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Malnutrition in all its forms has risen on global and national agendas in recent years because of the recognition of its magnitude and its consequences for a wide range of human, social, and economic outcomes. Although the WHO, national governments, and other organizations have endorsed targets and identified appropriate policies, programs, and interventions, a major challenge lies in implementing these with the scale and quality needed to achieve population impact. This paper presents an approach to implementation science in nutrition (ISN) that builds upon concepts developed in other policy domains and addresses critical gaps in linking knowledge to effective action. ISN is defined here as an interdisciplinary body of theory, knowledge, frameworks, tools, and approaches whose purpose is to strengthen implementation quality and impact. It includes a wide range of methods and approaches to identify and address implementation bottlenecks; means to identify, evaluate, and scale up implementation innovations; and strategies to enhance the utilization of existing knowledge, tools, and frameworks based on the evolving science of implementation. The ISN framework recognizes that quality implementation requires alignment across 5 domains: the intervention, policy, or innovation being implemented; the implementing organization(s); the enabling environment of policies and stakeholders; the individuals, households, and communities of interest; and the strategies and decision processes used at various stages of the implementation process. The success of aligning these domains through implementation research requires a culture of inquiry, evaluation, learning, and response among program implementers; an action-oriented mission among the research partners; continuity of funding for implementation research; and resolving inherent tensions between program implementation and research. The Society for Implementation Science in Nutrition is a recently established membership society to advance the science and practice of nutrition implementation at various scales and in varied contexts.

Background: Stunting affects ∼25% of children <5 y of age and is associated with impaired cognitive and motor development and increased morbidity and mortality. The pathogenesis of stunting is poorly understood. Objective: The purpose of this study was to identify altered metabolic pathways associated with child stunting. Design: We measured 677 serum metabolites using liquid chromatography-tandem mass spectrometry in a cross-sectional study of 400 Malawian children aged 12-59 mo, of whom 62% were stunted. Results: A low height-for-age z score (HAZ) was associated with lower serum concentrations of 1 ) ω-3 (n-3) and ω-6 (n-6) polyunsaturated fatty acids (PUFAs), 2 ) sulfated neurosteroids, which play a role in brain development, 3 ) carnitine, a conditionally essential nutrient with an important role in the carnitine shuttle for the metabolism of fatty acids and energy production, and 4 ) γ-glutamyl amino acids, which represent an altered γ-glutamyl cycle of glutathione metabolism. A low HAZ was associated with significantly higher serum concentrations of 5 biomarkers related to cigarette smoke exposure. Conclusions: This metabolomics study shows a cross-sectional association between stunting and low serum ω-3 and ω-6 long-chain PUFAs, which are essential for growth and development; low sulfated neurosteroids, which play a role in brain development; low carnitine, which is essential for β-oxidation of fatty acids; alterations in glutathione metabolism; and increased serum metabolites that are associated with secondhand tobacco smoke exposure. This trial was registered at www.controlled-trials.com as ISRCTN14597012., (© 2017 American Society for Nutrition.)

Background: Despite a high prevalence of anemia among nonpregnant Cambodian women, current reports suggest that iron deficiency (ID) prevalence is low. If true, iron supplementation will not be an effective anemia reduction strategy. Objective: We measured the effect of daily oral iron with or without multiple micronutrients (MMNs) on hemoglobin concentration in nonpregnant Cambodian women screened as anemic. Design: In this 2 × 2 factorial, double-blind, randomized trial, nonpregnant women (aged 18-45 y) with hemoglobin concentrations ≤117 g/L (capillary blood) were recruited from 26 villages in Kampong Chhnang province and randomly assigned to receive 12 wk of iron (60 mg; Fe group), MMNs (14 other micronutrients; MMN group), iron plus MMNs (Fe+MMN group), or placebo capsules. A 2 × 2 factorial intention-to-treat analysis with the use of a generalized mixed-effects model was used to assess the effects of iron and MMNs and the interaction between these factors. Results: In July 2015, 809 women were recruited and 760 (94%) completed the trial. Baseline anemia prevalence was 58% (venous blood). Mean (95% CI) hemoglobin concentrations at 12 wk in the Fe, MMN, Fe+MMN, and placebo groups were 121 (120, 121), 116 (116, 117), 123 (122, 123), and 116 (116, 117) g/L, with no iron × MMN interaction ( P = 0.66). Mean (95% CI) increases in hemoglobin were 5.6 g/L (3.8, 7.4 g/L) ( P < 0.001) among women who received iron ( n = 407) and 1.2 g/L (-0.6, 3.0 g/L) ( P = 0.18) among women who received MMNs ( n = 407). The predicted proportions (95% CIs) of women with a hemoglobin response (≥10 g/L at 12 wk) were 19% (14%, 24%), 9% (5%, 12%), 30% (24%, 35%), and 5% (2%, 9%) in the Fe, MMN, Fe+MMN, and placebo groups, respectively. Conclusions: Daily iron supplementation for 12 wk increased hemoglobin in nonpregnant Cambodian women; however, MMNs did not confer additional significant benefit. Overall, ∼24% of women who received iron responded after 12 wk; even fewer would be likely to respond in the wider population. This trial was registered at clinicaltrials.gov as NCT02481375., (© 2017 American Society for Nutrition.)

