural iron in Arabic bread) and four additional cutoffs based on test performance. The iron contents of samples testing negative by IST ranged from 10.4 to 18.4 ppm, with one outlier at 41.0 ppm, which was excluded from subsequent analyses. The iron contents of samples testing positive by IST ranged from 16.1 to 38.4 ppm. With the exception of negative predictive values for the two lowest cutoffs (≥ 15.0 and ≥ 16.1 ppm), all performance measures exceeded 83.3%. These results show promise for the IST as an inexpensive, field-friendly method for testing bread that could have a useful role in the monitoring and evaluation process for flour fortification programs.

Vegetable oil of poor quality is limiting the success of fortification with vitamin A in Egypt.

Laillou A, Hafez SA, Mahmoud AH, Mansour M, Rohner F, Fortin S, Berger J, Ibrahim NA, and Moench-Pfanner R.

September 2012, Food and Nutrition Bulletin

Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. To estimate vitamin A losses in oil with different chemical characteristics, samples of fortified oils with different chemical characteristics were collected from two Egyptian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during storage to determine losses over time, and peroxide values were determined. Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% (p < .001), respectively. In semi-dark conditions, the vitamin A losses after 4 weeks in fortified oil B and fortified oil A were significantly different: 26.1% and 0.7% (p < .001), respectively. In an accelerated storage test, the vitamin A loss in 8 days was 48.3% for fortified oil B and 4.2% for fortified oil A (p < .001). Based on these results, the study shows a significant effect of peroxide level (one indicator of the quality of oil) on the stability of vitamin A, regardless of storage conditions. To optimize and sustain vitamin A levels in fortified oil, governments and industries should minimize the peroxide level to less than 2 mEq/kg at production.

Applying Dietary Assessment Methods for Food Fortication and Other Nutrition Programs

Coates J, Colaiezzi B, Fiedler J, Wirth J, Lividini K, Rogers B.

September 2012, GAIN Working Paper Series

Dietary assessment data are essential for designing, implementing and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness and cost tradeoffs of employing alternative dietary assessment methods to obtain requisite programming information, but little guidance exists for doing so. This paper strives to fill this gap in the literature while providing practical guidance to inform programming decisions. Twenty-five semi-structured expert interviews were conducted and literature reviewed for scientific and operational information on four of the most common dietary assessment methods used in nutrition programming: Twenty-four hour recall (24HR), Food Frequency Questionnaires/Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditure Surveys (HCES).

A program needs-driven approach to selecting dietary assessment methods for decision-making in food fortification programs


September 2012, Food and Nutrition Bulletin

Dietary assessment data are essential for designing, monitoring, and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness, and cost tradeoffs of employing alternative dietary assessment methods, but little guidance exists. To assess the tradeoffs of using alternative dietary methods for food fortification programming, twenty-five semistructured expert interviews were conducted and literature was reviewed for information on the validity, usefulness, and cost of using 24-hour recalls, Food Frequency Questionnaires/ Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditures Surveys (HCES) for program stage-specific information needs. Criteria were developed and applied to construct relative rankings of the four methods. The following results were identified: Needs assessment: HCES offers the greatest suitability at the lowest cost for estimating the risk of inadequate intakes, but relative to 24-hour recall compromises validity. Design: HCES should be used to identify vehicles and to estimate coverage and likely impact due to its low cost and moderate-to-high validity. Baseline assessment: 24-hour recall should be applied using a representative sample. Monitoring: A simple, low-cost FFQ can be used to monitor coverage. Impact evaluation: 24-hour recall should be used to assess changes in nutrient intakes. FBS have low validity relative to other methods for all programmatic purposes.

Vitamin D status and determinants of deficiency among non-pregnant Jordanian women of reproductive age.


June 2012, European Journal of Clinical Nutrition

While sunlight is an important vitamin D source, previous investigations among women whose culture encourages skin covering have been small, not nationally representative, or both. We investigated serum 25-hydroxyvitamin D (25(OH)D(3)) status and factors associated with deficiency in a nationally representative survey of 2013 Jordanian women of reproductive age in Spring 2010. We measured 25(OH)D(3) concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with skin covering and other factors. Results showed 60.3% (95% CI: 57.1-63.4%) deficiency (12 ng/ml) and 95.7% (95% CI: 94.4-96.8%) insufficiency (20 ng/ml) among women. Prevalence of deficiency was 1.60 times higher for women who covered with a scarf/hijab (95% CI: 1.06-2.40, P = 0.024) and 1.87 times higher for women who wore full cover, or a niqab (95% CI: 1.20-2.93, P = 0.006), compared with the women who did not wear a scarf/hijab or niqab.

