Assessing the Coverage of Biofortified Foods: Development and Testing of Methods and Indicators in Musanze, Rwanda

Petry N, Wirth JP, Friesen VM, Rohner F, Nkundineza A, Chanzu E, Tadesse KG, Gahutu JB, Neufeld LM, Birol E, Boy E, Mudyahoto B, Muzhingi T, Mbuya MNN

August 2020 – Current Developments in Nutrition

Biofortification of staple crops has the potential to increase nutrient intakes and improve health outcomes. Despite the increasing scale of many biofortification programs, information on the coverage of biofortified foods in the general population is often lacking. Such information is needed to ascertain potential for impact and identify bottlenecks to parts of the impact pathway. To assess biofortification programs, 5 indicators of population-wide household coverage were developed, building on approaches previously used to assess large-scale food fortification programs. These were 1) consumption of the food; 2) awareness of the biofortified food; 3) availability of the biofortified food; 4) consumption of the biofortified food (ever); and 5) consumption of the biofortified food current). To ensure that the indicators are applicable to different settings they were tested in a cross-sectional household-based cluster survey in rural and peri-urban areas in Musanze District, Rwanda where planting materials for iron-biofortified beans (IBs) and orange-fleshed sweet potatoes (OFSPs) were delivered. The major bottlenecks to coverage of biofortified foods were awareness and availability. These methods and indicators fill a gap in the availability of tools to assess coverage of biofortified foods, and the results of the survey highlight their utility for identifying bottlenecks. Further testing is warranted to confirm the generalizability of the coverage indicators and inform their operationalization when deployed in different settings.

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.

Measuring the household coverage and quantifying nutrient contributions of biofortified foods in Musanze, Rwanda

GroundWork, Sagaci Research, University of Rwanda, and GAIN

May 2020 – Report Release, Geneva, Switzerland

While industrial food fortification has successfully reduced the prevalence of micronutrient deficiencies, many countries contain a sizable proportion of the population that does not consume commonly-fortified foods, such as wheat flour and vegetable oil. Biofortification, the process of enhancing the micronutrient content in plants by plant breeding has been proven to fill the nutrient gap, especially in hard-to-reach populations. Biofortified crops are steadily being introduced, and the scale of many biofortification programs is increasing. Information on the coverage and consumption of industrially-fortified and biofortified foods is critical to assess the performance and potential for impact of programs and provide information for decision making related to program improvement. As part of this study, we developed and tested various indicators of coverage and consumption of biofortified foods, and estimated their contribution to nutrient intakes of children (6-59 months of age) and women of reproductive age (15 to 49 years) in rural and peri-urban settings. The study was conducted in Rwanda’s Musanze District, where biofortified beans and orange fleshed sweet potato (OFSP) programs are currently in place.

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.

Développement de méthodes pour mesurer la couverture des aliments biofortifiés – étude pilote au Rwanda

Projet en cours

En collaboration avec l’Alliance mondiale pour l’amélioration de la nutrition (GAIN), Sagaci Research et l’Université du Rwanda, GroundWork développe et teste des méthodes pour évaluer la couverture et la consommation d’aliments biofortifiés. Cela comprend l’élaboration d’outils de collecte de données pour les entrevues avec les vendeurs sur le marché, les discussions de groupes de discussion et les entrevues auprès des ménages. Ces outils ont été testés et affinés dans le district de Musanze, au Rwanda, où des haricots à haute teneur en fer et des patates douces à chair orange ont été commercialisés. Avec la participation de GAIN, de HarvestPlus et du Centre international de la pomme de terre (CIP), GroundWork dirige le développement des outils, la gestion du travail sur le terrain, l’analyse des données et les rapports.