Background: Environmental enteric dysfunction (EED), a condition characterized by small intestine inflammation and abnormal gut permeability, is widespread in children in developing countries and a major cause of growth failure. The pathophysiology of EED remains poorly understood., Methods: We measured serum metabolites using liquid chromatography-tandem mass spectrometry in 400 children, aged 12-59months, from rural Malawi. Gut permeability was assessed by the dual-sugar absorption test., Findings: 80.7% of children had EED. Of 677 serum metabolites measured, 21 were negatively associated and 56 were positively associated with gut permeability, using a false discovery rate approach (q<0.05, p<0.0095). Increased gut permeability was associated with elevated acylcarnitines, deoxycarnitine, fatty acid β-oxidation intermediates, fatty acid ω-oxidation products, odd-chain fatty acids, trimethylamine-N-oxide, cystathionine, and homocitrulline, and with lower citrulline, ornithine, polyphenol metabolites, hippurate, tryptophan, and indolelactate., Interpretation: EED is a syndrome characterized by secondary carnitine deficiency, abnormal fatty acid oxidation, alterations in polyphenol and amino acid metabolites, and metabolic dysregulation of sulfur amino acids, tryptophan, and the urea cycle. Future studies are needed to corroborate the presence of secondary carnitine deficiency among children with EED and to understand how these metabolic derangements may negatively affect the growth and development of young children., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Stunting is the best summary measure of chronic malnutrition in children. Approximately one-quarter of children under age 5 worldwide are stunted. Lipid-based or micronutrient supplementation has little to no impact in reducing stunting, which suggests that other critical dietary nutrients are missing. A dietary pattern of poor-quality protein is associated with stunting. Stunted children have significantly lower circulating essential amino acids than do nonstunted children. Inadequate dietary intakes of essential amino acids could adversely affect growth, because amino acids are required for synthesis of proteins. The master growth regulation pathway, the mechanistic target of rapamycin complex 1 (mTORC1) pathway, is exquisitely sensitive to amino acid availability. mTORC1 integrates cues such as nutrients, growth factors, oxygen, and energy to regulate growth of bone, skeletal muscle, nervous system, gastrointestinal tract, hematopoietic cells, immune effector cells, organ size, and whole-body energy balance. mTORC1 represses protein and lipid synthesis and cell and organismal growth when amino acids are deficient. Over the past 4 decades, the main paradigm for child nutrition in developing countries has been micronutrient malnutrition, with relatively less attention paid to protein. In this Perspective, we present the view that essential amino acids and the mTORC1 pathway play a key role in child growth. The current assumption that total dietary protein intake is adequate for growth among most children in developing countries needs re-evaluation., Competing Interests: 3 Author disclosures: RD Semba, I Trehan, M Gonzalez-Freire, K Kraemer, R Moaddel, MI Ordiz, L Ferrucci, and MJ Manary, no conflicts of interest., (© 2016 American Society for Nutrition.)

