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Background: Micronutrient deficiencies in Latin America are a public health concern, nonetheless, lack of information still exists in many countries, so that the true magnitude of the problem remains uncertain., Objective: To summarise experiences that can inform the development of policies and programs to address micronutrient deficiencies throung supplementation in pregnant women and chlidren under five years of age in Latin American., Methods: Review of the most evidence on the effects of micronutrients supplementation, focusing on pregnant women and children under five years of age., Results: Certain population groups, as women of reproductive age and children under 2 years of age, are at increased risk for deficiency due to their high micronutrient requirements. This is compounded by the limited access to micronutrient-rich foods for many people living in vulnerable situations. Micronutrient supplementation is an effective intervention to prevent and treat deficiency and to mitigate its adverse effects on health, nutrition, and pregnancy outcomes in micronutrient-deficient populations. The potential benefits of supplementation programs, however, are realized only when they reach those who have the potential to benefit, that is, with inadequate intakes of micronutrients from dietary sources, and when the quality of design and delivery of the programs aresufficient to reach that population timely, regularly, and effectively to enable and motivate consumption., Conclusions: Several resources and experiences exist that can help favor the development of programs that can realize this biological and programmatic potential. There is need for continuous efforts to augment coverage and achieve results that can translate into economic benefits for individuals, families, and nations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In Mexico, anemia prevalence among women of reproductive age (WRA) decreased from 16.4% in 2006 to 11.6% in 2012, only to increase to 18.3% in 2016. The factors associated with this fluctuation are uncertain., Objective: We conducted a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in Mexico between 2006 and 2018., Methods: Using multivariate stepwise linear regression, we analyzed Mexico's Encuesta Nacional de Salud y Nutrición (ENSANUT) surveys from 2006, 2012, and 2018 to identify determinants of WRA anemia. We also conducted a review of anemia-relevant programs and policies, including financing documents, and conducted in-depth interviews and focus group discussions with key stakeholders in Mexico., Results: Among non-pregnant women (NPW) 15-49 years, mean hemoglobin (Hb) increased from 13.8 g/dL in 2006 to 14.0 g/dL in 2012, decreasing to 13.2 g/dL in 2018 (p<0.001). Inequities by geographical region and household wealth persisted throughout this period, with household wealth, urban residence and gravidity emerging as significant predictors of Hb among NPW. Qualitative analyses generally supported these findings. The most discussed program was Progresa-Oportunidades-Prospera (POP), where most resources for health were invested and most participants acknowledged that its cancellation in 2019 would lead to worsening in health and nutrition among the poor. Financing analyses showed a drop of funding for nutrition-related programs between 2014 and 2018. Cultural norms around gender roles were still prevalent, along with increasing rates of teenage pregnancy., Conclusions: Anemia prevention efforts need to refocus on poverty alleviation, continuity of adequate coverage and financing of nutrition programs, especially with safety nets, and increase in uptake of family planning, especially among adolescent girls., Competing Interests: Declaration of Competing Interest ☒ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Zulfiqar Bhutta reports financial support and article publishing charges were provided by Bill and Melinda Gates Foundation. Zulfiqar Bhutta reports financial support was provided by Gates Ventures. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Anaemia affects more than half of Indian women and children, but the contribution of its causes remains unquantified. We examined interrelationships between Hb and nutritional, environmental, infectious and genetic determinants of anaemia in non-pregnant mothers and children in Uttar Pradesh (UP)., Design: We conducted a cross-sectional survey of households in twenty-five districts of UP between October and December 2016. We collected socio-demographic data, anthropometry and venous blood in 1238 non-pregnant mothers and their children. We analysed venous blood samples for malaria, Hb, ferritin, retinol, folate, Zn, vitamin B 12 , C-reactive protein, α 1-acid glycoprotein (AGP) and β -thalassaemia. We used path analysis to examine pathways through which predictors of anaemia were associated with Hb concentration., Setting: Rural and urban households in twenty-five districts of UP., Participants: Mothers 18-49 years and children 6-59 months in UP., Results: A total of 36·4 % of mothers and 56·0 % of children were anaemic, and 26·7 % of women and 44·6 % of children had Fe deficiency anaemia. Ferritin was the strongest predictor of Hb ( β (95 % CI) = 1·03 (0·80, 1·27) g/dL in women and 0·90 (0·68, 1·12) g/dL in children). In children only, red blood cell folate and AGP were negatively associated with Hb and retinol was positively associated with Hb., Conclusions: Over 70 % of mothers and children with anaemia had Fe deficiency, needing urgent attention. However, several simultaneous predictors of Hb exist, including nutrient deficiencies and inflammation. The potential of Fe interventions to address anaemia may be constrained unless coexisting determinants are jointly addressed.

Background: Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh., Methods: We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes., Results: A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline., Conclusion: These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Sarma, Rahman, Tariqujjaman, Islam, Mbuya, Aaron, Askari, Harbour, Khondker, Bipul, Sultana, Rahman, Shahin, Chowdhury, Afsana, Ghosh, Banwell, D’Este, Salasibew, Neufeld and Ahmed.)

