Search

Background Focusing on adolescent schoolgirls in rural Bangladesh, this study aimed to describe the nutrition-relevant context required for effective intervention planning. It included attention to dietary behaviors, daily schedules and activities, and girls' beliefs and values. We placed a special emphasis on iron because anemia has been identified as a significant problem in adolescent girls in Bangladesh. Objectives The study was undertaken to inform a larger project to develop a replicable model for integrating nutrition activities into the multiple social programs in BRAC, a large nongovernmental service delivery organization in Bangladesh. Methods Following an initial phase of exploratory key informant interviewing, data collection was conducted through the use of focused ethnographic methods in 2 additional phases. Phase II consisted of in-depth interviews with school-going adolescents in rural communities in Rangpur District (n = 23). Interview modules included sociodemographic information; a qualitative 24-h dietary recall; respondents' concepts of "health," "healthy foods," and "anemia"; exposure to nutrition messages and ratings of their importance and feasibility; and actions to maintain health. In phase III, ratings and other data were collected systematically from a separate sample of 20 adolescent girls. Analyses included thematic analysis of transcribed and translated text and quantitative analysis of numeric data. Results Key findings include evidence that school-going girls consume a variety of foods and have substantial knowledge about good health and nutrition practices. However, we also found beliefs and practices that challenge the development of nutritionally sound food practices, including iron nutrition. The study revealed the importance of teachers and mothers as information sources, and the dietary and cultural roles of purchased snacks, which occur in connection with school attendance. Conclusions These findings, together with insights about girls' values, particularly conceptions related to "a healthy life," have implications for expanding BRAC activities to support the nutrition of adolescent school girls.

Prenatal multiple micronutrients (UNIMMAP) improve fetal growth only moderately compared to iron and folic acid alone (IFA). Whether this is due to insufficient amounts of UNIMMAP or to IFA being in reality an active control is unknown. We assessed the association between cumulative micronutrient intake (CMI) and fetal growth by secondary analysis of a randomized controlled trial in Burkina Faso where tablet intake was directly observed. We applied 2-part residual regression models adjusted for main confounders. Among the 1056 single pregnancies included, the mean CMI (+/- SD) was 124 +/- 54 tablets. The odds of delivering a small-for-gestational-age baby was reduced by 21% [(95%CI: 5, 35); P = 0.013] for each additional tertile of CMI. The association between CMI and birth weight was positively modified by gestational age at enrollment (P-interaction = 0.001). Each unit of CMI was associated with a 1.6-g [(95%CI: 0.3, 3.1); P = 0.019] higher birth weight at a mean-centered gestational age at enrollment, with a higher gradient observed later in pregnancy. Maternal BMI at enrollment was also a positive modifying factor (P-interaction = 0.02), with no association of CMI with birth weight for low BMI. There was no evidence of an effect modification by group allocation; i.e., we observed the same change in birth weight per unit of CMI with either IFA or UNIMMAP. Yet UNIMMAP increased birth weight by 69 g [(95%CI: 58, 81); P < 0.001] relative to IFA. We found similar results for thoracic and cephalic circumferences. In conclusion, for both IFA and UNIMMAP, the effect on fetal growth is cumulative. The supplementation should therefore begin as early as possible in pregnancy, even if the growth increment per CMI is higher in late than in early pregnancy. Women with a low BMI should also receive extra energy.

Background: The most appropriate dose of iron to prevent maternal anemia is still unclear. Objective: We assessed the dose-response relation between maternal hemoglobin and 2 prenatal iron supplements. Design: An intention-to-treat, double-blind, randomized controlled trial compared 30 mg Fe + folic acid and 13 other micronutrients (UNIMMAP; UNICEF/WHO/UNU multiple micronutrient supplement for pregnant and lactating women) with 60 mg Fe + folic acid (IFA) only in rural Burkina Faso. Home visitors directly observed tablet intake. Mixed-effects models were used for the data analysis. Results: At inclusion, 43.2% of the 1268 participants were anemic. On average, the hemoglobin concentration decreased over gestation by 0.019 g/dL (95% CI: 0.012, 0.025 g/dL) per week in the IFA and UNIMMAP groups. An increment in hemoglobin concentration per micronutrient tablet [b (6SE) = 0.006 6 0.001 g/dL; P , 0001] was observed only in women who were anemic at inclusion, whereas a decrease was observed in the other mothers (20.003 6 0.001 g/dL; P = 0.002, P for interaction , 0.0001); the finding was similar in both the IFA and UNIMMAP groups. Women with baseline anemia achieved the same hemoglobin concentration (mean 6 SD: 11.1 6 0.64 g/dL) as their counterparts who received 6180 tablets of either UNIMMAP or IFA. Despite this, micronutrient intake did not significantly prevent anemia (51.0% in the third trimester). It was, however, a risk factor for hemoconcentration (odds ratio per tertile of tablet intake: 2.10; 95% CI: 1.12, 3.94), independently of supplement type or initial hemoglobin concentration. Conclusions: UNIMMAP triggered the same hemoglobin dose response with half the amount of iron as provided by IFA treatment. The benefit of iron supplements in nonanemic women is unclear. Despite micronutrient supplementation, anemia remained highly prevalent during gestation, partly because of physiologic hemodilution. This trial was registered at clinicaltrials.gov as NCT00642408. Am J Clin Nutr 2011;93:1012‐8.