Fortification programs are considered to be an effective strategy to mitigate vitamin A deficiency in populations at risk. Fortified vegetable oils rich in polyunsaturated fatty acids were shown to be prone to oxidation, leading to limited vitamin A stability. Thus, it was hypothesized that fortified oils consisting of mainly saturated fatty acids might enhance the stability of vitamin A. Mildly (peroxide value: 1.0 meq O₂/kg) and highly (peroxide value: 7.5 meq O₂/kg) oxidized palm oil was stored, after fortification with 60 International Units/g retinyl palmitate, in 0.5 L transparent polyethylene terephthalate bottles under cold fluorescent lighting (12 h/day) at 32 °C for 57 days. An increase of the peroxide value by 15 meq O₂/kg, which was also reflected by a decrease of α-tocopherol congener by 15%-18%, was determined independent of the initial rancidity. The oxidative deterioration of the highly oxidized palm oil during storage was correlated with a significant 46% decline of the vitamin A content. However, household storage of mildly oxidized palm oil for two months did not induce any losses of vitamin A. Thus, mildly oxidized palm oil may be recommended for vitamin A fortification programs, when other sources of essential fatty acids are available.

Background: Stunting affects about one-quarter of children under five worldwide. The pathogenesis of stunting is poorly understood. Nutritional interventions have had only modest effects in reducing stunting. We hypothesized that insufficiency in essential amino acids may be limiting the linear growth of children., Methods: We used a targeted metabolomics approach to measure serum amino acids, glycerophospholipids, sphingolipids, and other metabolites using liquid chromatography-tandem mass spectrometry in 313 children, aged 12-59months, from rural Malawi. Children underwent anthropometry., Findings: Sixty-two percent of the children were stunted. Children with stunting had lower serum concentrations of all nine essential amino acids (tryptophan, isoleucine, leucine, valine, methionine, threonine, histidine, phenylalanine, lysine) compared with nonstunted children (p<0.01). In addition, stunted children had significantly lower serum concentrations of conditionally essential amino acids (arginine, glycine, glutamine), non-essential amino acids (asparagine, glutamate, serine), and six different sphingolipids compared with nonstunted children. Stunting was also associated with alterations in serum glycerophospholipid concentrations., Interpretation: Our findings support the idea that children with a high risk of stunting may not be receiving an adequate dietary intake of essential amino acids and choline, an essential nutrient for the synthesis of sphingolipids and glycerophospholipids., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Nearly all countries in the world today are burdened with malnutrition, manifesting as undernutrition, micronutrient deficiencies, and/or overweight and obesity. Despite some progress, efforts to alleviate malnutrition are hampered by a shortage in number, skills, and geographic coverage, of a workforce for nutrition. Here, we report the findings of the Castel Gandolfo workshop, a convening of experts from diverse fields in March 2014 to consider how to develop the capacity of a global cadre of nutrition professionals for the post-2015 development era. Workshop participants identified several requirements for developing a workforce for nutrition, including an ability to work as part of a multisectoral team; communication, advocacy, and leadership skills to engage decision makers; and a set of technical skills to address future challenges for nutrition. Other opportunities were highlighted that could immediately contribute to capacity development, including the creation of a consortium to link global North and South universities, online training modules for middle managers, and practical, hands-on experiences for frontline nutrition workers. Institutional and organizational support is needed to enable workshop recommendations on education and training to be effectively implemented and sustained. The findings from the Castel Gandolfo workshop can contribute to the delivery of successful nutrition-relevant actions in the face of mounting external pressures and informing and attaining the forthcoming Sustainable Development Goals., (© 2015 American Society for Nutrition.)

We report the fatty acid composition, and in particular, the n-3 and n-6 long-chain polyunsaturated fatty acids (LCPUFA), in erythrocytes from a convenience sample of 158 women and 135 schoolchildren residing in the southern Pacific Coast of Guatemala. Erythrocyte fatty acids were analyzed by gas-liquid chromatography with flame ionization detection and the profiles were expressed as a weight percent; the Omega-3 Index values were also determined. Schoolchildren had significantly higher mean ARA and total n-6 fatty acid levels than the women. Women had significantly higher EPA fatty acid levels than schoolchildren, but the reverse was true for DHA. For mean total n-3 fatty acid concentration, women and schoolchildren had similar values. The red cell weight percentages of selected fatty acids were also similar in women and schoolchildren. As compared with erythrocyte fatty acid data from developed countries, Guatemalan women and schoolchildren had consistently lower LCPUFA values. The traditional diet of Guatemalans living in the Pacific coastal region provided a worse erythrocyte fatty acid profile than that typically obtained from a Western diet. Additional fatty acid composition studies with associated dietary intake data in other inland locations may be useful for the interpretation of the nutritional status of Guatemalan children and adults., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Worldwide approximately two billion people have a diet insufficient in micronutrients. Even in the developed world, an increasing number of people consume nutrient-poor food on a regular basis. Recent surveys in Western countries consistently indicate inadequate intake of nutrients such as vitamins and minerals, compared to recommendations. The International Osteoporosis Foundation's (IOF) latest figures show that globally about 88% of the population does not have an optimal vitamin D status. The Lancet's "Global Burden of Disease Study 2010" demonstrates a continued growth in life expectancy for populations around the world; however, the last decade of life is often disabled by the burden of partly preventable health issues. Compelling evidence suggests that improving nutrition protects health, prevents disability, boosts economic productivity and saves lives. Investments to improve nutrition make a positive contribution to long-term national and global health, economic productivity and stability, and societal resilience.