Data on adolescents' dietary intake are essential to improve their diets and nutrition. However, the availability of (high-quality) data on adolescents' dietary intake is scarce with great global differences. We conducted a systematic scoping review to investigate the availability, characteristics, and gaps in global adolescent dietary data, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses-Extension for Scoping Reviews checklist and guidelines (registered under PROSPERO no. 171170 https://www.crd.york.ac.uk/PROSPERO/). We included peer-reviewed and grey literature articles (2010 onwards) on the dietary intake of male and female adolescents (10-24 y). Studies from all countries and languages and including any information related to types of food consumed, diet composition, dietary diversity, or meal patterns were considered. We excluded studies with insufficient methodological information, unclear description of population, samples sizes <25, school-based data sets containing <6 schools, and studies that focused on pregnant or unhealthy study populations. Data, including year(s) of data collection, age, gender, sample size, dietary assessment methods, number of food items/groups, study design, location, and representativeness, were extracted. A total of 52,889 titles were identified and 722 articles, describing 1,322 data sets, were retained for analysis. Nationally representative, detailed dietary data for adolescents aged 10-24 y are still lacking, particularly in sub-Saharan Africa, South Asia, and low-income countries. Data quality and representativeness remain limited, highlighting the need for data disaggregation by age, gender, locality, comprehensive dietary information, and broader geographic coverage. A notable amount of data was available through grey literature, especially in data-scarce countries. The study underscores the importance of addressing adolescent nutrition, emphasizing the urgent need for more robust, accessible, and representative data on adolescents' dietary intake to support effective nutritional efforts., (© 2023 The Authors.)

Populations in crisis!A global overview of health challenges and policy efforts within the scope of current nutrition issues, from persistent forms of undernutrition, including micronutrient deficiency, to diet-related chronic diseases. Nutrition science has evolved from a therapeutic and prevention emphasis to include a focus on diets and food systems. Working and consensus definitions are needed, as well as guidance related to healthy diets and the emerging issues that require further research and consensus building. Between nutrient deficiency and chronic disease, nutrition has evolved from focusing exclusively on the extremes of overt nutrient deficiency and chronic disease prevention, to equipping bodies with the ability to cope with physiologic, metabolic, and psychological stress. Just what is 'optimal nutrition', is that a valid public health goal, and what terminology is being provided by the nutrition science community? Nutrition research on 'healthspan', resilience, and intrinsic capacity may provide evidence to support optimal nutrition. Finally, experts provide views on ongoing challenges of achieving consensus or acceptance of the various definitions and interventions for health promotion, and how these can inform government health policies.Nutrition topics that receive particular focus in these proceedings include choline, NAD-replenishment in neurodegenerative diseases, and xanthophyll carotenoids. Choline is a crucial nutrient essential for cellular metabolism, requiring consumption from foods or supplements due to inadequate endogenous synthesis. Maternal choline intake is vital for fetal and infant development to prevent neural tube defects. Neurodegenerative diseases pose a growing health challenge, lacking effective therapies. Nutrition, including NAD-replenishing nutrients, might aid prevention. Emerging research indicates xanthophyll carotenoids enhance vision and cognition, potentially impacting age-related diseases., (© 2023. The Author(s).)

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364)., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Information on fortifiable food consumption is essential to design, monitor and evaluate fortification programmes, yet detailed methods like 24-h recalls (24HRs) that provide such data are rarely conducted. Simplified questionnaire-based methods exist but their validity compared with 24HRs has not been shown. We compared two simplified methods (i.e., a household food acquisition and purchase questionnaire [FAPQ] and a 7-day semiquantitative food frequency questionnaire [SQ-FFQ]) against 24HRs for estimating fortifiable food consumption. We assessed the consumption of fortifiable wheat flour and oil using a FAPQ and, for wheat flour only, a 7-day SQ-FFQ and compared the results against 24HRs. The participants included children 12-18 months (n = 123) and their mothers 18-49 years selected for a study assessing child vitamin A intake and status in Mandaluyong City, Philippines. For fortifiable wheat flour, the FAPQ estimated considerably lower mean intakes compared to 24HRs for children and mothers (2.2 vs. 14.1 g/day and 5.1 vs. 42.3 g/day, respectively), while the SQ-FFQ estimated slightly higher mean intakes (15.7 vs. 14.1 g/day and 51.5 vs. 42.3 g/day, respectively). For fortifiable oil, the FAPQ estimated considerably higher mean intakes compared to 24HRs for children and mothers (4.6 vs. 1.8 g/day and 12.5 vs. 6.1 g/day, respectively). The SQ-FFQ, but not the FAPQ, generated useful information on fortifiable food consumption that can inform fortification programme design and monitoring decisions in the absence of more detailed individual-level data. Potential adaptations to improve the FAPQ, such as additional questions on foods prepared away from home and usage patterns, merit further research., (© 2023 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

