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Background Extensive femoral bone loss poses a challenge in revision total hip arthroplasty (rTHA). Many techniques have been developed to address this problem including fully porous cylindrical stems, impaction bone grafting, and cementation of long stems, which have had varied success. Modular tapered fluted femoral stems (MTFS) show favorable results. We sought to determine the minimum 2-year radiographic and clinical performance of MTFS in rTHA in a population with extensive proximal femoral bone loss. Methods Our clinical database was queried retrospectively for all patients who underwent rTHA with an MTFS. We included patients with Paprosky 3 and 4 femoral bone loss and patients with Vancouver B2 and B3 periprosthetic femur fractures. Patients without 2-year follow-up were invited to return to clinic for X-ray evaluation and to complete clinical questionnaires. We assessed distance of stem subsidence and presence of stem fixation on final X-ray. We recorded all-cause revision and survival of the stem at final follow-up. Results One hundred twenty-nine patients were available for follow-up. Average follow-up time was 3.75 years. One hundred twenty-two stems (95%) remained in place at final follow-up. Median subsidence was 1.4 mm (range 0-21). All-cause revision rate was 16.3% (21 patients). Of the hips revised, 10 were for instability, 6 for infection, 1 for aseptic loosening, and 1 for periprosthetic femur fracture. Three were revised for other reasons. The stem was revised in 7 patients (5.4%), and the most common reason for stem revision was infection (5 patients). The other 2 stems were revised for aseptic loosening in a Paprosky 4 femur and periprosthetic femur fracture. Survival of tapered modular fluted stems with aseptic failure as an endpoint was 98.4%. The mean Hip disability and Osteoarthritis Outcome Score, Joint Replacement score at final follow-up was 73, and mean Veterans Rand 12 item health survey physical and mental scores were 32.8 and 52.2, respectively. Conclusion In patients with Paprosky 3, 4 femoral defects or Vancouver type B2, B3 fractures, modular tapered fluted stems for femoral revision show excellent outcomes at minimum 2-year follow-up.

High dose vitamin A (HDVA) concentrate began to be distributed in India in 1970 as a short-term, stop-gap approach to reduce clinical signs of vitamin A deficiency. As this problem declined globally, the purpose of distributing them changed to the reduction of young child mortality. However, their impact on this has also declined, if not disappeared, as suggested in India by the enormous DEVTA study. This may be because of improved protection against and treatment of the main morbidity involved, measles and diarrhea. At the same time, semi-annual provision of mega-doses of vitamin A is not without risks, in particular linked to children's vaccination status. While a single dose is inexpensive, large-scale implementation of HDVA programs is expensive, particularly the opportunity cost involved in reducing the time health workers involved have to deal with their other commitments. Balancing potential benefits, risks and costs leads us to recommend an immediate cessation of the distribution of HDVA in India.

Background Patient optimization is becoming increasingly important before arthroplasty to ensure outcomes. It has been suggested that depression is a modifiable risk factor that should be corrected preoperatively. It remains to be determined whether psychological intervention before surgery will improve outcomes. We theorized that the use of preoperative depression scales to predict postoperative outcomes may be influenced by the pain and functional disability of arthritis. To determine whether depression is a modifiable risk factor that should be corrected preoperatively we asked the following questions: (1) What is the prevalence of depression in arthroplasty patients preoperatively? (2) Do depressive symptoms improve after surgery? (3) Is preoperative depression associated with outcome? Methods Patients scheduled for surgery completed a patient health questionnaire (PHQ-9) to assess the presence and severity of depression pre-operatively and one year post-operatively. Results Sixty-five of the 282 patients had a PHQ-9 score >10 indicating moderate depression and 57 (88%) improved to P = .0012). Ten patients had a PHQ-9 score >20 indicating severe depression and 9 (90%) improved to P = .10). Of the 65 patients who had a PHQ-9 score >10 preoperatively, the median postoperative Hip Disability and Osteoarthritis Outcome Score (N = 40) was 92.3, while the median postoperative Knee Injury and Osteoarthritis Outcome Score (N = 25) was 84.6. The median postoperative Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score in nondepressed patients were 96.2 and 84.6, respectively ( P = .9041). Conclusion By diminishing pain and improving function through arthroplasty, depression symptoms improve significantly. Patients with depressive symptoms preoperatively had similar postoperative outcome scores compared to non-depressed patients. Patients should not be denied surgical intervention through optimization programs that include a depression scale threshold. Level of Evidence III.

Up to $500m a year could be put to better use by stopping ineffective and potentially harmful supplementation programmes in poorer countries, say JB Mason, CS Benn, and HPS Sachdev; but Keith P West Jr, Amanda C Palmer, and Alfred Sommer disagree, saying that such programmes have been proved to save millions of lives and should be withdrawn only when robust evidence permits

The development of ready-to-use therapeutic food (RUTF) for the treatment of uncomplicated cases of severe acute malnutrition in young children from 6 months to 5 years old has greatly improved survival through the ability to treat large numbers of malnourished children in the community setting rather than at health facilities during emergencies. This success has led to a surge in demand for RUTF in low income countries that are frequently food insecure due to environmental factors such as cyclical drought. Worldwide production capacity for the supply of RUTF has increased dramatically through the expansion and development of new manufacturing facilities in both low and high income countries, and new business ventures dedicated to ready-to-use foods have emerged not only for emergencies, but increasingly, for supplementing caloric intake of pregnant women and young children not experiencing acute undernutrition. Due to the lack of evidence on the long term health impact these products may have, in the midst of global nutrition transitions toward obesity and metabolic dysfunction, the increased use of manufactured, commercial products for treatment and prevention of undernutrition is of great concern. Using a framework built on the life course health development perspective, the current research presents several drawbacks and limitations of RUTF for nutrition of mothers and young children, especially in non-emergency situations. Recommendations follow for potential strategies to limit the use of these products to the treatment of acute undernutrition only, study the longer term health impacts of RUTF, prevent conflict of interests arising for social enterprises, and where possible, ensure that whole foods are supported for life-long health and nutrition, as well as environmental sustainability.