Oil fortification with retinyl palmitate is intended to lower the prevalence of vitamin A deficiency in populations at risk. Although the stability of vitamin A in vegetable oil has been shown to depend on environmental factors, very little information is known about the stability of vitamin A in preoxidized vegetable oils. The present study investigated the stability of retinyl palmitate in mildly oxidized (peroxide value < 2 mequiv O2/kg) and highly oxidized (peroxide value > 10 mequiv O2/kg) soybean oil stored under domestic and retail conditions. Soybean oil was filled in transparent bottles, which were exposed to cold fluorescent light at 22 or 32 °C for 56 days. Periodic oil sampling increased the headspace, thereby mimicking consumer handling. Loss of retinyl palmitate in soybean oil by a maximum of 84.8 ± 5.76% was accompanied by a decrease of vitamin E by 53.3 ± 0.87% and by an increase of the peroxide value from 1.20 ± 0.004 to 24.3 ± 0.02 mequiv O2/kg. Fortification of highly oxidized oil with 31.6 IU/g retinyl palmitate led to a doubling of the average decrease of retinol per day compared to fortification of mildly oxidized oil. In conclusion, oil fortification programs need to consider the oxidative status of the oil used for retinyl palmitate fortification.

Light, temperature, and oxygen availability has been shown to promote rancidity in vegetable oils. However, the contribution of each of these environmental factors to lipid oxidation in oil stored under household conditions is not known. We aimed to identify the major inducer of oxidative deterioration of soybean oil stored at constant (67.0 mL) or increasing (67.0-283 mL) headspace volume, 22 or 32 °C, with or without illumination by cold fluorescent light for 56 days by means of fatty acid composition, peroxide value, formation of conjugated dienes, lipid radicals, hexanal, and the decrease in the contents of tocopherols. Soybean oil stored in the dark for 56 days showed an increase of the peroxide value by 124 ± 0.62% (p = 0.006), whereas exposure of the oil to light in a cycle of 12 h light alternating with 12 h darkness for 56 days led to a rise of the peroxide value by 1473 ± 1.79% (p ≤ 0.001). Little effects on the oxidative status of the oil were observed after elevating the temperature from 22 to 32 °C and the headspace volume from 67.0 to 283 mL during 56 days of storage. We conclude that storing soybean oil in transparent bottles under household conditions might pose an increased risk for accelerated lipid oxidation induced by exposure to cold fluorescent light.

Background: The current approaches to assess growth are limited to anthropometry, are insensitive and nonspecific, and do not enable an improved understanding of how nutrition might impact growth. Consequently, new tools to develop better standards of care and programs to address ongoing concerns about nutrition and health are needed., Methods: The Biomarkers of Nutrition for Development (BOND) project is designed to support the discovery, development, and use of current and new biomarkers of nutritional exposure, status, function, and effect. The Biomarkers in Growth (BIG) project was initiated as a BOND program to develop a roadmap for moving the nutrition and growth agenda forward. The first step in this project was a session jointly organized by the BOND Secretariat and Sight and Life at the 20th International Congress on Nutrition in Granada, Spain., Results: The BIG session outlined current approaches to evaluating growth and understanding of the role of nutrition in linear growth, body composition, and long-term health outcomes and the potential role of systems biology in the assessment of the nutrition-growth relationship., Conclusion: The session presentations and deliberations highlighted the need for a concerted effort to address the critical gaps in our understanding of the biology and assessment of growth.

