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Standardized practices are needed in the analysis of inflammation biomarker values outside limits of detection (LODs) when used for inflammation correction of nutritional biomarkers.We assessed the direction and extent to which serum C-reactive protein (CRP) and α-1-acid-glycoprotein (AGP) values outside LODs (0.05 mg/L and4.0 g/L, respectively) affect inflammation regression correction of serum ferritin and compared approaches to addressing such values when estimating inflammation-adjusted ferritin and iron deficiency (ID).We examined 29 cross-sectional datasets from 7 countries with reproductive-age women (age 15-49 y) (n = 12,944), preschool-age children (age 6-59 mo) (n = 18,208), and school-age children (age 6-14 y) (n = 4625). For each dataset, we compared 6 analytic approaches for addressing CRPLOD: listwise deletion, single imputation (lower, middle, or upper bound; LOD/√2; random number), with multiple imputation (MI). For each approach, inflammation-adjusted ferritin and ID using BRINDA (Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia) regression correction were estimated. We calculated deviance of each estimate from that given by MI within each dataset and performed fixed-effects multivariate meta-regression with an analytic approach as a moderator to compare the reliability of each approach to MI.Across datasets, observations outside LOD ranged from 0.0 to 35.0% of CRP values and 0.0 to 2.5% of AGP values. Pooled deviance estimates for mean ferritin (μg/L) and ID (percentage points) were: listwise deletion -0.46 (95% CI: -0.76, -0.16) and 0.14 (-0.43, 0.72), lower bound 0.45 (0.14, 0.76) and -0.36 (-0.91, 0.20), middle bound -0.21 (-0.51, 0.09) and 0.22 (-0.34, 0.79), LOD/√2 -0.26 (-0.57, 0.04) and 0.25 (-0.31, 0.81), upper bound -0.31 (-0.61, -0.01) and 0.30 (-0.27, 0.86), and random number -0.08 (-0.38, 0.22) and 0.11 (-0.46, 0.67). There was moderation by approach in the ferritin model (P0.001).These findings demonstrate the need for standardized analyses of inflammation biomarker values outside LODs and suggest that random number single imputation may be a reliable and feasible alternative to MI for CRPLOD.

To address gaps in coverage and quality of nutrition services, AliveThrive (AT) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the AT interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring.This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the AT maternal nutrition intervention package.We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (50%). Most FLWs received supervision (90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%).Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.

Background Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services. Objectives We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices. Methods We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018–2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. Results Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7–14 percentage points (pp)] and counseling on core nutrition messages (DID: 10–23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron–folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A–rich foods (10 pp, 11 g/d), other vegetables and fruits (22–29 g/d), and gestational weight gain (0.4 kg). Conclusions Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.

Background Millions of children fail to meet their developmental potential and experience mental health concerns globally. Evidence is mixed on whether growth beyond the first 1000 d of life influences intellectual functioning and mental health in school-age children. Objectives We examined associations of childhood growth before and after the first 1000 d of life with child intellectual functioning and mental health at age 6-7 y. Methods We used data from a follow-up of a randomized controlled trial of preconception supplementation (PRECONCEPT study) in Vietnam. A total of 5011 women participated in the study and 1579 children were born during 2012-2014. At age 6-7 y, child intellectual functioning was assessed using the Wechsler Intelligence Scale for Children, and mental health concerns were measured using the Strengths and Difficulties Questionnaire. Multivariable linear models were used to examine the independent association of child size at age 2 y [height-for-age z-score (HAZ) and body-mass-index z-score (BMIZ)] and conditional measures of linear and ponderal growth between the ages of 2 and 7 y. Results HAZ at 2 y was positively associated with the Full-Scale Intelligence Quotient (β = 1.4; 95% CI: 0.5, 2.2 points) and its subdomains, namely Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index (β = 1.0-1.4 points). Higher HAZ at 2 y was associated with lower overall mental health concerns (β = -0.24; 95% CI: -0.47, -0.01) and peer problems (β = -0.08; 95% CI: -0.17, -0.01). Faster height gain between 2 and 7 y was associated with higher total intellectual functioning (β = 0.9; 95% CI: 0.02, 1.8) and fewer emotional issues (β = -0.09; 95% CI: -0.18, -0.01). BMIZ at 2 y was not associated with intellectual functioning but was marginally associated with higher conduct and peer problems. Conditional weight gain between 2 and 7 y was not associated with child intellectual functioning or mental health in young school-age children. Conclusions Child linear growth both during and beyond the first 1000 d is positively associated with intellectual functioning and mental health during the early school-age years.

Background Anemia is a worldwide concern. Nutritional deficiencies and inflammation are considered main contributors, but zinc deficiency has only recently been associated with anemia. Objectives In this study we assessed associations between zinc status and hemoglobin (Hb) concentrations and anemia in preschool children 6-59 mo old (PSC) and nonpregnant women of reproductive age 15-49 y old (WRA) in population-based nutrition surveys. Methods Cross-sectional data from 13 (PSC) and 12 (WRA) countries within the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were used. Multivariable linear models were constructed that included zinc status (plasma/serum zinc concentrations), Hb concentrations and anemia, iron status, age, sex, and inflammation (C-reactive protein and α-1-acid glycoprotein). Zinc was adjusted for inflammation in PSC according to the BRINDA algorithm. Results Data were available for 18,658 PSC and 22,633 WRA. Prevalence of anemia ranged from 7.5% to 73.7% and from 11.5% to 94.7% in PSC and WRA, respectively. Prevalence of zinc deficiency ranged from 9.2% to 78.4% in PSC and from 9.8% to 84.7% in WRA, with prevalence of zinc deficiency >20% in all countries except Azerbaijan (PSC), Ecuador (PSC), and the United Kingdom (WRA). Multivariable linear regression models showed that zinc concentrations were independently and positively associated with Hb concentrations in 7 of 13 countries for PSC and 5 of 12 countries for WRA. In the same models, ferritin concentration was also significantly associated with Hb among PSC and WRA in 9 and 10 countries, respectively. Zinc deficiency was significantly associated with anemia in PSC and WRA in 5 and 4 countries respectively. Conclusions Zinc deficiency was prevalent in most countries and associations between zinc and Hb in roughly half of the countries examined suggesting that strategies to combat zinc deficiency may help reduce anemia prevalence. More research on mechanisms by which zinc deficiency is associated with anemia and the reasons for the heterogeneity among countries is warranted.