Background Infant and young child feeding practices, including breastfeeding and complementary feeding of children under 2 years old, are crucially influenced by parent and family perceptions and experiences. Given the urgent need to improve nutrition of young children in low- and low-middle-income countries, both for reduction of morbidity and mortality in childhood and for future health outcomes, we propose to systematically review and synthesize available qualitative data specifically related to infant and young child feeding practices of parents and families in these settings, which may provide greater insights into barriers and facilitators to recommended feeding practices. Methods/design The proposed study will systematically review existing qualitative research reporting infant and young child feeding practices from low- and low-middle-income settings. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement will be used for reporting the stages of the review and dissemination. The search period will include all studies published from 2006 to 2016. The study selection process will follow established and recommended guidelines for reviews, and quality assessment will be conducted in two phases using critical appraisal and subsequently a confidence in findings approach derived from Grading of Recommendations, Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative (GRADE-CERQual). A full synthesis of the studies identified by the review will begin with thematic analysis and be followed by an interpretive approach to provide actionable information on the topic. Discussion The findings will provide insight into the barriers and facilitators related to behavior that may hinder or enable implementation of interventions aimed at improving infant and young child feeding practices in lower-income settings. Systematic review registration PROSPERO CRD42016035677 Electronic supplementary material The online version of this article (doi:10.1186/s13643-016-0292-7) contains supplementary material, which is available to authorized users.

Dear Sir: The article by Amouzou and others1 presents findings from an evaluation of integrated community case management (iCCM) in Malawi using a National Evaluation Platform (NEP) design. While it is a welcome effort to document this child survival strategy that is being tested in many low- and middle-income countries, the study findings have implications both for iCCM and for approaches to evaluation, which would benefit from further scrutiny. An important consideration in the evaluation of community-based care is ascertaining true exposure to the intervention in the study population. The article by Amouzou and others used a dose–response approach, with 27 districts as the unit of analysis, to measure the effect of an intervention (iCCM) that was specifically targeted at hard-to-reach areas. Their approach ignored spatial variation within districts and led to a diluted estimate of the effect of iCCM, as not all communities sampled in the household surveys were exposed to iCCM-trained health surveillance assistants (HSAs). A more effective approach would have been to stratify the samples by a measure of spatial exposure, for instance average travel time to the nearest HSA and ratio of HSAs per population within a given buffer of the cluster.2 Moreover, the exposure was limited at 1.5 HSAs per 1,000 children under 5 years of age (lower than the Ministry of Health target of one per 1,000 population, equivalent to about one HSA per 200 children). For community-based nutrition programs, a ratio of one community worker per 100–200 children is associated with impact on child malnutrition.3 Furthermore, the regression analysis used overall care seeking from all formal providers as the dependent variable, not care seeking from HSAs who actually delivered iCCM. A more accurate approach would have been to use change in care seeking to HSAs as the dependent variable. In addition, care seeking does not necessarily result in appropriate treatment. Therefore, it may be misleading to conclude that iCCM had no impact on under-five mortality without assessing changes in coverage of appropriate treatment of childhood illnesses. As more countries are scaling up community-based delivery platforms,4 it is critical that methods to evaluate the impact of these services take into consideration spatial exposure to community health workers. National household surveys, which are the main source of exposure and outcome data in the NEP design, are designed to provide estimates at the district or regional level, and therefore cannot provide valid estimates among populations exposed to iCCM when exposure varies within the district or region. We agree with the authors' request for more investigation into why about one-third of HSAs do not live in the community they serve and how this may affect access for sick children.5 Given the considerations presented, we question the validity of the conclusion that iCCM had no impact on care seeking or mortality in Malawi. An alternative interpretation could be that at this exposure, the effects were too small to establish with the methods used; an estimate of the possible effect size, rather than negative conclusions, would be more useful. There are important policy and programmatic risks in concluding that iCCM has no impact. Policy makers could change the course of programs or plans, donors could shift priorities, and program managers could be demotivated by a sense of failure. Thus, there is need for caution when interpreting the findings. We support the authors' call for continuous large-scale evaluation in global health, including rigorous methodology with appropriate evaluation designs, to provide robust conclusions of relevance to improving health services.

Drought and conflict in the Horn of Africa are causing population displacement, increasing risks of child mortality and malnutrition. Humanitarian agencies are trying to mitigate the impact, with limited resources. Data from previous years may help guide decisions. Trends in different populations affected by displacement (1997–2009) were analyzed to investigate: (1) how elevated malnutrition and mortality were among displaced compared to host populations; (2) whether the mortality/malnutrition relation changed through time; and (3) how useful is malnutrition in identifying high mortality situations. Under-five mortality rates (usually from 90-day recall, as deaths/10,000/day: U5MR) and global acute malnutrition (wasting prevalences, < −2SDs of references plus edema: GAM) were extracted from reports of 1,175 surveys carried out between 1997–2009 in the Horn of Africa; these outcome indicators were analyzed by livelihood (pastoral, agricultural) and by displacement status (refugee/internally displaced, local resident/host population, mixed); associations between these indicators were examined, stratifying by status. Patterns of GAM and U5MR plotted over time by country and livelihood clarified trends and showed substantial correspondence. Over the period GAM was steady but U5MR generally fell by nearly half. Average U5MR was similar overall between displaced and local residents. GAM was double on average for pastoralists compared with agriculturalists (17% vs. 8%), but was not different between displaced and local populations. Agricultural populations showed increased U5MR when displaced, in contrast to pastoralist. U5MR rose sharply with increasing GAM, at different GAM thresholds depending on livelihood. Higher GAM cut-points for pastoralists than agriculturalists would better predict elevated U5MR (1/10,000/day) or emergency levels (2/10,000/day) in the Horn of Africa; cut-points of 20–25% GAM in pastoral populations and 10–15% GAM in agriculturalists are suggested. The GAM cut-points in current use do not vary by livelihood, and this needs to be changed, tailoring cut points to livelihood groups, to better identify priorities for intervention. This could help to prioritize limited resources in the current situation of food insecurity and save lives.