Background: Many developing countries now face the double burden of malnutrition, defined as the coexistence of a stunted child and overweight mother within the same household., Objective: This study sought to estimate the prevalence of the double burden of malnutrition and to identify associated maternal, child, and household characteristics in rural Indonesia and Bangladesh., Design: A total of 247,126 rural households that participated in the Indonesia Nutrition Surveillance System (2000-2003) and 168,317 rural households in the Bangladesh Nutritional Surveillance Project (2003-2006) were included in the analysis. Maternal and child double burden (MCDB) and its association with individual and household characteristics were determined by using logistic regression models., Results: MCDB was observed in 11% and 4% of the households in rural Indonesia and Bangladesh, respectively. Maternal short stature [Indonesia (OR: 2.32; 95% CI: 2.25, 2.40); Bangladesh (OR: 2.11; 95% CI: 1.96, 2.26)], and older age were strong predictors of MCDB. Child characteristics such as older age and being female were associated with an increased odds of MCDB, whereas currently being breastfed was protective against MCDB [Indonesia (OR: 0.84; 95% CI: 0.81, 0.84); Bangladesh (OR: 0.55; 95% CI: 0.52, 0.58)]. A large family size and higher weekly per capita household expenditure predicted MCDB [Indonesia (OR: 1.34; 95% CI: 1.28, 1.40); Bangladesh (OR: 1.94; 95% CI: 1.77, 2.12)]., Conclusions: Double burden is not exclusive to urban areas. Future policies and interventions should address under- and overweight simultaneously in both rural and urban developing country settings.

The workshop involved key researchers from academic and development organizations reviewing what we have learned about multiple micronutrients and applying that knowledge to providing guidance to public health policy and program design. The participants highlighted the importance of evidence-based interventions, not to restrict evidence slanted toward one single origin but to appreciate the totality of evidence from history, epidemiology, basic science, randomized-controlled studies, and meta-analyses to inform policy and guideline development for the implementation of effective programs. It has to be understood and accepted that although the need for an evidence-based approach to nutritional recommendations is fundamental and cannot be disputed, there are distinct differences between evidence-based medicine and evidence-based nutrition practice. The level of confidence and certainty needed to launch programs to reduce micronutrient deficiencies can be different from what is required to treat a disease. An effective approach would be to ensure that both research and programs at scale are running in parallel and that both receive adequate attention and funding to fine tune the program or stop it when it is no longer required. There was much valuable discussion on the topic of what types of research methodologies are suitable for what type of intervention and, importantly, what is required before public health policy can be set. This paper is an introduction to a series of articles in this supplement that discuss the evidence on multiple micronutrients and what is required to establish policies and launch effective multiple micronutrient programs.

The efficacy of micronutrient powders (MNP) in the treatment of anemia in moderately anemic children aged 6-24 mo has been clearly demonstrated. The evidence of the effectiveness of MNP in large-scale programs, however, is scarce. This article describes the program experience and findings of large-scale MNP distribution in refugee camps and in an emergency context in Bangladesh, Nepal, and Kenya. The MNP contained 15-16 micronutrients as per the WHO/World Food Programme/UNICEF joint statement, whereas the iron content was reduced to 2.5 mg from NaFeEDTA in a malaria-endemic area in Kenya. Hundreds of thousands of children aged 6-59 mo and pregnant and lactating women were targeted to consume MNP either daily or every other day over an extended period of time. Extensive social marketing campaigns were undertaken to promote regular use of the product. A number of studies were embedded in the programs to assess the impact of MNP on the nutritional status of target beneficiaries. Some improvements in anemia prevalence estimates were observed in particular subgroups, but other results did not show significant improvements. A significant decrease in the prevalence of stunting was observed in Nepal and Kenya but not in Bangladesh. Diarrhea episodes decreased significantly among children receiving MNP in Nepal. A key challenge is to ensure high MNP acceptance and adherence among beneficiaries. Investigation of non-nutritional causes of anemia is warranted in settings with high compliance but no improvement in hemoglobin status. Further investigation into the most appropriate manner to use MNP in malaria endemic settings is warranted.