There is a widely recognized need to increase funding available for improving nutrition in low- and middle-income countries and to move beyond traditional grants from development agencies and private foundations. This includes the so-called innovative financing approaches, such as impact investment (i.e., investing with the intent to generate positive social impact). Impact investment is no substitute for much-needed public funding to support direct nutrition interventions, but such approaches could make sense where supporting nutrition entails a "business case" that could create profit for a business-thus fostering the positive returns needed by investors. This includes some food-based approaches, as most households purchase food from for-profit companies and entrepreneurs. Investment in firms that produce nutritious foods for local markets could be profitable and-if it were to improve food affordability, accessibility, or desirability-could help improve diet quality. In this Perspective, we describe these innovative financing mechanisms and discuss their potential for supporting nutritious foods. We note that doing so would require a simple yet evidence-based approach to screening nutritious foods for potential investment, and we describe our experience operationalizing this through a novel nutrition impact investment mechanism: the Nutritious Foods Financing Facility. We conclude by highlighting remaining gaps to explore the potential of impact investment in nutrition and what the nutrition community can do to help fill them-and to mitigate the risk of such approaches being applied in ways that do not lead to positive social impact for nutrition., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Using a quasi-experimental design, our study aimed to determine the effectiveness of the 'Eggs Make Kids Sharp & Bright and Strong & Active' demand-creation campaign in Nigeria. The intervention arm received emotionally compelling radio and television advertisements about eggs, and was exposed to promotional activities and advertising about eggs at points of purchase, schools and health facilities; the comparison arm received no intervention. Children 6-59 months of age (intervention: n = 1359; comparison: n = 1485) were assessed 14 months apart. Intent-to-treat analyses with analysis of covariance method assessed the impact of the intervention on caregivers' behaviour towards eggs, caregivers' willingness to pay for eggs, availability of eggs in households, and consumption of eggs by children 6-59 months of age. Analyses were adjusted for possible confounders and perceived effects of COVID-19 on finances and food consumption. Compared to the comparison arm, the intervention arm showed a greater prevalence of household egg acquisition (odds ratio = 1.34, p < 0.0001), and larger improvements in caregiver self-efficacy (β = 0.242, p = 0.004) and intent to feed eggs to children (β = 0.080, p = 0.021). No effects were found on children's egg consumption or caregivers' reported willingness to pay for eggs. The lack of impact on child egg consumption despite increased acquisition of eggs and caregiver self-efficacy suggests that other barriers to child consumption may exist. Additional research should further investigate factors that may influence intrahousehold distribution of eggs and whether these may also influence other nutritious foods., (© 2022 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Micronutrient deficiencies compromise immune systems, hinder child growth and development, and affect human potential worldwide. Yet, to our knowledge, the only existing estimate of the global prevalence of micronutrient deficiencies is from over 30 years ago and is based only on the prevalence of anaemia. We aimed to estimate the global and regional prevalence of deficiency in at least one of three micronutrients among preschool-aged children (aged 6-59 months) and non-pregnant women of reproductive age (aged 15-49 years)., Methods: In this pooled analysis, we reanalysed individual-level biomarker data for micronutrient status from nationally representative, population-based surveys. We used Bayesian hierarchical logistic regression to estimate the prevalence of deficiency in at least one of three micronutrients for preschool-aged children (iron, zinc, and vitamin A) and for non-pregnant women of reproductive age (iron, zinc, and folate), globally and in seven regions using 24 nationally representative surveys done between 2003 and 2019., Findings: We estimated the global prevalence of deficiency in at least one of three micronutrients to be 56% (95% uncertainty interval [UI] 48-64) among preschool-aged children, and 69% (59-78) among non-pregnant women of reproductive age, equivalent to 372 million (95% UI 319-425) preschool-aged children and 1·2 billion (1·0-1·4) non-pregnant women of reproductive age. Regionally, three-quarters of preschool-aged children with micronutrient deficiencies live in south Asia (99 million, 95% UI 80-118), sub-Saharan Africa (98 million, 83-113), or east Asia and the Pacific (85 million, 61-110). Over half (57%) of non-pregnant women of reproductive age with micronutrient deficiencies live in east Asia and the Pacific (384 million, 279-470) or south Asia (307 million, 255-351)., Interpretation: We estimate that over half of preschool-aged children and two-thirds of non-pregnant women of reproductive age worldwide have micronutrient deficiencies. However, estimates are uncertain due to the scarcity of population-based micronutrient deficiency data., Funding: US Agency for International Development., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The ASN Board of Directors appointed the Nutrition Research Task Force to develop a report on scientific methods used in nutrition science to advance discovery, interpretation, and application of knowledge in the field. The genesis of this report was growing concern about the tone of discourse among nutrition professionals and the implications of acrimony on the productive study and translation of nutrition science. Too often, honest differences of opinion are cast as conflicts instead of areas of needed collaboration. Recognition of the value (and limitations) of contributions from well-executed nutrition science derived from the various approaches used in the discipline, as well as appreciation of how their layering will yield the strongest evidence base, will provide a basis for greater productivity and impact. Greater collaborative efforts within the field of nutrition science will require an understanding that each method or approach has a place and function that should be valued and used together to create the nutrition evidence base. Precision nutrition was identified as an important emerging nutrition topic by the preponderance of task force members, and this theme was adopted for the report because it lent itself to integration of many approaches in nutrition science. Although the primary audience for this report is nutrition researchers and other nutrition professionals, a secondary aim is to develop a document useful for the various audiences that translate nutrition research, including journalists, clinicians, and policymakers. The intent is to promote accurate, transparent, verifiable evidence-based communication about nutrition science. This will facilitate reasoned interpretation and application of emerging findings and, thereby, improve understanding and trust in nutrition science and appropriate characterization, development, and adoption of recommendations., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Supplementation in malnourished pregnant women should not displace natural healthy foods. Objective: To estimate the differential effects of three nutritional supplements on macro- and micronutrient intake of pregnant women beneficiaries of the conditional cash transfer program Prospera (CCT-POP). Methods: Prospective cluster randomized trial. Communities were randomly assigned to receive a fortified beverage (Beverage), micronutrient tablets (Tablets), or micronutrient powder (MNP). Pregnant women (at <25 weeks) were recruited. The food frequency questionnaire was applied at 25 and 37 weeks of pregnancy and at one and three months postpartum (mpp). Differential effects of the three supplements on the median change in nutrient intake from baseline to each follow-up stage were estimated. Results: Median change in protein intake from dietary and supplement sources were significantly lower for MNP and Tablets than for Beverages (baseline to 37 w: −7.80 ± 2.90 and −11.54 ± 3.00, respectively; baseline to 1 mpp: −7.34 ± 2.90 for MNP, p < 0.001). Compared to Beverages, median increases were higher for the MNP for vitamins C (31.2 ± 11.7, p < 0.01), E (1.67 ± 0.81, p < 0.05), and B12 (0.83 ± 0.27, p < 0.01) from baseline to 37 wk; from baseline to 1 mpp, there was a higher median increase in B12 (0.55 ± 0.25, p < 0.05) and folate (63.4 ± 24.3, p < 0.01); and from baseline to 3 mpp, a higher median increase in iron (2.38 ± 1.06, p < 0.05) and folate (94.4 ± 38.1, p < 0.05). Conclusions: Intake of micronutrients was higher for MNP and Tablets, likely due to food displacement among Beverage consumers. Although iron bioavailability and absorption inhibitors were not considered for the present analyses, the distribution of Tablets or MNP had several advantages in this context where micronutrient deficiency remains high among pregnant women, but macronutrient intake is generally adequate or even high.