Regular semi-annual distribution of high-dose (200,000 IU) vitamin A capsules (VACs) to children 1 - 5 years of age (previously identified as underweight), in Leyte Province, the Philippines, was compared to providing extra VACs to give three-monthly dosing, and to vitamin A-fortified cooking oil (VAFO) promotion (with continued VACs every 6 months). Serum retinol (SR) was measured at baseline and after 12 or 18 months (for VAFO). No sustained increase in SR was determined from the three-month VAC dosing regimen, and the prevalence of vitamin A deficiency (VAD) as assessed by SR (< 20 mcg / dL) remained around 30 % (in line with national survey estimates over the previous 15 years). The major difference found was that 18 months of VAFO (of which 9 months had sustained promotion) was associated with reducing the prevalence of VAD to < 10 %. The effective fortification and lack of effect of semi-annual VAC results are in line with previous studies; testing with dosing of VAC every three months is a new intervention. The results imply that promotion of fortified oil would reduce VAD in these conditions; whether it can replace or needs to be added to semi-annual VAC dosing remains to be determined. A phased changeover to reliance on fortified commodities (including oil) with careful monitoring of VAD trends is indicated.

Background Malnutrition in preschool children, usually measured as wasting, is widely used to assess possible needs for emergency humanitarian interventions in areas vulnerable to drought, displacement, and related causes of food insecurity. The extent of fluctuations in wasting by season, year-to-year, and differential effects by livelihood group, need to be better established as a basis for interpretation together with ways of presenting large numbers of survey results to facilitate interpretation. Objective To estimate levels of and fluctuations in wasting prevalences in children from surveys conducted in arid and semiarid areas of the Greater Horn of Africa according to livelihood (pastoral, agricultural, mixed, migrant), season or month, and year from 2000 to 2006. Methods Results from around 900 area-level nutrition surveys (typical sample size, about 900 children) were compiled and analyzed. These surveys were carried out largely by nongovernmental organizations, coordinated by UNICEF, in vulnerable areas of Eritrea, Ethiopia, Kenya, Somalia, Southern Sudan, and Uganda. Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data were used for comparison. Data were taken from measurements of children 0 to 5 years of age (or less than 110 cm in height). Results Among pastoral child populations, the average prevalence of wasting (< −2 SD weight-for-height) was about 17%, 6–7 percentage points higher than the rates among agricultural populations or populations with mixed livelihoods. Fluctuations in wasting were greater among pastoralists during years of drought, with prevalences rising to 25% or higher; prevalences among agricultural populations seldom exceeded 15%. This difference may be related to very different growth patterns (assessed from DHS and UNICEF/MICS surveys), whereby pastoral children typically grow up thinner but taller than children of agriculturalists. Wasting peaks are seen in the first half of the year, usually during the dry or hunger season. In average years, the seasonal increase is about 5 percentage points. Internally displaced people and urban migrants have somewhat higher prevalence rates of wasting. Year-to-year differences are the largest, loosely correlated with drought at the national level but subject to local variations. Conclusions Tracking changes in wasting prevalence over time at the area level—e.g., with time-series graphical presentations—facilitates interpretation of survey results obtained at any given time. Roughly, wasting prevalences exceeding 25% in pastoralists and 15% in agriculturalists (taking account of timing) indicate unusual malnutrition levels. Different populations should be judged by population-specific criteria, and invariant prevalence cutoff points avoided; interpretation rules are suggested. Survey estimates of wasting, when seen in the context of historical values and viewed as specific to different livelihood groups, can provide useful timely warning of the need for intervention to mitigate developing nutritional crises.

Background Intermittent food insecurity due to drought and the effects of HIV/AIDS affect child nutritional status in sub-Saharan Africa. In Southern Africa in 2001–3 drought and HIV were previously shown to interact to cause substantial deterioration in child nutrition. With additional data available from Southern and Eastern Africa, the size of the effects of drought and HIV on child underweight up to 2006 were estimated. Objective To determine short- and long-term trends in child malnutrition in Eastern and Southern Africa and how these are affected by drought and HIV. Methods A secondary epidemiologic analysis was conducted of area-level data derived from national surveys, generally from the mid-1990s to the mid-2000s. Data from countries in the Horn of Africa (Ethiopia, Kenya, and Uganda) and Southern Africa (Lesotho, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe) were compiled from available survey results. Secondary data were obtained on weight-for-age for preschool children, HIV prevalence data were derived from antenatal clinic surveillance, and food security data were obtained from United Nations sources (Food and Agriculture Organization, International Labour Office, and others). Results Overall trends in child nutrition are improving as national averages; the improvement is slowed but not stopped by the effects of intermittent droughts. In Southern Africa, the prevalence rates of underweight showed signs of recovery from the 2001–03 crisis. As expected, food production and price indicators were related (although weakly) to changes in malnutrition prevalence; the association was strongest between changes in food production and price indicators and changes in malnutrition prevalence in the following year. Areas of higher HIV prevalence had better nutrition (in both country groups), but this counterintuitive association is removed after controlling for socioeconomic status. In low-HIV areas in Eastern Africa, nutrition deteriorates during drought, with prevalence rates of underweight 5 to 12 percentage points higher than in nondrought periods; less difference was seen in high-HIV areas, in contrast to Southern Africa, where drought and HIV together interact to produce higher prevalence rates of underweight. Conclusions Despite severe intermittent droughts and the HIV/AIDS epidemic (now declining but still with very high prevalence rates), underlying trends in child underweight are improving when drought is absent: resilience may be better than feared. Preventing effects of drought and HIV could release potential for improvement and, when supported by national nutrition programs, help to accelerate the rates of improvement, now generally averaging around 0.3 percentage points per year, to those needed to meet Millennium Development Goals (0.4 to 0.9 percentage points per year).