Background Growth faltering is associated with adverse consequences during childhood and later life. However, questions remain on the relative importance of preconception maternal nutritional status (PMNS) and child growth during the first 1000 d of life. Objectives We examined associations between PMNS, gestational weight gain (GWG), and child growth during the first 1000 d with attained body size at age 6–7 y. Methods We used data from a follow-up of a double-blinded randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 5011 women). The outcomes included offspring height-for-age z score (HAZ), BMI-for-age z score (BMIZ), and prevalence of stunting and overweight/obese at age 6–7 y (n = 1579). We used multivariable linear and Poisson regression models to evaluate the relative contributions of PMNS (height and BMI), GWG, and conditional growth in 4 periods: fetal, 0–6 mo, 6–12 mo, and 12–24 mo. Results PMNS was positively associated with child-attained size at 6–7 y. For each 1-SD higher maternal height and BMI, offspring had 0.28-SD and 0.13-SD higher HAZ at 6–7 y, respectively. Higher maternal BMI and GWG were associated with larger child BMIZ (β: 0.29 and 0.10, respectively). Faster linear growth, especially from 6 to 24 mo, had the strongest association with child HAZ at 6–7 y (β: 0.39–0.42), whereas conditional weight measures in all periods were similarly associated with HAZ (β: 0.10–0.15). For BMIZ at 6–7 y, the magnitude of association was larger and increased with child age for conditional weight gain (β: 0.21–0.41) but smaller for conditional length gain. Faster growth in the first 2 y was associated with reduced risk of stunting and thinness but increased risk of overweight/obese at 6–7 y. Conclusions Interventions aimed at improving child growth while minimizing the risk of overweight during the school age years should target both women of reproductive age prior to conception through delivery and their offspring during the first 1000 d. The trial was registered at clinicaltrials.gov as NCT01665378.

BackgroundIn the presence of inflammation, the serum or plasma ferritin concentration ("ferritin" hereafter) transiently increases, confounding its interpretation as an iron status marker. The extent to which adiposity-related inflammation may influence ferritin interpretation is uncertain.ObjectivesWe describe relationships between weight status, inflammation, and ferritin among nonpregnant women of reproductive age (WRA; 15-49 years) and preschool-age children (PSC; 6-59 months) with normal weight to overweight or obesity (OWOB) in differing geographic settings.MethodsCross-sectional data were separately analyzed from 18 surveys (WRA) and 25 surveys (PSC) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project, excluding observations with underweight, wasting, pregnancy, or malaria. Relationships were assessed between BMI (in WRA) or BMI-for-age z-score (BAZ; in PSC), inflammatory biomarkers of C-reactive protein (CRP) and/or α-1-acid glycoprotein (AGP), ferritin by linear regression, and potential mediation by CRP and/or AGP in relationships between BMI or BAZ and ferritin with structural equation modeling. Regression and mediation models accounted for complex survey designs. Results were grouped by World Bank income classifications.ResultsIn 5 of 6 surveys among WRA from upper-middle and high-income countries, ferritin was significantly positively associated with BMI, and this relationship was partially (or fully, in the United States) mediated by CRP and/or AGP. Mediation was present in 4 of 12 surveys for WRA in low- and lower-middle income countries. Among PSC, ferritin was positively associated with CRP and/or AGP in all surveys, but there were no significant CRP- or AGP-mediated relationships between ferritin and BAZ, except a negative relationship in the Philippines.ConclusionsWhere having OWOB is common among WRA, measurements of inflammatory biomarkers and their uses in interpreting ferritin may improve iron status assessments. While these relationships were inconsistent among PSC, inflammation was common and should be measured to interpret iron status. Included Kenyan trial data are registered at clinicaltrials.gov as NCT01088958.

Background Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking. Objectives We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization. Methods We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact. Results At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp). Conclusions Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.

Background Although there is growing evidence on the role of preconception nutrition for birth outcomes, very few studies have evaluated the long-term effects of nutrition interventions during the preconception period on offspring cognitive outcomes. Objective We evaluate the impact of preconception weekly multiple micronutrients (MMs) or iron and folic acid (IFA) supplementation compared with folic acid (FA) alone on offspring intellectual functioning at age 6-7 y. Methods We followed 1599 offspring born to women who participated in a double-blinded randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements containing either 2800 μg FA only, 60 mg iron and 2800 μg FA, or MMs (15 micronutrients including IFA) from baseline until conception, followed by daily prenatal IFA supplements until delivery. We used the Wechsler Intelligence Scale for Children to measure full-scale IQ (FSIQ) and 4 related domains of intellectual functioning [Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI) scores] at 6-7 y. Group comparisons were done using ANOVA tests for all children and the subgroup born to women who consumed the supplements ≥26 wk before conception (per-protocol analyses). Results The final sample with data at 6-7 y (n = 1321) was similar for baseline maternal and offspring birth characteristics and age at follow-up by treatment group. Compared with the offspring in the FA group, those in the MM group had higher FSIQ (β = 1.7; 95% CI: 0.1, 3.3), WMI (β = 1.7; 95% CI: 0.2, 3.2), and PSI (β = 2.5; 95% CI: 0.9, 4.1). Similar findings were observed in the per-protocol analyses. There were no significant differences by treatment group for VCI and PRI. Conclusions Preconception supplementation with MMs improved certain domains of intellectual functioning at age 6-7 y compared with FA. These findings suggest the potential for preconception micronutrient interventions to have long-term benefits for offspring cognition.

Background Accurate assessment of iron and vitamin A status is needed to inform public health decisions, but most population-level iron and vitamin A biomarkers are independently influenced by inflammation. Objectives We aimed to assess the reproducibility of the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) regression approach to adjust iron [ferritin, soluble transferrin receptor (sTfR)] and vitamin A [retinol-binding protein (RBP), retinol] biomarkers for inflammation (α-1-acid glycoprotein and C-reactive protein). Methods We conducted a sensitivity analysis comparing unadjusted and adjusted estimates of iron and vitamin A deficiency using the internal-survey regression approach from BRINDA phase 1 (16 surveys in children, 10 surveys in women) and 13 additional surveys for children and women (BRINDA phase 2). Results The relations between inflammation and iron or vitamin A biomarkers were statistically significant except for vitamin A biomarkers in women. Heterogeneity of the regression coefficients across surveys was high. Among children, internal-survey adjustments increased the estimated prevalence of depleted iron stores (ferritin 8.3 mg/L) decreased by a median of 15 pp (15 pp and 20 pp in BRINDA phase 1 and phase 2, respectively). Vitamin A deficiency (RBP