Comparison of a possession score and a poverty index in predicting anaemia and undernutrition in pre-school children and women of reproductive age in rural and urban Côte d’Ivoire.


June 2012, Public Health Nutrition

This article determines whether a possession score or a poverty index best predicts undernutrition and anaemia in women of reproductive age (15-49 years; WRA) and children aged 6-59 months living in Côte d’Ivoire. These socio-economic measures were compared for their ability to predict anaemia and malnutrition in women and children. Using data from a nationally representative survey conducted in Côte d’Ivoire in 2007, the poverty index showed a stronger relationship with nutritional status than the possession score; mean Hb difference between the poorest and wealthiest quintiles in children and WRA was 8·2 g/l and 6·5 g/l, respectively (13·9 % and 19·8 % difference in anaemia, respectively; P < 0·001), and Z-scores and BMI were significantly better in the wealthiest quintile (P < 0·001).

Mapping malaria risk among children in Cote d’Ivoire using Bayesian geo-statistical models.


May 2012, Malaria Journal

Using different data sources, a systematic review was carried out to compile and georeference survey data on Plasmodium spp. infection prevalence in Cote d’Ivoire, focusing on children aged 16 years. The period from 1988 to 2007 was covered. A suite of Bayesian geo-statistical logistic regression models was fitted to analyse malaria risk. High-risk areas were mainly found in the north-central and western area, while relatively low-risk areas were located in the north at the country border, in the northeast, in the south-east around Abidjan, and in the central-west between two high prevalence areas. The malaria risk map at high spatial resolution gives an important overview of the geographical distribution of the disease in Cote d’Ivoire. It is a useful tool for the national malaria control programme and can be utilized for spatial targeting of control interventions and rational resource allocation.

Micronutrient Deficits Are Still Public Health Issues among Women and Young Children in Vietnam


April 2012, PLoS ONE

As no national data existed on the prevalence of micronutrient deficiencies, a survey was conducted in 2010 to assess the micronutrient status of randomly selected women of reproductive age (n=1526) and children aged 6–75 months (n=586). In women, according to international thresholds, prevalence of zinc deficiency (ZnD, 67.2±2.6%) and vitamin B12 deficiency (11.7±1.7%) represented public health problems, whereas prevalence of anemia (11.6±1.0%) and iron deficiency (ID, 13.7±1.1%) were considered low, and folate (3%) and vitamin A (VAD, 2%) deficiencies were considered negligible. However, many women had marginal folate (25.1%) and vitamin A status (13.6%). Moreover, overweight (BMI≥23 kg/m2 for Asian population) or underweight occurred in 20% of women respectively highlighting the double burden of malnutrition. In children, a similar pattern was observed for ZnD (51.9±3.5%), anemia (9.1±1.4%) and ID (12.9±1.5%) whereas prevalence of marginal vitamin A status was also high (47.3±2.2%). There was a significant effect of age on anemia and ID prevalence, with the youngest age group (6–17 mo) having the highest risk for anemia, ID, ZnD and marginal vitamin A status as compared to other groups. Though the prevalence of anemia and ID in Vietnam has been markedly reduced over the last decade, a large part of the population is still at risk for other deficiencies such as zinc, vitamin A, folate and vitamin B12 especially the youngest children aged 6–17 mo.

Quantification of vitamin A in palm oil using a fast and simple portable device: method validation and comparison to high-pressure liquid chromatography.


September 2011, International Journal for Vitamin and Mineral Research

Vitamin A deficiency continues to be a global public health problem. Fortification of oil with vitamin A is considered a cost-effective, feasible strategy to prevent this problem but quality control poses a challenge to program implementation. To overcome this, we have validated a newly developed device that quantitatively measures the content of retinyl palmitate in refined palm oil, is simple to use, and yields immediate results.Linearity of analysis ranged from 2.5 – 30 mg retinol equivalents (RE)/ kg of palm oil, with 2.5 mg RE/kg being the determination limit; inter- and intra-assay precision ranged from 1.4 – 7.1 %. Comparison with a high-performance liquid chromatography method showed high agreement between the methods (R(2) = 0.92; Limits of Agreement: -1.24 mg to 2.53 mg RE/kg), and further comparisons illustrate that the new device is useful in low-resource settings. This device offers a field- and user-friendly solution to quantifying the vitamin A content in refined palm oil.