Background The relation between anthropometric measures and mortality risk in different populations can provide a basis for deciding how malnutrition prevalences should be interpreted. Objective To assess criteria for deciding on needs for emergency interventions in the Horn of Africa based on associations between child wasting and mortality from 2000 to 2005. Methods Data were analyzed on child global acute malnutrition (GAM) prevalences and mortality estimates from about 900 area-level nutrition surveys from Ethiopia, Kenya, Somalia, Sudan, and Uganda; data on drought, floods, and food insecurity were added for Kenya (Rift Valley) and Ethiopia, from Food and Agriculture Organization (FAO) reports at the time. Results Higher rates of GAM were associated with increased mortality of children under 5 years of age (U5MR), more strongly among populations with pastoral livelihoods than with agricultural livelihoods. In all groups spikes of GAM and U5MR corresponded with drought (and floods). Different GAM cutoff points are needed for different populations. For example, to identify 75% of U5MRs above 2/10,000/day, the GAM cutoff point ranged from 20% GAM in the Rift Valley (Kenya) to 8% in Oromia or SNNPR (Ethiopia). Conclusions Survey results should be displayed as time series within geographic areas. Variable GAM cutoff points should be used, depending on livelihood or location. For example, a GAM cutoff point of 15% may be appropriate for pastoral groups and 10% for agricultural livelihood groups. This gives a basis for reexamining the guidelines currently used for interpreting wasting (or GAM) prevalences in terms of implications for intervention.

BackgroundIn Africa, approximately 25 million people live with HIV/AIDS and 12 million children are orphaned. Although evidence indicates that orphans risk losing opportunities for adequate education, health care, and future employment, the immediate effects of orphanhood on child nutritional status remain poorly understood.ObjectiveThis paper assesses the nutritional impact of orphanhood, with particular emphasis on taking account of various factors potentially confounding or masking these impacts.MethodsChild anthropometry and orphan status were examined in 23 Multiple Indicator Cluster Surveys and Demographic and Health Surveys throughout sub-Saharan Africa, which were subsequently merged into larger, region-specific datasets (East, West, and Southern Africa). To compare orphans and nonorphans, linear regression and probit models were developed, taking account of orphan status and type, presence of a surviving parent in the household, household structure, child age and sex, urban versus rural residence, and current wealth status.ResultsFew differences emerged between orphans and nonorphans in controlled and uncontrolled comparisons, regardless of orphan type, presence of surviving parent, or household structure. Age differentials did confound nutritional comparisons, although in the counterintuitive direction, with orphans (who were 8 months older on average) becoming less malnourished when age differences were taken into account. Wealth did appear to be associated with orphanhood status, although it did not significantly confound nutritional comparisons.ConclusionsOrphans were not consistently more malnourished than nonorphans, even when potential confounding variables were examined. Since household wealth status is likely to change after becoming affected by HIV, ruling out wealth as a potential confounder would require more detailed, prospective studies.

Combined data on micronutrient deficiencies (and underweight prevalences) were previously assembled for the Micronutrient Report in 2001 published by the Micronutrient Initiative and the International Development Research Centre. To update these data and understand recent trends we carried out a global survey of national micronutrient programs and survey results from 2001 to 2003 mainly through e-mail contact with governmental United Nations and nongovernmental offices in some 100 developing countries (referred to below as the "country survey"). The published literature and unpublished material were searched by various means including through on-line databases and web searching. The results described here were first used for the publication on "Vitamin and Mineral Deficiency" issued by Micronutrient Initiative and UNICEF in 2004 for which an early draft of the present results was provided. This document now presents the results on prevalences at the national regional and global (all developing countries) levels with further detail. Here the methods are recorded and the estimates are provided in tables figures and annexes. The information from countries responding to the questionnaire in the country survey (49 replied with new data) are available on file and certain of these have been transferred to the Web. (excerpt)

Micronutrient-deficiency control programs have been greatly extended at the national level in the last 10 to 15 years. However, rigorous evaluations of these are scarce, so that conclusions on impact are tentative and based mainly on indirect evidence. The coverage of vitamin A capsule distribution programs has exceeded 70% in most study countries. In countries implementing national iodized salt programs, the coverage reaches 60% to 90% of households with adequately iodized salt. Of the three micronutrients, coverage of iron tablet supplementation is the least well documented due to inadequate program monitoring systems and population survey data. Supplementation of preschool children 6 to 59 months of age with vitamin A capsules has plausibly contributed to the reduction in clinical vitamin A deficiency and its near-elimination in many countries. The impact of vitamin A capsule supplementation on children's biochemical vitamin A status (serum retinol) in national programs may be less. National data on salt iodization show a consistent relation to reduced prevalence of iodine-deficiency disorder symptoms (goiter); the rates of cretinism and other results of iodine deficiency are almost certainly falling too. The evaluation of the impact of salt iodization programs on biochemical iodine status is limited by a lack of data. Although trials have demonstrated the efficacy of iron supplementation in reducing the prevalence of anemia, the interpretation of national-level data is not so clear. Given the substantial financial and technical commitment required to implement national micronutrient-deficiency control programs, it is vital that investment enable the evaluation of the impact of these programs. It is becoming increasingly important to collect data on subclinical deficiency (e.g., biochemical data) to assess program impact.