Objective:To examine whether mothers’ perceived neighbourhood food access is associated with their own and their young children’s consumption of animal-flesh food, fruits and vegetables in peri-urban areas of Cambodia.Design:A cross-sectional survey measured food consumption frequency and perceived neighbourhood food access, the latter including six dimensions of food availability, affordability, convenience, quality, safety and desirability. Multivariate logistic regression was used to assess the association between perceived food access and food consumption.Setting:Peri-urban districts of Phnom Penh and Siem Reap, CambodiaParticipants:198 mothers of children between 6 and 24 months old.Results:Over 25 % of the mothers and 40 % of the children had low consumption (< once a day) of either animal-flesh food or fruits and vegetables. Compared with perceived high food access, perceived low food access was associated with an adjusted 5·6-fold and 4·3-fold greater odds of low animal-flesh food consumption among mothers (95 % CI 2·54, 12·46) and children (95 % CI 2·20, 8·60), respectively. Similarly, relative to perceived high food access, perceived low food access was associated with 7·6-times and 5·1-times higher adjusted odds of low fruits and vegetables consumption among mothers (95 % CI 3·22, 18·02) and children (95 % CI 2·69, 9·83), respectively.Conclusions:Mothers’ perceived neighbourhood food access was an important predictor of their own and their young children’s nutrient-rich food consumption in peri-urban Cambodia. Future work is needed to confirm our findings in other urban settings and examine the role of neighbourhood food environment in the consumption of both nutrient-rich and nutrient-poor food.

OBJECTIVES: Considering the known metabolic relationships between adiposity, inflammation, and iron status, we examined whether inflammation mediates the relationship between BMI and serum ferritin (SF) concentration among women of reproductive age (15–49 years) with normal to high BMI in a low-income country (Malawi) and an upper-middle income country (Azerbaijan). METHODS: Cross-sectional survey data were analyzed from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Women with underweight (BMI 5 μg/L or α-1-acid glycoprotein [AGP] >1 g/L), and iron deficiency (inflammation-adjusted SF

Positive Deviance/Hearth (PDH) is an internationally recognized nutrition rehabilitation program. However, nutritional improvements are inconsistent across contexts. It is unclear if variations are due to differences in program design, implementation, utilization, or other contextual factors. Furthermore, few PDH programs have addressed the high time and work burdens of caregivers and volunteers. To address this, the study integrated interactive voice calling (IVC) with PDH.A program impact pathway (PIP) analysis was used to evaluate the secondary outcomes of facilitators, barriers, and contextual factors that influenced the design, implementation, and utilization of a Positive Deviance/Hearth-Interactive Voice Calling program to improve the nutritional status of children in Cambodia.A PIP analysis was done on data collected through in-depth interviews with caregivers (In the design phase, facilitators included quality training, technical support and design tools, community mobilization, and linkage to existing health services. Barriers included poor community mobilization. For the implementation phase, facilitators were good volunteer knowledge, follow-up tools and guidance, supervision, and spot checks of volunteers. Barriers were lack of time and overworked older caregivers. For the utilization phase, facilitators included family and volunteer support and access to phones, whereas barriers were lack of support, time, and financial resources; low levels of education and old age of caregivers; and inconsistent phone use. Contextual factors included food insecurity and increased childcare responsibilities of grandmothers due to migration of mothers.The PIP analysis identified facilitators, barriers, and contextual factors that may affect the design, intervention, and utilization of IVC interventions for health and nutrition behavior change and elements to consider when designing and implementing them. When implementing child nutrition programs in Cambodia, supporting interventions addressing mental health and time and resource constraints of elderly caregivers should also be included.This trial was registered at clinicaltrials.gov as NCT03399058.

Maternal undernutrition remains a critical public health problem. There are large regional and within-country disparities in the burden of underweight, anemia, and micronutrient deficiencies across the globe. Driving these disparities are complex and multifactorial causes, including access to health services, water and sanitation, women’s status, and food insecurity as well as the underlying social, economic, and political context. Women’s health, nutrition, and wellbeing across the continuum of preconception to pregnancy are critical for ensuring positive pregnancy and long-term outcomes for both the mother and child. In this review, we summarize the evidence base for nutrition interventions before and during pregnancy that will help guide programs targeted towards women’s nutrition. Growing evidence from preconception nutrition trials demonstrates an impact on offspring size at birth. Preconception anemia and low preconception weight are associated with an increased risk of low birth weight and small for gestational age births. During pregnancy, several evidence-based strategies exist, including balanced-energy protein supplements, multiple micronutrient supplements, and small-quantity lipid nutrient supplements for improving birth outcomes. There, however, remain several important priority areas and research gaps for improving women’s nutrition before and during pregnancy. Further progress is needed to prioritize preconception nutrition and access to health and family planning resources. Additional research is required to understand the long-term effects of preconception and pregnancy interventions particularly on offspring development. Furthermore, while there is a strong evidence base for maternal nutrition interventions, the next frontier requires a greater focus on implementation science and equity to decrease global maternal undernutrition disparities.

OBJECTIVES: Bioelectrical impedance analysis (BIA) is an accurate, inexpensive and field-friendly methods to assess body composition, but there is limited information on its use and validity for children in low-middle income countries. Our aim was to develop and validate population-specific prediction equations for estimating total fat mass (FM) and fat free-mass (FFM) in Vietnamese children using reactance and resistance from BIA and anthropometric variables. METHODS: We conducted a cross-sectional survey of 120 children in Thai Nguyen, Vietnam. Body composition was measured using dual energy x-ray absorptiometry (DXA), BIA and anthropometry (height, weight, triceps and subscapular skinfolds, and waist, hip, and mid upper arm circumferences). To develop prediction equations, we split the sample into development (70%) and validation datasets (30%). The model performance was evaluated using PRESS (Predicted residual error sum of squares), RMSE (Root mean squared error), MEA (Mean absolute error) and R,(2). RESULTS: %MCEPASTEBIN% The development of prediction equations for total FM resulted in seven models. We identified a top performing model with the least number of parameters (age, sex, weight and resistance index), low RMSE (178 and 164 for FM and FFM, respectively), low MAE (136 and 141 for FM and FFM, respectively), high R2 (>.90), and the least difference between predicted and actual values (FM 25 0.03 g and FFM 8 0.01 g). CONCLUSIONS: We developed valid and highly predictive equations to estimate FM and FFM in Vietnamese children using BIA. These findings have important implications for future research examining the risks associated with overweight and obesity in young children in resource-poor settings. FUNDING SOURCES: Rollins School of Public Health (RSPH) Dean's Pilot and Innovation Grant, the New Jersey Institute for Food, Nutrition, and Health, and the Nestle Foundation.