Background: Stunting is highly prevalent in developing countries and is associated with greater morbidity and mortality. Micronutrient deficiencies contribute to stunting, and micronutrient-fortified foods are a potential strategy to reduce child stunting., Objective: To examine the relationship between the use of fortified powdered milk and noodles and child stunting in a large, population-based sample of Indonesian children., Methods: Consumption of fortified milk and fortified noodles was assessed in children 6 to 59 months of age from 222,250 families living in rural areas and 79,940 families living in urban slum areas in Indonesia., Results: The proportions of children who consumed fortified milk and fortified noodles were 34.0% and 22.0%, respectively, in rural families, and 42.4% and 48.5%, respectively, in urban families. The prevalence of stunting among children from rural and urban families was 51.8% and 48.8%, respectively. Children from rural and urban families were less likely to be stunted if they consumed fortified milk (in rural areas, OR = 0.87; 95% CI, 0.85 to 0.90; p < .0001; in urban areas, OR = 0.80; 95% CI, 0.76 to 0.85; p < .0001) or fortified noodles (in rural areas, OR = 0.95; 95% CI, 0.91 to 0.99;p = .02; in urban areas, OR = 0.95; 95% CI, 0.91 to 1.01; p = .08) in multiple logistic regression models adjusted for potential confounders. In both rural and urban families, the odds of stunting were lower when a child who consumed fortified milk also consumed fortified noodles, or when a child who consumed fortified noodles also consumed fortified milk., Conclusions: The consumption of fortified milk and noodles is associated with decreased odds of stunting among Indonesian children. These findings add to a growing body of evidence regarding the potential benefits of multiple micronutrient fortification on child growth.

Background: Home fortification with micronutrient powder has been shown to be a low-cost, feasible, and effective approach to address micronutrient deficiencies. A large-scale program distributing micronutrient powder to approximately 50,000 refugees was implemented at the Kakuma Refugee Camp in Kenya. Uptake of the micronutrient powder at distribution points dropped nearly 70%,from 99% to a low of 30%, and remained at 45% to 52% despite increased social marketing efforts., Objective: To identify factors at the distal and proximal levels leading to the low uptake of micronutrient powder through a qualitative inquiry., Methods: In-depth interviews were conducted with community leaders, stakeholders, implementing partners, and beneficiaries. Direct observations of food preparation and child feeding were conducted. Focus group discussions were employed to examine perceptions and practices of beneficiaries regarding micronutrient powder use., Results: Superficial formative research and lack of interagency coordination led to insufficient social marketing prior to the program. In addition, community health workers were inadequately trained. This resulted in inadequate communication regarding the health benefits and use of micronutrient powder to the beneficiaries. Reliance on personal experiences with micronutrient powder and issues with its packaging, in part, led to confusion and deleterious rumors, resulting in decreased uptake of micronutrient powder at distribution points., Conclusions: A successful micronutrient powder program requires careful design, with emphasis on conducting thorough formative research, ensuring the involvement and commitment of all stakeholders from the outset, investigating the role of cultural factors, and ensuring provision of sufficient, adequate, and timely information to the beneficiaries.

Background: Micronutrient powder has been endorsed as an effective means to improve the micronutrient status of emergency-affected populations., Objective: To document the experience and findings of a cross-sectional assessment of the micronutrient powder program implemented as part of the emergency response to Cyclone Sidr., Methods: Micronutrient powder was distributed to 100,714 children under 5 years of age and 59,439 pregnant or lactating women severely affected by Cyclone Sidr in Bangladesh. A cross-sectional assessment, including hemoglobin and anthropometric measurements, was conducted after the completion of the micronutrient powder program among children under 5 years of age, lactating mothers, and postmenarcheal adolescent girls in the intervention area. Comparison groups for each, drawn from the control area, which had not received micronutrient powder, were assessed at the same time., Results: The prevalence of anemia among children under 5 years of age was approximately 80% in both areas. Among children in the intervention area, those who consumed at least 75% of the micronutrient powder sachets had a lower prevalence of stunting than those who consumed less than 75% of the sachets (40% vs. 52%, p < .05). Among lactating mothers in the intervention area, the prevalence rates of thinness and anemia were lower among those who consumed at least 75% of the sachets than among those who consumed less than 75% of the sachets (thinness, 31% vs. 46%, p < .05; anemia, 50% vs. 61%, p = .07). For adolescent girls in the intervention and control areas, none of whom had received micronutrient powder, the prevalence rates of anemia were 52% and 45%, respectively (p = .05)., Conclusions: Micronutrient powder may reduce anemia among lactating mothers, when the compliance rate is high. Anemia prevalence prior to micronutrient powder distribution had not been investigated and could have been higher among children and lactating mothers in the intervention than in the control area, resulting in the negation of the potential positive impact of micronutrient powder on anemia.