The prevalence of vitamin A (VA) deficiency, which affects about one-third of children in developing countries, is falling only slowly. This is despite extensive distribution and administration of periodic (4- to 6-monthly) high-dose VA capsules over the past 20 years, now covering a reported 80% of children in developing countries. This massive programme was motivated largely by an expectation of reducing child mortality, stemming from findings in the 1980s and early 90s. Efficacy trials since 1994 have in most cases not confirmed a mortality impact of VA capsules. Only one large scale programme evaluation has ever been published, which showed no impact on 1-6-year-old mortality (the DEVTA trial, ending in 2003, in Uttar Pradesh, India). Periodic high-dose VA capsules may have less relevance now with changing disease patterns (notably, reductions in measles and diarrhoea). High-dose VA 6-monthly does not reduce prevalence of the deficiency itself, estimated by low serum retinol. It is proposed that: (i) there is no longer any evidence that intermittent high-dose VA programmes are having any substantial mortality effect, perhaps due to changing disease patterns; (ii) frequent intakes of vitamin A in physiological doses -e.g. through food-based approaches, including fortification, and through regular low-dose supplementation-are highly effective in increasing serum retinol (SR) and reducing vitamin A deficiency; (iii) therefore a policy shift is needed, based on consideration of current evidence. A prudent phase-over is needed towards increasing frequent regular intakes of VA at physiological levels, daily or weekly, replacing the high-dose periodic capsule distribution programmes. Moving resources in this direction must happen sooner or later: it should be sooner.

Severe iodine deficiency causes stunting and mental retardation in utero, but the relation between mild deficiency and child growth is not well known. The use of iodated salt in relation to anthropometric data was examined from recent survey data. After potential confounding factors had been controlled for, significant associations were seen in Bangladesh, India, Nepal, and Sri Lanka. The use of iodated salt was related to increased weight-for-age and mid-upper-arm circumference, most strongly in the second year of life, mainly affecting soft tissue (thinness). The relation with weight-for-age was greater among children of mothers with lower body mass index. The use of iodated salt was related to birthweight in Sri Lanka and in the Philippines, where iodated oil capsules given during pregnancy had a negative effect when used with high levels of iodine in salt. The associations generally were concentrated in large geographic areas, possibly because of interactions with other environmental factors (e.g., selenium and arsenic). The apparent growth response to iodine may reflect functional effects of mild deficiency, which is widespread, possibly including effects on brain development.

Background: From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months – about 500 days – is the most important and vulnerable in a child’s life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here.Objective and design: This paper aims to summarize research on policies and programs to protect women’s nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers.Results: The priority problems addressed are: intrauterine growth restriction (IUGR), women’s anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron–folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries.Conclusions: This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.Keywords: maternal nutrition; women’s health; intrauterine growth restriction; anemia; nutrition interventions(Published: 6 June 2014)Citation: Glob Health Action 2014, 7: 23623 - http://dx.doi.org/10.3402/gha.v7.23623

www.thelancet.com Vol 382 July 27, 2013 307 foot (Ethiopia and Rwanda) or bicycle (Malawi) to collect supplies. In many parts of Africa, supplies are much worse. In Bangladesh, the large scale production of ORS—developed over the past two decades—has many unique features, including the establishment by large non-governmental organisations of substantial pharmaceutical manu facturing capacity. Bangladesh now produces 97% of key commodities locally—a situation not possible to replicate in most countries in the medium term. Since the 1980s in Bangladesh and Zimbabwe, and now in Niger, CHWs or volunteers promote household use of sugar-salt solution or similar (lobon and gur) as a fi rst step before referral for ORS. The failure to recommend home fluids in The Lancet Series undermines these eff orts. We could only find one review of recommended home fluids which concluded that there is insufficient evidence to recommend their use. Little research has been done providing insuffi cient and low quality evidence. Yet recommended home fluids are being used and are still recommended (albeit half-heartedly) in the latest WHO/UNICEF Global Action Plan for Pneumonia and Diarrhoea. Do we not have an ethical obligation to also train CHWs to promote recommended home fl uids (including sugar-salt solution or cereal-based fl uids) in the common situation where ORS is unavailable? We urgently need more research on home fluids. Furthermore, we need clear strategies, commitments, and fi nancial investments in community mobilisation and intersectoral actions for prevention of diarrhoea through improved water quality and availability, improved sanitation, and handwashing with soap.

ObjectiveTo outline a framework and a process for assessing the needs for capacity development to achieve nutrition objectives, particularly those targeting maternal and child undernutrition.DesignCommentary and conceptual framework.SettingLow- and middle-income countries.ResultA global movement to invest in a package of essential nutrition interventions to reduce maternal and child undernutrition in low- and middle-income countries is building momentum. Capacity to act in nutrition is known to be minimal in most low- and middle-income countries, and there is a need for conceptual clarity about capacity development as a strategic construct and the processes required to realise the ability to achieve population nutrition and health objectives. The framework for nutrition capacity development proposed recognises capacity to be determined by a range of factors across at least four levels, including system, organisational, workforce and community levels. This framework provides a scaffolding to guide systematic assessment of capacity development needs which serves to inform strategic planning for capacity development.ConclusionsCapacity development is a critical prerequisite for achieving nutrition and health objectives, but is currently constrained by ambiguous and superficial conceptualisations of what capacity development involves and how it can be realised. The current paper provides a framework to assist this conceptualisation, encourage debate and ongoing refinement, and progress capacity development efforts.