OBJECTIVES: Frontline workers (FLWs) deliver essential nutrition services to reduce maternal undernutrition in India, but coverage and quality remain sub-optimal. Alive & Thrive aimed to strengthen delivery of interpersonal counselling, community mobilization and micronutrient supplements through the government antenatal care (ANC) platform in UP. We studied pathways through which the nutrition-intensified ANC (I-ANC) was intended to impact FLWs capacity, knowledge, and service delivery, compared to standard ANC (S-ANC). METHODS: We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019), ∼500 FLWs per survey. Differences between I-ANC and S-ANC were compared along six impact pathway components (training, availability of materials, supportive supervision, knowledge, service delivery, and counselling content) using mixed-effects regression adjusted for clustering. RESULTS: Training exposure was higher in I-ANC than S-ANC (9 percentage points, pp). Nutrition training topics were low-moderate (30–60%) in both arms. Job aids were more available in I-ANC (70–80%) than S-ANC (30–40%). Supply of iron-folate and calcium supplements were low in both arms, with 10–50% having stock-outs. FLWs in I-ANC were more likely to receive supervision visits (7 pp), but gaps remained in both arms. Compared to S-ANC, FLWs in I-ANC had higher knowledge on diet diversity (6 pp), adequate intake (10 pp), iron-folate (10 pp) and calcium supplements (30 pp), pregnancy weight gain (20–30 pp), and early breastfeeding (5 pp), but similarly low knowledge of exclusive breastfeeding. ANC check-ups by FLWs were 20 pp higher in I-ANC. FLWs in I-ANC did more counselling on adequate diet, supplements, and weight gain (10–20 pp). Counselling on diet diversity and breastfeeding were low in both arms. CONCLUSIONS: Health systems strengthening efforts helped improve the delivery of maternal nutrition interventions in antenatal care in this context, but gaps remain. Several health system elements along the program pathway – supply chain management, training, supervisory practices – require strengthening to further improve FLW knowledge and nutrition service delivery. FUNDING SOURCES: Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

BackgroundRising prevalence of overweight/obesity (OWOB) alongside persistent micronutrient deficiencies suggests many women face concomitant OWOB and undernutrition.ObjectivesWe aimed to 1) describe the prevalence of the double burden of malnutrition (DBM) among nonpregnant women of reproductive age, defined as intraindividual OWOB and either ≥1 micronutrient deficiency [micronutrient deficiency index (MDI)>0; DBM-MDI] or anemia (DBM-anemia); 2) test whether the components of the DBM were independent; and 3) identify factors associated with DBM-MDI and DBM-anemia.MethodsWith data from 17 national surveys spanning low- and middle-income countries (LMICs) and high-income countries from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project (n=419 to n=9029), we tested independence of over- and undernutrition using the Rao-Scott chi-square test and examined predictors of the DBM and its components using logistic regression for each survey.ResultsMedian DBM-MDI was 21.9% (range: 1.6%-39.2%); median DBM-anemia was 8.6% (range: 1.0%-18.6%). OWOB and micronutrient deficiencies or anemia were independent in most surveys. Where associations existed, OWOB was negatively associated with micronutrient deficiencies and anemia in LMICs. In 1 high-income country, OWOB women were more likely to experience micronutrient deficiencies and anemia. Age was consistently positively associated with OWOB and the DBM, whereas the associations with other sociodemographic characteristics varied. Higher socioeconomic status tended to be positively associated with OWOB and the DBM in LMICs, whereas in higher-income countries the association was reversed.ConclusionsThe independence of OWOB and micronutrient deficiencies or anemia within individuals suggests that these forms of over- and undernutrition may have unique etiologies. Decision-makers should still consider the prevalence, consequences, and etiology of the individual components of the DBM as programs move towards double-duty interventions aimed at addressing OWOB and undernutrition simultaneously.

Background In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers’ experiences and challenges in collecting and using data for decision making. Objective The aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making. Methods In-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences. Results Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors. Conclusions The use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions., Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Structural barriers such as staff vacancies need to be addressed to improve data utilization.

Background: Maternal health and nutrition play a crucial role in early child growth and development. However, little is known about the benefits of preconception micronutrient interventions beyond the role of folic acid (FA) and neural tube defects.Objective: We evaluated the impact of weekly preconception multiple micronutrient (MM) or iron and folic acid (IFA) supplementation on child growth and development through the age of 2 y compared with FA alone.Methods: We followed 1599 offspring born to women who participated in a randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements that contained either 2800 μg FA, 60 mg Fe and 2800 μg FA, or 15 MMs including IFA, from baseline until conception followed by daily prenatal IFA supplements until delivery. Child anthropometry was measured at birth and at 3, 6, 12, 18, and 24 mo. Child development was measured with the use of the Bayley Scales for Infant Development III at 24 mo.Results: The groups were similar for baseline maternal and offspring birth characteristics. At 24 mo of age, the offspring in the IFA group had significantly higher length-for-age z scores (LAZs) (0.14; 95% CI: 0.03, 0.26), reduced risk of being stunted (0.87; 95% CI: 0.76, 0.99), and smaller yearly decline in LAZs (0.10; 95% CI: 0.04, 0.15) than the offspring in the FA group. Similar trends were found for the offspring in the MM group compared with the FA group for LAZs (0.10; 95% CI: -0.02, 0.22) and the risk of being stunted (0.88; 95% CI: 0.77, 1.01). Offspring in the IFA group had improved motor development (P = 0.03), especially fine motor development (0.41; 95% CI: 0.05, 0.77), at the age of 24 mo, but there were no differences for measures of cognition or language.Conclusions: Preconception supplementation with IFA improved linear growth and fine motor development at 2 y of age compared with FA. Future studies should examine whether these effects persist and improve child health and schooling. The trial was registered at clinicaltrials.gov as NCT01665378.