Many workers in global supply chains remain nutritionally vulnerable despite the income they earn. The Seeds of Prosperity (SOP) program was implemented in Tamil Nadu and Assam, India, for tea supply chain workers (estate workers, small holder farmers, and farm workers). The aim was to enhance demand for diverse and nutritious foods and improve practices related to handwashing. The program used a behavior change communication approach wherein participants received weekly 1-hour group sessions with messaging on dietary diversity for 5 weeks and handwashing for 4 weeks. An impact evaluation was conducted to estimate changes in reported dietary and hygiene knowledge and behaviors among women. The study used a longitudinal quasi-experimental design in a subsample of program participants at baseline and post-intervention among both intervention and comparison. There was a small but significant increase in mean dietary diversity (DD) for all 4 worker groups (ranging from DD score changes of 0.3 to 0.7; P < .05) and in the proportion of women meeting the minimum dietary diversity in 2 of the 4 groups. Similarly, a significant increase in the mean number of handwashing moments was observed in 2 of the worker groups. An increase in home garden use was observed in 1 of the 4 worker groups. While the SOP program resulted in improvements in dietary diversity, most tea farming women still do not achieve minimum dietary diversity. Nutritious food access may be an important constraint to further improvement.

Introduction: Multiple micronutrient supplementation (MMS) during pregnancy has a greater potential for reducing the risk of low birth weight (LBW) compared with the standard iron-folic acid supplementation. WHO recently included MMS on their Essential Medicines List. The Social Marketing Company (SMC) in Bangladesh is implementing a countrywide, market-based roll-out of MMS to pregnant women. We aimed to evaluate the implementation of the supplementation programme and its impact on reducing LBW., Methods and Analysis: A two-arm, quasi-experimental and mixed-methods evaluation design will be used to evaluate the impact of this 36-month roll-out of MMS. In the intervention areas, pregnant women will purchase MMS products from the SMC's pharmacy networks. Pregnant women in comparison areas will not be exposed to this product until the end of the study. We will collect 4500 pregnant women's data on anthropometric, socioeconomic, nutrition-related and relevant programme indicators during recruitment and bimonthly follow-up until the end of their pregnancy. We will measure children's birth weight within 72 hours of birth and evaluate the changes in LBW prevalence. We will observe market-based MMS service delivery-related conditions of the pharmacies and the quality of the provider's service delivery. Concurrently, we will carry out a process evaluation to appraise the programme activities and recommend course correction. Cluster-adjusted multivariable logistic regression or log-binomial regression analysis of quantitative outcome data will be performed. For qualitative data, we will follow a thematic analysis approach. We will consolidate our study findings by triangulating the data derived from different methods., Ethics and Dissemination: This study received ethical approval from the institutional review board of icddr,b (PR number 21001). We will recruit eligible participants after obtaining their informed written/verbal consent (and assent where needed) with full disclosure about the study. The results will be disseminated through peer-reviewed publications and conference presentations., Trial Registration Number: NCT05108454., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this study was to compare the effect of three micronutrient products on biomarkers of iron and zinc status of Mexican children 6−12 months of age. As part of research to improve the impact of a national program, 54 communities were randomly assigned to receive: (1) fortified food (FF), provided by the program at the time, or (2) micronutrient powders (MNP) or (3) syrup. Each product contained 10 mg each of zinc and iron, plus other micronutrients. Children consumed the product 6 days/week for four months. Primary outcomes were changes in serum zinc, ferritin, soluble transferrin receptor, hemoglobin concentrations, and their deficiencies. Zinc concentration increased significantly from baseline to follow-up in all groups, with the largest change in the syrup group (geometric mean difference: +4.4 µmol/L; 95%CI: 3.2, 5.5), followed by MNP (+2.9 µmol/L; 95%CI: 2.1, 3.6) and FF (+0.9 µmol/L; 95%CI: 0.3, 1.6). There was a significant increase in hemoglobin concentration (+5.5 g/L; 2.5, 8.4) and a significant reduction in anemia prevalence (44.2% to 26.8%, p < 0.01) only in the MNP group. Compliance differed significantly among groups (MNP vs. FF, p = 0.04; MNP vs. syrup, p = 0.04), but may not fully explain the greater improvement in zinc and iron status in the syrup and MNP groups. The food matrix may influence nutrient utilization from supplements.

Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population., (© 2021 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Daily consumption of iron-containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron-containing supplement consumption is questionable. The WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron-containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron-containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron-containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%-75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron-containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations., (© 2022 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Most low- and middle-income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500-mg doses/day). WHO recommends 1.5-2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low-dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost-effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron-containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food-based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation., (© 2022 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of New York Academy of Sciences.)