Background Efficacious strategies to improve maternal nutrition and subsequent maternal, neonatal, and child health exist, but their utilization and application at scale is limited. Objective This study explored the gaps, barriers, and opportunities for maternal nutrition policy and programming in Nigeria, a country with a disproportionate share of the global burden of maternal and child mortality Methods Research was conducted in three phases in four Local Government Authorities in Taraba State. Phase 1 consisted of a desk review of policies, programs, and sociodemographic and health indicators pertinent to maternal nutrition. In-depth interviews were conducted with key informants in state and local ministries of health as well as international nongovernmental organizations and community- and faith-based organizations. Phase 2 utilized in-depth interviews and focus group discussions with community leaders, health promoters, and mothers. Phase 3 consisted of key informant interviews with federal policy and program leaders in government ministries and nongovernmental organizations. Results Nutrition, especially maternal nutrition, is not prioritized and is poorly funded in both the governmental and the nongovernmental systems. Perceived weak advocacy for nutrition and its role in economic development and the lack of coordination among governmental and nongovernmental actors were said to contribute to low prioritization. Dependence on health facilities as the primary platform for delivering maternal nutrition is problematic, given severe resource constraints and perceived community barriers, including cost, distance, and poor quality of care. Conclusions Advocacy for maternal nutrition that improves understanding of its consequences for health and economic development could hasten prioritization, coordination, and investment in maternal nutrition at the national, state, and local levels. Innovative, multisectoral strategies that move beyond facility-based platforms are needed to reduce the burden of maternal undernutrition in Northeast Nigeria.

BackgroundMaternal undernutrition persists as a serious problem in Ethiopia. Although there are maternal nutrition interventions that are efficacious and effective in improving maternal, neonatal, and child health (MNCH) outcomes, implementation has been limited.ObjectiveThis study explored needs, perceptions, priorities, facilitating factors and barriers to implementation of relevant policies and programs to find opportunities to improve maternal nutrition in EthiopiaMethodsBackground information was compiled and synthesized for a situation analysis. This informed focus group discussions and in-depth interviews with mothers, community leaders, health workers, and district health officials in four woredas (districts) in Tigray and Southern Nations, Nationalities and Peoples Region.ResultsFindings focused on three priority issues: maternal anemia, intrauterine growth retardation (IUGR), and maternal thinness and stunting. Community-level investigations found that women's low status, food insecurity and poverty, and workload were key factors perceived to contribute to women's undernutrition. Awareness of and demand for services to improve women's nutrition were low, except for high demand for supplementary food. On the supply side, barriers included low prioritization of maternal nutrition in health and nutrition service delivery and weak technical capacity to deliver context-sensitive maternal nutrition interventions at all levels.ConclusionsCommunity-based health and nutrition services were promising platforms for expanding access to interventions such as micronutrient supplements and social and behavior change communication. Investments are needed to support these community-based programs, including training, supplies, supervision and monitoring. To address IUGR at scale, increased access to cash or food transfers could be explored.

Background Inadequate nutrient intake, early and multiple pregnancies, poverty, caste discrimination, and gender inequality contribute to poor maternal nutrition in India. While malnutrition is seen throughout the life cycle, it is most acute during childhood, adolescence, pregnancy, and lactation. Although nutrition policies are on the books and interventions are in place, child malnutrition and maternal undernutrition persist as severe public health problems. Objective To evaluate the implementation of maternal nutrition programs in India. Methods The research was conducted in two phases. Phase 1 consisted of a desk review of national and state policies pertinent to maternal nutrition and national-level key informant interviews with respondents who have a working knowledge of relevant organizations and interventions. Phase 2 utilized in-depth interviews and focus group discussions at the state, district, and community levels in eight districts of two states: Tamil Nadu and Uttar Pradesh. All data were analyzed thematically. Results India has a rich portfolio of programs and policies that address maternal health and nutrition; however, systematic weaknesses, logistical gaps, resource scarcity, and poor utilization continue to hamper progress. Conclusions Elevating the priority given to maternal nutrition in government health programs and implementing strategies to improve women's status will help to address many of the challenges facing India's nutrition programs. Programs can be strengthened by promoting integration of services, ensuring effective procurement mechanisms for micronutrient and food supplements, establishing regional training facilities for improved program implementation, and strengthening program monitoring and evaluation.

Background Undernutrition in women in poor countries remains prevalent and affects maternal, neonatal and child health (MNCH) outcomes. Improving MNCH outcomes requires better policies and programs that enhance women's nutrition. Objective The studies aimed to better understand awareness, perceptions, barriers to intervention, and policy and program priorities and approaches, through different platforms, addressing three related priority problems: anemia, intra-uterine growth retardation (IUGR), and maternal thinness and stunting (including incomplete growth with early pregnancy). Methods Results of a global literature review on program effectiveness, and from case studies in Ethiopia, India, and Nigeria, were synthesized. Results and conclusions Anemia can be reduced by iron-folate supplementation, but all aspects for successful implementation, from priority to resources to local capacity, require strengthening. For IUGR, additional interventions, of food supplementation or cash transfers, may be required for impact, plus measures to combat early pregnancy. Breaking the intergenerational cycle of women's undernutrition may also be helped by child nutrition programs. Potential interventions exist and need to be built on: iron-folate and multiple micronutrient supplementation, food fortification (including iodized salt), food supplementation and/or cash transfer programs, combatting early pregnancy, infant and young child nutrition. Potential platforms are: the health system especially antenatal care, community-based nutrition programs (presently usually child-oriented but can be extended to women), child health days, safety net programs, especially cash transfer and conditional cash transfer programs. Making these more effective requires system development and organization, capacity and training, technical guidelines and operational research, and advocacy (who takes the lead?), information, monitoring and evaluation.

Background A 2004 UNICEF/UNAIDS/USAID survey in Blantyre, Malawi, examined methods to improve monitoring and evaluation of interventions aimed at orphans and vulnerable children. Objective A derivative of this larger study, the present study utilized the household data collected to assess differences in food security status among orphan households with the aim of helping food security programmers focus resources on the households most affected. Methods Orphan households were classified by number and type of orphans supported. Descriptive analyses and logistic regressions were performed to assess differential vulnerability to food insecurity according to these classifications. Results Multiple-orphan households and multiple-orphan households that cared for at least one foster child were 2.42 and 6.87 times more likely to be food insecure, respectively, than nonorphan households. No other category of orphan household was at elevated risk. Conclusions The food security impact of caring for orphans varied significantly among orphan households, requiring food security planners to focus resources on the households most heavily impacted by HIV/AIDS, including multiple-orphan households, rather than focusing on conventional designations of vulnerability, such as orphans and vulnerable children.