BackgroundThe associations between anemia and household water source and sanitation remain unclear.ObjectivesWe aimed to assess the associations between anemia and household water source or sanitation in preschool children (PSC; age 6-59 mo) using population-based surveys from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.MethodsWe analyzed national and subnational data from 21 surveys, representing 19 countries (n = 35,963). Observations with hemoglobin (Hb) and ≥1 variable reflecting household water source or sanitation were included. Anemia was defined as an altitude-adjusted Hb concentration

OBJECTIVES: The Household Food Insecurity Access Scale (HFIAS) is widely used though it has limited cross-cultural applicability. Among families with underweight children in three Cambodian districts, the HFIAS-derived prevalence of moderate/severe food insecurity was about 45%, though interviewers reported that caregivers have difficulty understanding the questions.This study seeks to develop a locally appropriate tool for measuring household food security in Cambodia. METHODS: Caregivers of children ages 6–24 months were screened using the Household Hunger Scale. Following Coping Strategies Index (CSI) guidance, three focus group discussions (FGD) were held with 25 food insecure caregivers from 10 villages. Participants developed a list of coping strategies in response to the question, “What do you do when you do not have enough food, and do not have enough money to buy food?” By consensus, participants weighted coping strategies in order of increasing severity. Strategies were assessed for inclusion using CSI criteria. The research and local teams combined the three lists into a single tool maintaining much of the local vocabulary. RESULTS: FGD 1 identified 16 coping strategies: one was excluded because it could not be done readily, and two were combined. FGD 2 identified 16: one was excluded because it was not repeatable, and four were combined into two. FGD 3 identified 19: six were combined into three. Seven strategies were identified in all three FGDs and seven were identified in two FGDs. Four strategies were identified in only one FGD. The resulting index is comprised of 18 coping strategies. Three strategies were weighted least severe (1). Example: “Eat rice without fish or meat.” Seven were weighted somewhat severe (2). Example: “Make food last longer by eating smaller portions and keeping it for longer than intended.” Five were weighted as more severe (3). Example: “Sell or consume seed stock held for next season.” Three strategies were weighted as most severe (4). Example: “Borrow rice or money from a lender or employer with high interest.” CONCLUSIONS: Context-specific coping strategies may be useful in measuring food security in Cambodia. Future research is needed to examine the validity of this tool in comparison to established food insecurity experiences scales. FUNDING SOURCES: World Vision Hong Kong. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

OBJECTIVES: The objective of this study was to estimate the prevalence of child malnutrition and the determinants of nutrition status among circular migrant families working in the brick industry in Bihar, India, focusing on differences by origin. METHODS: We used a stratified, cluster sampling design consisting of a cross-sectional survey in 552 randomly selected brick kilns (clusters) throughout Bihar. Circular migration was defined as residence outside the home block for at least 60 days for employment plus at least one home return in the previous year. Per kiln, three circular migrant households with children 0–35 months of age were randomly selected. We collected kiln, household and child-level data including anthropometric measurements for each selected child (n = 1198). Descriptive, bivariate and logistic regression analyses were conducted in SAS. The primary outcomes were stunting (

OBJECTIVES: Current WHO hemoglobin (Hb) cutoffs (12 µg/L (15 µg/L ( >5y)], RBP or retinol >0.7 µmol/L, CRP ≤ 5 mg/L or AGP ≤ g/L, and no malaria (if measured)]. We examined Hb levels, cut-offs at specified percentiles (%ile) and country variations with age-adjusted generalized mixed models using country as random intercept. RESULTS: The final analytic sample was 41,314; the healthy inclusion criteria resulted in 17–88% data loss of the original data depending on country. Age and country-adjusted mean (SE) of Hb was 116.9 (1.44)g/L for PSC, and 129.1 (1.49)g/L for WRA and was significantly (P

OBJECTIVES: Animal milk can be contaminated with mycotoxins (secondary metabolites of fungi) through poor quality feed and may be a source of human exposure. Our objective was to develop and optimize a method to detect biologically relevant concentrations of 8 mycotoxins (Aflatoxins B1, B2, G1, G2, M1, M2; Ochratoxins A, B) in animal milk. METHODS: We used ultra-high performance liquid chromatography/tandem mass spectrometry using selected reaction monitoring (UHPLC/MS-SRM) to quantify mycotoxins in animal milk samples (total N = 38; n = 10 each from cow and commercial milk and n = 9 from buffalo and goat) from the southern Indian states of Karnataka and Tamil Nadu. Method development was conducted and stable isotope dilution employed, using AFB1-D3 for aflatoxins and OTA-D5 for ochratoxins. We validated the method and examined matrix effects, freeze-thaw and auto-sampler stability. Our dynamic ranges from quantification were between 7.8–5000 pg/mL. RESULTS: Among samples collected from Southern India, 8 of 10 cow [median 103.35 pg/mL; n = 3 > 500 pg/mL]; 0 of 9 buffalo and 10 of 10 commercial [median: 151.5 pg/mL], milk samples were above the LOQ. AFM2 was also seen in samples from both regions, but in lower quantities when compared to AFM1 [median (north): 25.8 pg/mL; median (south): 70.95 pg/mL]. All except 3 samples were below the LOQ (31.3 pg/mL) for OTA, however we detected a sodium adduct of OTA above LOQ, across samples. We found [Na-OTA] in goat milk [median: 5.9 ng/mL] > buffalo [median: 2.2 ng/mL] > commercial [median: 2.04 ng/mL] > cow [median: 0.8 ng/mL]. Other mycotoxins were seen in concentrations close to or below LOQ. We did not identify significant stability issues. CONCLUSIONS: We developed a highly sensitive method with biologically relevant dynamic ranges for detection of mycotoxins in milk samples. We found AFM1, AFM2, and Na-OTA in milk samples from Southern India. Further studies with larger sample sizes are warranted to establish the extent of mycotoxin contamination in milk. FUNDING SOURCES: Funded by University Research Committee, Emory University and International Society for Research in Human Milk and Lactation.

OBJECTIVES: We aimed to assess the associations between water source and sanitation with anemia in preschool children (age: 6–59 months) in 16 population-based surveys. METHODS: We analyzed data from the BRINDA project. Sixteen surveys, representing 15 countries (n = 25,214), that had measures of hemoglobin, household water source and sanitation, type of residence, and socioeconomic (SES) status were included in this analysis. Anemia was defined as altitude-adjusted hemoglobin concentration