Background: Although the potential impact of food fortification to improve the micronutrient status of populations has been demonstrated beyond a doubt, it is constrained in practice by critical gaps in program design and implementation. These are partly linked to suboptimal decision making., Objectives: We aimed to demonstrate how the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence to Decision (EtD) framework for health system and public health decisions can be applied to formulate recommendations and make decisions in national food fortification programming., Methods: Following a program impact pathway, we reviewed the literature to define the key decision types and identify the corresponding decision makers necessary for designing and implementing effective food fortification programs. We then applied the GRADE EtD framework to the Nigerian fortification program to illustrate how evidence-informed assessments and conclusions can be made., Results: Fortification program decisions were classified into 5 types: 1 ) program initiation; 2 ) program design; 3 ) program delivery; 4 ) program impact; and 5 ) program continuation. Policymakers, food processors, and (in cases dependent on or considering external funding) development partners are the main decision makers in a fortification program, whereas technical partners play important roles in translating evidence into contextualized recommendations. The availability and certainty of evidence for fortification programs are often low (e.g., quality and coverage data are not routinely collected and there are challenges evaluating impact in such population-based programs using randomized controlled trials) yet decisions must still be made, underscoring the importance of using available evidence. Furthermore, when making program initiation and continuation decisions, coordination with overlapping micronutrient interventions is needed where they coexist., Conclusions: This framework is a practical tool to strengthen decision-making processes in fortification programs. Using evidence in a systematic and transparent way for decision making can improve fortification program design, delivery, and ultimately health impacts., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health., Competing Interests: Declaration of interests MB reports grants from the UK Medical Research Council and grants from the UK National Institute for Health Research (NIHR), during the conduct of the study. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations., Competing Interests: Declaration of interests DH was the Deputy Chief Scientific Adviser at the Department for Education (England) from September, 2020, to September, 2021. HA reports grants from the Bill & Melinda Gates Foundation, outside the submitted work. WH reports grants from Fondation Botnar, outside the submitted work. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Double fortified salt (DFS) has proven efficacy in addressing iron deficiency and anaemia, thus improving maternal and child nutrition outcomes. However, DFS delivery in large-scale settings is less understood, with limited documentation of its fidelity of implementation (FOI). We assessed the FOI of the DFS intervention in Uttar Pradesh, India, to improve the design and implementation of such programmes that aim to reduce the anaemia burden, especially in women of reproductive age (WRA). We conducted in-depth interviews with DFS programme staff (n = 25) and end-user WRAs (23), guided by a programme impact pathway. We transcribed and thematically analysed the interviews and used an adapted analytic framework to document FOI across four domains-objects of intervention, implementation staff, implementation context and target of implementation. DFS utilisation remained low due to a combination of factors including poor product quality, distribution challenges, ineffective promotion and low awareness amongst end-user WRAs. Motivation levels were higher amongst district-level staff compared to frontline staff, who lacked supervisory support and effective incentives to promote DFS. Three typologies of DFS users emerged-'believers', 'thrifters' and 'naysayers'-who indicated differing reasons for DFS purchase and its use or nonuse. The implementation of the DFS programme varied significantly from its theorised programme impact pathway. The adapted analytic framework helped document FOI and assess the programme's readiness for impact assessments and subsequent scale-up. The programme needs product quality improvements, incentivised distribution and stronger promotion to effectively deliver and improve the realisation of its potential as an anaemia prevention strategy., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Objective: We explore factors such as the blood sampling site (capillary vs venous), the equipment (HemoCue vs automated haematology analyser) and the model of the HemoCue device (201+ vs 301) that may impact haemoglobin measurements in capillary and venous blood., Methods: Eleven studies were identified, and bias, concordance and measures of diagnostic performance were assessed within each study., Findings: Our analysis included 11 studies from seven countries (Cambodia, India, The Gambia, Ghana, Laos, Rwanda and USA). Samples came from children, men, non-pregnant women and pregnant women. Mean bias ranged from -8.7 to 2.5 g/L in Cambodian women, 6.2 g/L in Laotian children, 2.4 g/L in Ghanaian women, 0.8 g/L in Gambian children 6-23 months and 1.4 g/L in Rwandan children 6-59 months when comparing capillary blood on a HemoCue to venous blood on a haematology analyser. Bias was 8.3 g/L in Indian non-pregnant women and 2.6 g/L in Laotian children and women and 1.5 g/L in the US population when comparing capillary to venous blood using a HemoCue. For venous blood measured on the HemoCue compared with the automated haematology analyser, bias was 5.3 g/L in Gambian pregnant women 18-45 years and 11.3 g/L in Laotian children 6-59 months., Conclusion: Our analysis found large variability in haemoglobin concentration measured on capillary or venous blood and using HemoCue Hb 201+ or Hb 301 or automated haematology analyser. We cannot ascertain whether the variation is due to differences in the equipment, differences in capillary and venous blood, or factors affecting blood collection techniques., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