Objective To investigate how paraprofessional Community Nutrition Educators’ (CNEs’) perceptions of work context relate to job satisfaction and intention to leave the position. Design Cross-sectional statewide survey of program personnel. Setting Expanded Food and Nutrition Education Program (EFNEP) sites (n = 32) serving low- income families in New York. Participants CNEs delivering EFNEP (n = 115). Main Outcome Measures CNE job satisfaction and intention to leave. Analysis Multivariate regression analysis predicting work attitudes from perceived work context, CNE personality traits, and characteristics of CNEs, supervisors, and programs. Results Despite low satisfaction with pay, overall job satisfaction was high and intention to leave was low. Satisfaction was positively related to CNEs’ perceptions of program value, work relationships, and having a voice in relevant decisions (adjusted R 2 = 0.60). Intention to leave was negatively related to perceptions of program value and supervision and satisfaction with pay (adjusted R 2 = 0.36), but the latter relationship was found only among more educated CNEs. Conclusions and Implications CNEs’ satisfaction and intention to leave were strongly associated with perceptions of program value, work relationships, and consultative management. Intrinsically motivating work, often viewed as the domain of professionals, is critical for the morale and retention of paraprofessional nutrition educators.

Premastication of foods for infants was a crucial behavioural adaptation to neoteny that ensured nutritional adequacy during the period of complementary feeding throughout the course of human evolution until recent times. While the paps and gruels of agricultural systems provided an alternative and modern food technology appears to make it unnecessary, we argue that, in addition to its role in nutrition, premastication also played a crucial role in supporting infant health. Its abandonment, particularly in poor communities, has placed children at increased risk of inadequate nutrition and decreased ability to confront infections associated with the introduction of complementary foods. We present two empirical studies. Section I is a cross-cultural study of the ethnographic literature in order to estimate prevalence in non-Western societies. One-third of ethnographies in the worldwide sample with data on infant feeding report premastication. Section II presents the results of a qualitative study in China, conducted in order to provide data on the likelihood that this percent is incorrect due to under-reporting. The finding that 63% of Chinese university students received premasticated food as infants, whereas none of eight ethnographic studies performed in Han China identified premastication in their reports, provides support for the conclusion that the cross-cultural study grossly underestimates its prevalence in non-Western societies. Section III is a discussion of potential benefits and risks of infant exposure to maternal saliva. We conclude with the argument for a concerted research effort to determine whether premastication can solve not only the ‘weanling dilemma’ in poor countries but also some of the health problems among the better-off.

We read Woolf and Johnson’s letter with great interest. The similarity of the findings for developing countries and the United States is impressive,1 as they reflect the influence of the shared assumptions in the research community that lead to low investments in research to improve the fidelity (quality) of health care delivery and utilization. We have a slight correction to make to their letter. Our research shows that 6 million (not 4 million) lives can be saved by improved delivery and utilization without any additional or improved technology. In addition, 2 million children could be saved by new technology (for which current technology is inadequate) if the new technology were delivered and utilized at present rates, and 2 million could be saved by improving both technology and delivery and utilization. Thus, the prevention of 80% of child deaths requires improving delivery and utilization, which nevertheless only receives 3% of research funding.2 We do not believe that resource allocation needs to be a zero-sum game, that is, that existing funds must be used either for research on delivery and utilization or for development of new technology. We argued in our study for more funding for the former relative to the latter, not that funds be taken away from the latter to fund the former. We hope that the empirical evidence in both studies will help to persuade the research community that greater research attention to issues of delivery and utilization is essential if the benefits of currently available technology are to be realized.

We determined the proportion of research on childhood mortality directed toward better medical technology (i.e., by improving old technology or creating new technology) compared with research on technology delivery and utilization. We also estimated mortality reductions from a research-funding strategy focusing primarily on developing technology compared with one that also focused on delivery and utilization. Ninety-seven percent of grants were for developing new technologies, which could reduce child mortality by 22%. This reduction is one third of what could be achieved if existing technologies were fully utilized. There is a serious discrepancy between current research and the research needed to save children’s lives. In addition to increased research on the efficacy of treatment, there is an even greater need for increased research on delivery and use of technology.

Randomized controlled trials (RCTs) are essential for evaluating the efficacy of clinical interventions, where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other settings. However, causal chains in public health interventions are complex, making RCT results subject to effect modification in different populations. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility designs. For evaluating large-scale interventions, studies with plausibility designs are often the only feasible option and may provide valid evidence of impact. There is an urgent need to develop evaluation standards and protocols for use in circumstances where RCTs are not appropriate.

OBJECTIVES. Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a physiologically synergistic relationship with morbidity, evidence of an epidemiologic synergism has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships. METHODS. Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition. RESULTS. The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population. CONCLUSIONS. These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research.