Background India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time. Objective This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women. Methods We used India's National Family Health Surveys data collected in 2005-2006 (n = 110,887) and 2015-2016 (n = 645,193). We applied multiple regression and decomposition analysis to assess determinants of underweight (BMI z score 1 SD; ≥25 kg/m2). Results Over the past decade, the prevalence of underweight decreased (43% to 38% and 33% to 19%) and the prevalence of overweight/obesity increased (3% to 5% and 15% to 24%), among adolescents and women, respectively, with high heterogeneity across states. Factors associated with a lower prevalence of underweight among women included higher socioeconomic status (SES) (OR: 0.35; 95% CI: 0.31, 0.41), urban residence (OR: 0.49; 95% CI: 0.45, 0.54), improved diet diversity (OR: 0.75; 95% CI: 0.69, 0.82), and latrine use (OR: 0.76; 95% CI: 0.70, 0.82). Higher education levels, decision-making, and ownership of money were also associated with a lower prevalence of underweight. Factors positively associated with overweight/obesity among women included SES (OR: 3.24; 95% CI: 2.81, 3.73), urban residence (OR: 2.23; 95% CI: 2.05, 2.42), diet diversity (OR: 1.21; 95% CI: 1.10, 1.32), latrine use (OR: 1.31; 95% CI: 1.21, 1.43), and education (OR: 1.39; 95% CI: 1.24, 1.55). Adolescents shared similar determinants to women. Overall, SES was a key driver of changes in women's BMI, explaining 29% of the reduction in undernutrition and 46% of the increase in overweight/obesity. Conclusions Despite overall declines, regional and age disparities remain in the overall burden of underweight and the increases in overweight/obesity are concerning. The identified divergent risk factors (SES, residence, diet, education) highlight that simply improving economic status will not ensure healthy BMI status for women and girls. Balanced multidisciplinary approaches are needed to address both undernutrition and overweight.

Background Vitamin B-12 and folate deficiencies in women and children have important public health implications. However, the evidence is conflicting and limited on whether the influence of inflammation on biomarker concentrations may be sufficiently and consistently influenced by inflammation to require adjustment for interpreting concentrations or estimating population prevalence of deficiencies. Objective We examined correlations between concentrations of the inflammation biomarkers C-reactive protein (CRP) and α1-acid glycoprotein (AGP) and serum vitamin B-12 and serum and RBC folate among nonpregnant women of reproductive age (WRA; 15–49 yr) and preschool children (PSC; 6–59 mo). Methods We analyzed cross-sectional data from 16 nationally representative nutrition surveys conducted in WRA (n = 32,588) and PSC (n = 8,256) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project. Spearman correlations between CRP or AGP and vitamin B-12 or folate concentrations were examined, taking into account complex survey design effects. Results Correlations between inflammation and vitamin B-12 or folate were weak, with no clear pattern of association in either WRA or PSC. Correlation coefficients between CRP and vitamin B-12 for WRA and PSC ranged from −0.25 to 0.16, and correlations between AGP and vitamin B-12 ranged between −0.07 and 0.14. Similarly, correlations between CRP and serum folate ranged from −0.13 to 0.08, and correlations between AGP and serum folate between −0.21 and 0.02. Only 3 surveys measured RBC folate, and among them, correlations for WRA ranged from −0.07 to 0.08 for CRP and −0.04 for AGP (1 country). Conclusions Based on the weak and inconsistent correlations between CRP or AGP and vitamin B-12 or folate biomarkers, there is no rationale to adjust for inflammation when estimating population prevalence of vitamin B-12 or folate deficiencies in WRA or PSC.

OBJECTIVES: Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use. METHODS: In-depth interviews (N = 35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers. RESULTS: Sub-district government staff reported using government data (i.e., HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e., monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors. CONCLUSIONS: Use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Collaboration facilitated the use of data, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions. FUNDING SOURCES: Bill & Melinda Gates Foundation (through Alive & Thrive, managed by FHI 360) and Emory University.

OBJECTIVES: While there is growing evidence on the role of preconception nutrition for birth outcomes, very few studies have evaluated the effects of nutrition interventions during the preconception period on maternal health. This study evaluates the impact of preconception weekly multiple micronutrients (MM) or iron and folic acid (IFA) supplementation compared to FA alone on maternal nutritional status through 6–7y post-partum (PP). METHODS: We followed women who participated in a randomized controlled trial of preconception supplementation in Vietnam and delivered live offspring (n = 1599). Women received weekly supplements containing either 2800 μg FA only, 60 mg iron and 2800 μg FA, or MM (15 micronutrients including IFA), from baseline until conception; followed by daily prenatal IFA supplements until delivery. Anthropometric measurements were obtained at recruitment and at 2 and 6–7 y PP. Group comparisons were done using ANOVA or chi-square tests. RESULTS: The groups were similar for baseline (preconception) maternal and offspring birth characteristics. Mean (SD) Body Mass Index (BMI; kg/m2) increased from 19.6 (2.1) at baseline, to 20.4 (2.4) and 21.6 (2.8) at 2 and 6–7 y PP (n = 931). The prevalence of overweight (BMI ≥ 23.5 kg/m2) also increased from 4.7% to 9% and 21%, at baseline, 2, and 6–7 years PP respectively, while underweight (BMI

OBJECTIVES: Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensified ANC (I-ANC) compared to standard ANC (S-ANC) on diet diversity, consumption of iron-folic acid (IFA) and calcium supplements, and early breastfeeding practices. METHODS: We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019) (n ∼660 pregnant women and 1800 recently delivered women per survey) and a process evaluation. We derived difference-in-difference effect estimates, adjusted for geographic clustering, gestational age, infant age, and sex. RESULTS: Coverage of interventions was high at endline; 70–90% women were contacted by frontline workers at home or nutrition centers. Women in the I-ANC arm were significantly more likely to have received counseling on core nutrition messages (10–18 percentage points [pp]) than those in the S-ANC arm. Dietary diversity improved modestly among pregnant women in the I-ANC arm compared to the S-ANC arm (effect: 8.3 pp). The number of food groups consumed increased slightly over time but remained low in both arms. The percentage of women who consumed 100 + IFA improved equally in both arms (from 8 to 25%). Small significant impacts were observed for any consumption of IFA and calcium supplements (effects 10.3 and 12.4 pp, respectively). Significant impacts were also observed for non-prelacteal feeding (effect: −6.3 pp) and exclusive breastfeeding (effect: 7.4 pp) but not for early initiation of breastfeeding. The process evaluation found that system-level and supply-chain challenges, household context, and local diet preferences affected implementation and uptake. CONCLUSIONS: Intensifying nutrition in existing government ANC services resulted in modest improvements in maternal nutrition practices. Dietary diversity and consumption of supplements remained sub-optimal. Additional efforts are needed for further improvement of maternal nutrition services. FUNDING SOURCES: Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