School-aged children and adolescents have complex interactions with their food environments-the point of engagement of individuals with the food system-and are influenced by a diversity of individual, household and organizational factors. Although a wide range of methods have been proposed to define, monitor and evaluate food environments, few are tailored to school-aged children and adolescents. Here, we interrogate published literature on food metrics and methodologies for the characterization of food environments for school-aged children and adolescents living in low- and middle-income counties. We identify key priority actions and potential indicators for better monitoring and evaluation to galvanize policymaking to improve the healthiness of these interactions, which are so crucial to future adult well-being., (© 2021. Springer Nature Limited.)

Objective: We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables., Design: We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage., Settings: Sixty-eight sub-districts from ten districts of Bangladesh., Participants: Children aged 6-59 months and their caregivers., Results: A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage., Conclusions: The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.

Background: Double-fortified salt (DFS) with iron and iodine has been demonstrated to be efficacious but questions of unintended effects on the gains in salt iodization remain. The main cross-sectional study based on the use of DFS over 1 y showed a reduction in iron deficiency risk. Whether the programs and the levels of added iron can adversely affect iodine status is yet to be established., Objectives: We hypothesized that the addition of iron to iodized salt can adversely affect iodine status in women of reproductive age (WRA)., Methods: A cross-sectional substudy was conducted in 4 matched-pair adjacent districts of rural Uttar Pradesh, India, in 2019. Under the public distribution system (PDS), DFS was available for 1 y through Fair Price Shops, in the 2 DFS supply districts (DFS-SDs). In these districts, iodized salt was also available in the market. In the 2 compared DFS nonsupply districts (DFS-NSDs), only iodized salt was available. In the substudy, participants included WRA ( n  = 1624) residing in rural areas of the selected districts. Iodine content in urine and salt samples was measured in each of the groups., Results: Significantly fewer women from the DFS-SDs had median urinary iodine concentration values indicative of moderate to mild iodine deficiency compared with the women from the DFS-NSDs. The salt purchase pattern and iodine content revealed that significantly fewer (21.99%) households in the DFS-SDs were purchasing inadequately iodized crystal salt, compared with 36.04% households in the DFS-NSDs., Conclusions: The data reject the working hypothesis and suggest a beneficial effect of the DFS program on the iodine status in WRA, thereby supporting a recommendation of DFS supply through the PDS., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Food systems are increasingly recognized as critical for advancing nutrition, and the food environment is viewed as the nexus between those systems and dietary consumption. Developing a measurement framework of the market food environment is a research priority, particularly for low- and middle-income countries (LMICs), which face rapid shifts in markets, dietary patterns, and nutrition outcomes., Objectives: In this study, we sought to assess current conceptions and measures of the market food environment that could be adapted for use in LMICs., Methods: We conducted a narrative review of the literature to identify measures of the market food environment in recent use. First, we identified and reviewed frameworks of the food environment for LMICs with a specific focus on the market food environment. Second, we compiled 141 unique measures of the market food environment from 20 articles into a list that was pile-sorted by 5 nutrition experts into domains. We then categorized the measures based on percentage agreement across all sorts. Finally, we compared measured and conceptual domains of the market food environment to identify measurement gaps and needed adaptations., Results: Conceptual frameworks provide differing definitions of the market food environment but conform in their definitions of food availability, price, marketing, and product characteristics. Greater clarity is needed in defining relevant vendor and product characteristics. Eight measured domains of the market food environment emerged from the literature review, with significant overlap among conceptual domains. Measurement gaps exist for food quality, safety, packaging, desirability, and convenience. Personal characteristics also emerged as measured domains, although these are not part of the food environment per se., Conclusions: These results are a step toward elucidating how, why, and where we measure the market food environment in LMICs. Future research should focus on prioritizing the most meaningful methods and metrics and on developing new measures where gaps exist., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Although mandatory fortification of oil with vitamin A is efficacious, its effectiveness can be compromised by suboptimal compliance to standards. In this study, we assessed (1) the availability of oil brands across the eight divisions of Bangladesh, (2) fortification quality (the extent to which vitamin A content is aligned with fortification standards) of oil brands and producers and (3) the market volume represented by available edible oil types. We visited different retail outlets in rural and urban market hubs to ascertain available oil brands and bulk oil types and collected samples. We used high-performance liquid chromatography to quantify average vitamin A content and compared them to the national oil fortification standards. Among the 66 packaged brands analyzed, 26 (39%) were not fortified, and 40 (61%) were fortified, with 28 (42%) fortified above the standard vitamin A minimum. Among the 41 bulk oil type composites analyzed, 24 (59%) were not fortified, and 17 (41%) were fortified, with 14 (34%) fortified below and 3 (7%) fortified above the standard minimum. Vitamin A fortification is high for packaged and branded edible oil but low for oil sold in unbranded, loose form. As bulk oil makes up a large proportion of the oil market volume, this means the majority of the oil volume available to the population is either not (25%) or fortified below the standard requirement (39%). Regulatory inspections of producers selling bulk oil should be prioritized to support and incentivize the industry to make all oil traceable and fortified to standard.

Background: Anemia, iron deficiency, and iodine deficiency are problems of important public health concern in many parts of the world, with consequences for the health, development, and work capacity of populations. Several countries are beginning to implement double fortified salt (DFS) programs to simultaneously address iodine and iron deficiencies., Objective: Our objective was to summarize the evidence for efficacy and effectiveness of DFS on the full range of status and functional outcomes and across different implementation and evaluation designs essential to successful interventions., Methods: We conducted a systematic review and meta-analysis of published and gray literature examining the effects of DFS on nutritional status, cognition, work productivity, development, and morbidity of all population groups. We searched for articles in Medline, Embase, CINAHL, Cochrane Central Register, and ProQuest for randomized trials, quasi-randomized trials, and program effectiveness evaluations., Results: A total of 22 studies (N individuals = 52,758) were included. Efficacy studies indicated a significant overall positive effect on hemoglobin concentration [standardized mean difference (95% CI): 0.33 (0.18, 0.48)], ferritin [0.42 (0.08, 0.76)], anemia [risk ratio (95% CI): 0.80 (0.70, 0.92)], and iron deficiency anemia [0.36 (0.24, 0.55)]. Effects on urinary iodine concentration were not significantly different between DFS and iodized salt. The impact on functional outcomes was mixed. Only 2 effectiveness studies were identified. They reported programmatic challenges including low coverage, suboptimal DFS quality, and storage constraints., Conclusions: Given the biological benefits of DFS across several populations in efficacy research, additional evaluations of robust DFS programs delivered at scale, which consider effective implementation and measure appropriate biomarkers, are needed., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2021.)