Background Child Health Days have been implemented since the early 2000s in a number of sub-Saharan African countries with support from UNICEF and other development partners with the aim to reduce child morbidity and mortality. Objective To estimate the effect of Child Health Days on preventive public health intervention coverage, and possible trade-offs of Child Health Days with facility-based health systems coverage, in sub-Saharan Africa. Methods Data were assembled and analyzed from population-based sample surveys and administrative records and from local government sources, from six countries. Field observations (published elsewhere) provided context. Results Child Health Days contributed to improving measles immunization coverage by about 10 percentage points and, importantly, provided an opportunity for a second dose. Child Health Days achieved high coverage of vitamin A supplementation and deworming, and improved access to insecticide-treated nets. Reported measles cases declined to near zero by 2003–5—a result of the combined efforts of routine immunizations and supplementary immunization activities, often integrated with Child Health Days. Collectively these activities were successful in reaching and sustaining a high enough proportion of the child population to achieve herd immunity and prevent measles transmission. Conclusions Additional efforts and resources are needed to continue pushing coverage up, particularly for measles immunization, in rural/hard-to-reach areas, amongst younger children, and less educated/poorer groups. In countries with low routine immunization coverage, Child Health Days are still needed.

Vitamin A deficiency : policy implications of estimates of trends and mortality in children

National programs for vitamin A supplementation and iodization of the salt supply were launched and sustained with high (but not universal) coverage in most of the countries studied. Iron programs (requiring daily or weekly supplementation, in contrast to vitamin A), which were distributed mainly through antenatal care, had lower coverage and acceptance. Constraints to supplementation were supply, awareness of health staff and communities, and (for vitamin A) insecurity with phasing out of the national immunization days, which have been a major vehicle for distribution. Administration to women postpartum becomes even more important and needs greater coverage. Iodized salt programs have expanded well, with good interagency collaboration and local management, supported by legislation (which may need strengthening); constraints remain in terms of too many salt producers, inadequate quality, import issues, and prices. More integrated, multifaceted programs are needed, with priority to developing and implementing fortification—especially in finding effective ways to ironfortify rice. Data are lacking, with fewer surveys once programs start, constraining monitoring and program control and adaptation. Nonetheless, interventions appear to have gone to scale remarkably successfully.

Internationally recognized research findings on the potential health benefits of preventing micronutrient deficiencies—especially reduced child mortality from vitamin A deficiency and prevention of in utero developmental damage and mental retardation from iodine deficiency—have contributed to raising the awareness of deficiencies and the commitment of many governments to their reduction or near-elimination. The procedures undertaken to decide on large-scale programs followed conventional patterns in the 12 countries included in this study (11 Asian countries plus South Africa). Thus, a sequence of national surveys, institutional arrangements through intersectoral technical committees, legislation, incorporation of programs into national plans, and resource mobilization, including external assistance, was similar for all three micronutrients. Vitamin A supplementation twice yearly to children, then to women postpartum, has reached the national level. Iodized salt is universally adopted at the national level in most countries, with a need for continuing efforts to reach underserved populations and to implement legislation and quality control. Iron programs, usually aiming at daily supplementation during pregnancy, have been pursued, but with less intensity. However, it is clear that these procedures have succeeded in creating a rapid expansion of large-scale deficiency-control programs, which while evolving are generally being maintained.

Community-based research on child survival in sub-Saharan Africa has focussed on the increased provision of curative health services by a formalised cadre of lay community health workers (CHWs), but we have identified a particular configuration, that deserves closer scrutiny. We identified a two-tiered CHW system, with the first tier being the lessor known or ‘hidden’ community/village level volunteers and the second tier being formal, paid CHWs, in Ethiopia, Mali, and Niger. Whilst the disease-focussed tasks of the formal CHW tier may be more amenable to classic epidemiological surveillance, we postulate that understanding the relationship between formalised CHWs and volunteer cadres, in terms of scope, location of practice and ratio to population, would be important for a comprehensive evaluation of child survival in these countries. We report on the findings from our joint qualitative and quantitative investigations, highlighting the need to recognise the ‘hidden’ contribution of volunteers. We need to better characterize the volunteers’ interaction with community-based and primary care services and to better understand ways to improve the volunteer systems with the right type of investments. This is particularly important for considering the models for scale-up of CHWs in sub-Saharan Africa. Keywords : community-based care; community volunteers; sub-Saharan Africa; developing countries; child mortality; population health; global health; health systems (Published: 12 March 2015) Citation : Glob Health Action 2015, 8 : 27214 - http://dx.doi.org/10.3402/gha.v8.27214