OBJECTIVES: While there is growing evidence on the role of preconception nutrition for birth outcomes, very few studies have evaluated the effects of nutrition interventions during the preconception period on child development. This study evaluates the impact of preconception weekly multiple micronutrients (MM) or iron and folic acid (IFA) supplementation compared to FA alone on child growth and development at age 6–7y. METHODS: We followed 1599 offspring born to women who participated in a randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements containing either 2800 μg FA only, 60 mg iron and 2800 μg FA, or MM (15 micronutrients including IFA), from baseline until conception; followed by daily prenatal IFA supplements until delivery. Child anthropometry and development were measured at 6–7y. Child development was measured using the Wechsler Intelligence Scale for Children IV®. Group comparisons were done using ANOVA or chi-square tests for both intention-to-treat (ITT) and per-protocol analyses (PP, women consumed supplements ≥26 wk before conception). RESULTS: The groups were similar for baseline maternal and offspring birth characteristics and age at follow-up. We found significant differences (P

Background Food fortification is one approach for addressing anemia, but information on program effectiveness is limited. Objective We evaluated the impact of Costa Rica's fortification program on anemia in women aged 15-45 y and children aged 1-7 y. Design Reduced iron, an ineffective fortificant, was replaced by ferrous fumarate in wheat flour in 2002, and ferrous bisglycinate was added to maize flour in 1999 and to liquid and powdered milk in 2001. We used a one-group pretest-posttest design and national survey data from 1996 (baseline; 910 women, 965 children) and 2008-2009 (endline; 863 women, 403 children) to assess changes in iron deficiency (children only) and anemia. Data were also available for sentinel sites (1 urban, 1 rural) for 1999-2000 (405 women, 404 children) and 2008-2009 (474 women, 195 children), including 24-h recall data in children. Monitoring of fortification levels was routine. Results Foods were fortified as mandated. Fortification provided about one-half the estimated average requirement for iron in children, mostly and equally through wheat flour and milk. Anemia was reduced in children and women in national and sentinel site comparisons. At the national level, anemia declined in children from 19.3% (95% CI: 16.8%, 21.8%) to 4.0% (95% CI: 2.1%, 5.9%) and in women from 18.4% (95% CI: 15.8%, 20.9%) to 10.2% (95% CI: 8.2%, 12.2%). In children, iron deficiency declined from 26.9% (95% CI: 21.1%, 32.7%) to 6.8% (95% CI: 4.2%, 9.3%), and iron deficiency anemia, which was 6.2% (95% CI: 3.0%, 9.3%) at baseline, could no longer be detected at the endline. Conclusions A plausible impact pathway suggests that fortification improved iron status and reduced anemia. Although unlikely in the Costa Rican context, other explanations cannot be excluded in a pre/post comparison.

OBJECTIVES: Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a program evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential program influence on improving breastfeeding. METHODS: A cross-sectional survey was conducted among 1838 recently delivered women, 1194 husbands and 1353 mothers/mothers-in-law (MMIL) in Uttar Pradesh, India. We used bivariate and multivariate logistic regression models to examine the association between key determinants (maternal, household, community and health services) and breastfeeding outcomes (early initiation of breastfeeding (EIBF), pre-lacteal feed and exclusive breastfeeding (EBF). We used population attributable risk analysis to estimate potential improvement in breastfeeding practices. RESULTS: Breastfeeding practices were suboptimal: Low EIBF (26.3%) and EBF (54%) but high pre-lacteal feeding (33%). EIBF was positively associated with maternal knowledge, counseling during pregnancy/delivery, and vaginal delivery at a health facility. Pre-lacteal feeds were less likely to be given to infants when the mothers had higher knowledge, beliefs and self-efficacy, and delivered at a health facility and MMIL had attended school. EBF was positively associated with maternal knowledge, beliefs and self-efficacy, parity and socio-economic status. High maternal stress and domestic violence contributed to lower EBF. Under optimal program implementation, we estimate EIBF can be improved by 25%, pre-lacteal feeding can be reduced by 25% and EBF can be increased by 23%. CONCLUSIONS: A multifactorial approach, including maternal, health service, family and community-level interventions has the potential to lead to significant improvements in breastfeeding practices in Uttar Pradesh. FUNDING SOURCES: The Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

OBJECTIVES: Low BMI among women and girls has implications for their health and that of the next generation. Yet, little is known about the determinants of low BMI despite the known high burden of undernutrition in India. We aimed to use nationally representative data to examine national and state trends for BMI and to identify the determinants of low BMI among adolescent girls and women. METHODS: We used India's National Family Health Survey (NFHS), collected in 2005–2006 and 2015–16. Using data on adolescents 15–19y (N = 21,450; N = 117,722) and women 20–49y (N = 89,437; N = 527,471), we examined national and state trends for BMI. We used multiple regression analysis to examine the role of individual (e.g., diet), interpersonal (e.g., domestic violence) and family-level factors (e.g., socio-economic status (SES)) on low BMI (defined as BMI z-score

OBJECTIVES: Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examines multi-factorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. METHODS: Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. RESULTS: During pregnancy, women consumed ∼40 IFA and calcium tablets, 18% consumed diverse diet and 17% were weighed ≥ 3 times. Nutrition knowledge was a key modifiable factor associated with consumption of diverse diet (OR = 2.2 times, β = 0.7 food groups), IFA (2.3 times, 17 tablets), calcium (11.7 times, 18 tablets) and weight monitoring (0.7 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better maternal nutrition practices. Under optimal program implementation, we estimate 51% women would have adequate diet diversity, an average consumption of 100 IFA and 90 calcium tablets, and women would be weighed 4.4 times during pregnancy CONCLUSIONS: While the current situation is bleak, many of the key factors associated with maternal dietary diversity, IFA/calcium consumption and weight gain monitoring are modifiable. Strengthening existing program operations to improve the supply of interventions and to create adequate demand through behavior change communication has the potential to result in large improvements in maternal nutrition practices from their baseline levels. However, these efforts will not be sufficient to meet WHO-recommended levels without also putting in place more favorable socio-economic conditions and additional resources. FUNDING SOURCES: Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360. Additional funding support is from CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.

We investigated the causes of stunting and wasting using nationally representative data on preschool children from India (2005–2006, N = 41,306) and Guatemala (2008–2009, N = 10,317). We estimated stunting and wasting using the 2006 WHO standard and the 1976 WHO/National Center for Health Statistics (NCHS) reference. India and Guatemala had high levels of stunting; wasting was common in India but rare in Guatemala. Use of the WHO standard (based on breast-fed children) increased the prevalence of stunting in both countries but dramatically changed the pattern of wasting by age in India. In Indian children 0–5 mo of age, wasting more than tripled, from 8% to 30%, leading to the highest prevalence of wasting. Using the NCHS reference, the lowest and highest prevalence among Indian children occurred in children 0–5 and 12–23 mo, respectively. Also, we showed that household wealth and the condition of women were related to both stunting and wasting; review of the literature on wasting failed to identify factors that were not also related to stunting (e.g., seasonality, infections, and intrauterine growth retardation). Possible explanations for high levels of wasting in India include the poor status of women, the “thin-fat“ infant phenotype, chronic dietary insufficiency, poor dietary quality, marked seasonality, and poor levels of sanitation. Use of the WHO standard calls for urgent attention to improving prenatal and infant nutrition and uncovers an alarming level of wasting in the young infant in India that use of the NCHS growth reference (based on bottle-fed infants) had masked.