Background: Double fortified salt (DFS) is efficacious in addressing iron deficiency, but evidence of its effectiveness is limited. The few published evaluations do not include details on program implementation, limiting their utility for programmatic decisions., Objectives: We sought to characterize the coverage of a DFS program implemented through the Public Distribution System (PDS) in Uttar Pradesh, India, and understand the drivers of DFS adherence., Methods: After 8 mo of implementation, we surveyed 1202 households in 5 districts and collected data on sociodemographic characteristics, asset ownership, food security, and regular PDS utilization. We defined DFS program coverage as the proportion of PDS beneficiaries who had heard of and purchased DFS, and we defined DFS adherence as DFS use reported by households. We used principal component analysis to create an asset-based index of relative wealth, and we categorized households into higher/lower relative wealth quintiles. We conducted path analyses to examine the drivers of DFS adherence, particularly the mediated influence of household wealth on DFS adherence. The evaluation is registered with 3ie's Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-58f6eeb45c050)., Results: The DFS program had good coverage: 83% of respondents had heard of DFS and 74% had purchased it at least once. However, only 23% exclusively used DFS. Respondents had low awareness about DFS benefits and considered DFS quality as poor. Being in a lower household wealth quintile and being food insecure were significant drivers of DFS adherence, and regular PDS utilization acted as a mediator. Adherence was lower in urban areas., Conclusions: We observed significant heterogeneity in DFS implementation as reflected by high coverage and low adherence. Findings from this process evaluation informed the design of an adaptive impact evaluation and provided generalizable insights for ensuring that the potential for impact is realized. Efforts are needed to increase awareness, improve product quality, as well as mitigate against the sensory challenges identified., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified., Objectives: We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA)., Methods: In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI)., Results: Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda., Conclusions: Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: Universal home fortification of complementary foods with iron-containing multiple micronutrient powders (MNPs) is a key intervention to prevent anaemia in young children in low-income and middle-income countries. However, evidence that MNPs might promote infection raises uncertainty about whether MNPs give net health benefits and are cost-effective. We aimed to determined country-specific net benefit or harm and cost-effectiveness of universal provision of MNPs to children aged 6 months., Methods: We developed a microsimulation model to estimate net country-specific disability-adjusted life-years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) due to anaemia, malaria, and diarrhoea averted (or increased) by provision of a 6-month course of MNPs to children aged 6 months, compared with no intervention, who would be followed up for an additional 6 months (ie, to age 18 months). Anaemia prevalence was derived from Demographic and Health Surveys or similar national surveys, and malaria and diarrhoea incidence were sourced from the Global Burden of Disease Study. Programme and health-care costs were modelled to determine cost per DALY averted (US$). Additionally, we explored the effects of reduced MNP coverage in a sensitivity analysis., Findings: 78 countries (46 countries in Africa, 20 in Asia or the Middle East, and 12 in Latin America) were included in the analysis, and we simulated 5 million children per country. 6 months of universal distribution of daily MNPs, assuming 100% coverage, produced a net benefit (DALYs averted) in 54 countries (24 in Africa, 19 in Asia and the Middle East, 11 in Latin America) and net harm in 24 countries (22 in Africa, one in Asia, and one in Latin America). MNP intervention provided a benefit on YLDs associated with anaemia, but these gains were attenuated and sometimes reversed by increases in YLLs associated with malaria and diarrhoea, reducing the benefits seen for DALYs. In the 54 countries where MNP provision was beneficial, the median benefit was 28·1 DALYs averted per 10 000 children receiving MNPs (IQR 20·6-40·4), and median cost per DALY averted was $3576 (IQR 2474-4918). DALY effects positively correlated with moderate and severe anaemia prevalence in Asia, the Middle East, and Latin America, but correlated inversely in Africa. Suboptimal coverage markedly reduced DALYs averted and cost-effectiveness., Interpretation: Net health benefits of MNPs vary between countries, are highest where prevalence of moderate and severe anaemia is greatest but infection prevalence is smallest, and are ameliorated when coverage of the intervention is poor. Our data provide country-specific guidance to national policy makers., Funding: International Union of Nutrition Sciences., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Biofortification of staple crops has the potential to increase nutrient intakes and improve health outcomes. Despite program data on the number of farming households reached with and growing biofortified crops, 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., Objectives: We aimed to develop and test methods and indicators for assessing household coverage of biofortified foods., Methods: 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., Results: Among the 242 households surveyed, consumption of beans and sweet potatoes was 99.2% and 96.3%, respectively. Awareness of IBs or OFSPs was 65.7% and 48.8%, and availability was 23.6% and 10.7%, respectively. Overall, 15.3% and 10.7% of households reported ever consuming IBs and OFSPs, and 10.4% and 2.1% of households were currently consuming these foods, respectively. The major bottlenecks to coverage of biofortified foods were awareness and availability., Conclusions: 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., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC., (© 2019 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals, Inc. on behalf of New York Academy of Sciences.)

Malnutrition during the first years of life has immediate adverse health consequences, including increased mortality risk, and impaired long-term health and capacities. Undernutrition is an important contributor to poor linear growth, stunting, which affects over 149 million children <5 years of age worldwide, one-third of whom live in India. Over 49 million children are wasted; yet globally, there are also 40 million overweight children. Up-to-date data on the magnitude and distribution of micronutrient malnutrition globally and in many countries are lacking. Anemia has been used as a proxy for micronutrient malnutrition; yet anemia, like stunting, has a complex etiology and numerous nonnutritional as well as nutritional causes. Undernutrition, specifically stunting, wasting, and micronutrient deficiency increasingly coexist with overweight, but accurate data to assess the extent to which these co-exist in countries, households, and individuals and the factors that predict it are scarce. Recent analyses in several countries suggest that there is substantial variability within and among regions in the prevalence and determinants of malnutrition. More and better data that can be used to tailor policies and programs to local contexts are urgently needed if we are to accelerate progress toward addressing malnutrition in all its forms., (© 2020 Nestlé Nutrition Institute, Switzerland/S. Karger AG, Basel.)

Background: The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze., Objectives: We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program., Methods: We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions., Results: Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions., Conclusions: Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented., (Copyright © American Society for Nutrition 2019.)