Severe malnutrition, defined by severe wasting (weightfor-height < –3 z-scores or < 70% of the median National Center for Health Statistics/World Health Organization [NCHS/WHO] reference) and/or the presence of nutritional edema, is a life-threatening condition requiring urgent treatment. How many lives would better treatment of severe child malnutrition save? The prevalence of severe malnutrition is estimated as around 2% in the least-developed countries and 1% in other developing countries [1], which translates to about 10 million severely malnourished children at one time. About 10 million children under five die each year [2, 3]. Some 4 million of these are neonatal deaths, which are not generally preventable by addressing severe malnutrition, but a significant proportion of the remaining 6 million may be preventable in this way. Malnutrition, severe or otherwise, is estimated to be a contributing factor in over 50% of child deaths [4], and it is estimated that the reduction in child mortality and morbidity (i.e., loss of disability-adjusted life-years [DALYs] averted) if malnutrition were eliminated would be at least one-third [5]. No direct estimates are available of the contribution of severe malnutrition to child deaths. However, the figure suggested by Collins et al. [6] in this volume of possibly 1 million child deaths (out of 6 million) associated with severe malnutrition is certainly possible. This estimate should be compared with those from other sources of data [7], but nevertheless its order of magnitude suggests that severe malnutrition in children is an important public health problem. Moderate malnutrition contributes more to the overall disease burden than severe malnutrition, since it affects many more children, even if the risk of death is lower [8]. Moreover, preventing all forms of malnupreventing all forms of malnupreventing trition remains the priority. However, existing prevention programs are imperfect, especially in the poorest countries or in countries undergoing an emergency crisis, and the prevalence of moderate plus severe malnutrition (as underweight) persists at around 25% and is falling only slowly. Many children still go on to become severely malnourished, even when prevention programs are in place, and these children will require treatment. Hence therapeutic programs are still needed as “safety nets” in parallel with prevention programs. Thus, extensive benefit would ensue from more effective and widely available treatment of severe malnutrition. Yet until recently, developing and applying better treatment methods has had low priority—severe malnutrition can almost be regarded as a neglected disease. For example, in the Lancet series on child survival

ObjectiveTo investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3.DesignEpidemiological analysis of sub-national and national surveys with related data.SettingData from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices.SubjectsSecondary data: children 0–5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance.ResultsChild nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997–2002), 17 to 32% in Copperbelt (Zambia, 1999–2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999–2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas – with greater reliance on trade and wage employment – have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status.ConclusionsFirst, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.

Policies for protecting the nutrition of displaced people (including refugees) have evolved significantly since the sharp increase in numbers began in the 1970s. Food supplies have often been grossly inadequate, probably contributing to the very high mortality rates and severe malnutrition observed in camps. These are related, in part, to low estimates of food energy needs, moving from the idea of "survival" rations (1200-1800 kcal/person/ day) through "minimum" (1900 kcal) to a current target level, likely to be usually adequate, of 2100 kcal. Some donors aim to provide 2400 kcal to preclude the need for supplementary feeding. Micronutrient needs in food supplies have received less attention, despite reemerging epidemics of micronutrient deficiencies (e.g., scurvy, pellagra) in camp populations. Supplied commodity baskets are still not routinely designed to meet micronutrient needs. The relative roles of different feeding programs need clarification; therapeutic feeding in severe malnutrition is well established, although experience of supplementary feeding is mixed. Better information on nutrition, health and survival is now routinely available; in particular, using trigger levels of mortality rates (e.g., 1/10,000/day as a crisis) has helped enhance action. The existence of severe wasting in children is highly predictive of increased mortality and could be tested as a readily observed indicator. Overall, procedures for alleviating and preventing malnutrition have indeed improved, but much more slowly than the scientific basis could allow. A general conclusion is that learning lessons and applying them more quickly could still prevent much malnutrition and save many lives among displaced people.

Invited Commentary on Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data. Stevens GA, Finucane MM, Paciorek CJ, Flaxman SR, White RA, Donner AJ, Ezzati M; Nutrition Impact Model Study Group (Child Growth). Lancet. 2012 Sep 1;380(9844):824-34. Epub 2012 Jul 5. A recent article by Stevens and colleagues1 presents new estimates of trends in malnutrition. While these are not very different to those already published, the interpretation of why progress is being achieved is limited and narrower than that which is commonly agreed. In preparing their paper the authors have not referred to a whole body of literature, that we would like to draw the reader’s attention to; noting for transparency that we have been closely involved with much of this, especially the Reports on the World Nutrition Situation.2 The 6th Report the SCN draws attention to the influence of maternal undernutrition and teenage pregnancy on child undernutrition rates through birth weight in Asia especially. The new methodology uses statistical techniques to estimate national and regional prevalence of underweight and stunted children under-five years for 1985–2011. These largely mirror those available from WHO (quoted by the authors) and by the UN (UN SCN) which are not quoted. The database itself is similar to that used by these others, but the loss of 35% (251 data points) of the data noted (although the reason in the figure is unclear, and the figure is not referenced from the text) is of concern. Equally a major task in obtaining a consistent set of data is adjusting for differing age bands, which is not clearly addressed. The models used have similarities to those used for many years in the World Nutrition Reports, although the variables used for interpolating prevalences are more restricted, and some found useful elsewhere, like lagging GNI/GDP, are not explored. The big picture on child nutrition trends is thus similar to what we already know: child undernutrition is far greater in Asia and Africa than in Southern America, and while progress has been greatest in Asia, in Africa there has been none. (The claim that stagnation or deterioration in Africa ‘had not been noted in previous analyses’ misses the results in the World Nutrition Reports, e.g. pp. 45–47 in ref 2, and earlier reports.) However the success in meeting this MDG goal is more extensive than they report, when looked at by sub-region: almost all of Asia and Central and South America are on track; Sub-Saharan Africa is not (Ref 2, p 47): Africa has more countries, so estimating by numbers of countries gives a pessimistic assessment. In fact, there have been stunning achievements in progress, especially for the massive population countries of S Asia; by population, a majority is reaching the goals. But new interpretation is where there is a real opportunity, as this can guide policy. The authors’ interpretation points to the importance of equitable economic growth and investment in pro-poor food and primary care programmes, but they give insufficient emphasis to the importance of the latter. Much of the progress that is due to deliberate programming of interventions comes from primary care and community-based programmes.3 In their description of primary care programmes the authors give too much emphasis to ‘food’ and especially to complementary feeding and treatment of diarrhoea but omit any reference to the importance of exclusive breast feeding. Another omission is the neglect of maternal malnutrition4, which as a crucial part of the first thousand days of life, needs more recognition.