The determinants of placental transport of dietary iron remain largely uncharacterized. The objective of this research was to elucidate determinants of fetal Fe transfer from maternally ingested dietary heme and non-heme Fe. The study was undertaken in 19 pregnant females (16–32 y) who ingested intrinsically labeled 58Fe-heme and a nonheme Fe source (57FeSO4) during the third trimester of pregnancy. At delivery, maternal and cord blood was obtained to assess neonatal 57Fe and 58Fe enrichment as a function of maternal/neonatal Fe status [serum ferritin (SF), transferrin receptor, hemoglobin (Hb), total body Fe, and hepcidin]. There was a greater percentage of maternally absorbed 58Fe tracer present in the neonates compared to the 57Fe tracer (5.4 ± 2.4 vs. 4.0 ± 1.6; P < 0.0001). Net dietary nonheme Fe (mg) and heme Fe (mg) transferred to the fetus were both inversely correlated with measures of maternal serum hepcidin (P = 0.002, r2 = 0.43; P = 0.004, r2 = 0.39) and SF (P = 0.0008, r2 = 0.49; P = 0.003, r2 = 0.41) and directly associated with neonatal Hb (P = 0.004, r2 = 0.39; P = 0.008, r2 = 0.35). The results of this study suggest that during pregnancy there appears to be preferential fetal use of maternally ingested Fe derived from a dietary, animal-based heme source compared to Fe ingested as ferrous sulfate. Maternal serum hepcidin and maternal/neonatal Fe status may play a role in placental uptake of dietary heme and nonheme Fe.

Heme iron absorption during pregnancy and the role of hepcidin in regulating dietary heme iron absorption remains largely unexplored. The objective of this research was to examine relative differences in heme (animal based) and nonheme (ferrous sulfate) iron utilization. This study was undertaken in 18 pregnant (ages 16-32 y; wk 32-35 of gestation) and 11 nonpregnant women (ages 18-27 y). Women were randomly assigned to receive both an animal-based heme meal (intrinsically labeled (58)Fe pork) and labeled ferrous sulfate ((57)Fe) fed on alternate days. Blood samples obtained 2 wk postdosing were used to assess iron status indicators and serum hepcidin and iron utilization based on RBC incorporation of iron isotopes. Heme iron utilization was significantly greater than nonheme iron utilization in the pregnant (47.7 ± 14.4 vs. 40.4 ± 13.2%) and nonpregnant women (50.1 ± 14.8 vs. 15.3 ± 9.7%). Among pregnant women, utilization of nonheme iron was associated with iron status, as assessed by the serum transferrin receptor concentration (P = 0.003; r(2) = 0.43). In contrast, heme iron utilization was not influenced by maternal iron status. In the group as a whole, women with undetectable serum hepcidin had greater nonheme iron utilization compared with women with detectable serum hepcidin (P = 0.02; n = 29); however, there were no significant differences in heme iron utilization. Our study suggests that iron utilization from an animal-based food provides a highly bioavailable source of dietary iron for pregnant and nonpregnant women that is not as sensitive to hepcidin concentrations or iron stores compared with ferrous sulfate.

Little is known about the expression of heme transporters in human placenta and possible associations between these transporters and maternal or neonatal iron status. To address this area of research, relative protein expression of 2 heme transporters, Feline Leukemia Virus, Subgroup C, Receptor 1 (FLVCR1) and Breast Cancer Resistance Protein (BCRP), was assessed using Western-blot analysis in human placental tissue in relation to maternal/neonatal iron status and placental iron concentration. Placental FLVCR1 (n = 71) and BCRP (n = 83) expression were assessed at term (36.6-41.7 wk gestation) in a cohort of pregnant adolescents (13-18 y of age) at high-risk of iron deficiency. Both FLVCR1 and BCRP were detected in all placental samples assayed. Placental FLVCR1 expression was positively related to placental BCRP expression (n = 69; R(2) = 0.104; P < 0.05). Adolescents that were anemic at delivery had lower placental FLVCR1 expression (n = 49; P < 0.05). Placental FLVCR1 expression was positively associated with placental iron concentration at delivery (n = 61; R(2) = 0.064; P < 0.05). In contrast, placental BCRP expression was not significantly associated with maternal iron status or placental iron content. Both FLVCR1 and BCRP are highly expressed in human placental tissue, but only FLVCR1 was significantly inversely associated with maternal iron status and placental iron concentration. Further analysis is needed to explore potential functional roles of FLVCR1 in human placental iron transport.

Background: Hepcidin is a key regulator of iron homeostasis, but to date no studies have examined the effect of hepcidin on iron absorption in humans. Objective: Our objective was to assess relations between both serum hepcidin and serum prohepcidin with nonheme-iron absorption in the presence and absence of food with the use of dual stable iron isotope techniques. Design: The study group included 18 healthy nonpregnant women. Women received in random order a supplemental iron source (7.6 mg of ferrous sulfate providing 0.9 mg of 58 Fe as ferrous sulfate) and 6.8 mg of 57 Fe ferrous sulfate tracer administered with a nonheme food source [orange-fleshed sweet potato (OFSP): 1.4 mg native iron]. Iron absorption was determined by analyzing blood samples taken 14 d after dosing with the use of magnetic sector thermal ionization mass spectrometry. Serum hepcidin was assessed by a new competitive serum enzyme-linked immunosorbent assay (ELISA) specific for the refolded, mature 25-amino acid form, and serum prohepcidin was assessed by an ELISA specific for amino acids 28‐47 of the hepcidin prohormone. Results: In these women, iron absorption averaged 14.71 6 10.7% from the supplemental iron compared with 3.63 6 6.5% from the OFSP. Absorption of nonheme iron assessed in the presence (P ¼ 0.038) and absence (P ¼ 0.0296) of food was significantly associated with serum hepcidin but was not significantly related to serum prohepcidin. Conclusion: Serum hepcidin, but not prohepcidin, was inversely associated with iron absorption from supplemental and food-based nonheme-iron sources in iron-replete healthy women. Am J Clin Nutr 2009;89:1‐6.