Background: Micronutrient powder is a potential strategy to improve iron status and reduce anemia in refugee populations., Objective: To evaluate the effect of the availability of home fortification with a micronutrient powder containing 2.5 mg of sodium iron ethylenediaminetetraacetate (NaFeEDTA) on iron status and hemoglobin in women and children in the Kakuma Refugee Camp in northwest Kenya., Methods: Hemoglobin and soluble transferrin receptor were measured in 410 children 6 to 59 months of age and 458 women of childbearing age at baseline (just before micronutrient powder was distributed, along with the regular food ration) and at midline (6 months) and endline (13 months)follow-up visits., Results: At the baseline, midline, and endline visits, respectively, the mean (+/- SE) hemoglobin concentration in women was 121.4 +/- 0.8, 120.8 +/- 0.9, and 120.6 +/- 1.0 g/L (p = .42); the prevalence of anemia (hemoglobin < 120 g/L) was 42.6%, 41.3%, and 41.7% (p = .92); and the mean soluble transferrin receptor concentration was 24.1 +/- 0.5, 20.7 +/- 0.7, and 20.8 +/- 0.7 nmol/L (p = .0006). In children, the mean hemoglobin concentration was 105.7 +/- 0.6, 109.0 30322 1.5, and 105.5 +/- 0.3 g/L (p = .95), respectively; the prevalence of anemia (hemoglobin < 110 g/L) was 55.5%, 52.3%, and 59.8% (p = .26); and the mean soluble transferrin receptor concentration was 36.1 +/- 0.7, 29.5 +/- 1.9, and 28.4 +/- 3.2 nmol/L (p = .02), in models that were adjusted for age using least squares means regression., Conclusions: In children and in women of childbearing age, the availability of micronutrient powder was associated with a small improvement in iron status but no significant change in hemoglobin in this refugee camp setting.

We characterized the relationship of the presence of an improved latrine with diarrhea and under-five child mortality in Indonesia. The proportion of rural and urban families, respectively, without an improved latrine was 52.1% and 16.2%, with a child with a history of diarrhea in the last 7 days was 8.2% and 9.7%, and with a history of under-five child mortality was 11.1% and 8.5%. Among rural and urban families, respectively, lack of an improved latrine was associated with a child history of diarrhea in the last 7 days (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.18-1.29, P < 0.0001; OR = 1.20, 95% CI = 1.13-1.27, P < 0.0001) and under-five child mortality (OR = 1.29, 95% CI = 1.25-1.31, P < 0.0001; OR = 1.22, 95% CI = 1.12-1.32, P < 0.0001) in separate multivariable logistic regression models adjusting for covariates. The lack of a household improved latrine is associated with diarrhea and under-five child mortality in Indonesia.

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesia's rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

In Bangladesh, poor rural families often deal with high food costs by purchasing primarily rice. Our objective was to characterize the relationship between household expenditure on rice and nonrice foods with maternal and child malnutrition. Food expenditure data and anthropometry were obtained in a population-based sample of 304,856 households in the Bangladesh Nutrition Surveillance Project, 2000-2005. Food expenditures were categorized as rice and nonrice foods and expressed as quintiles of proportional food expenditure. Of children aged 6-11, 12-23, and 24-59 mo, the prevalence of stunting was 33.5, 56.3, and 53.1%, respectively. The prevalence of maternal underweight (BMI < 18.5 kg/m(2)) was 37.3%. Among children aged 6-11, 12-23, and 24-59 mo, rice expenditures were associated with stunting [odds ratio (OR) 1.11, 95% CI 1.02-1.20, P = 0.01; OR 1.09, 95% CI 1.04-1.13, P < 0.0001; OR 1.13, 95% CI 1.08-1.18, P < 0.0001), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders, and nonrice food expenditures were associated with stunting (OR 0.87, 95% CI 0.80-0.95, P = 0.002; OR 0.86, 95% CI 0.83-0.90, P < 0.0001; OR 0.89, 95% CI 0.85-0.94, P < 0.0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. In the highest compared with the lowest quintile, rice expenditures (OR 1.12, 95% CI 1.08-1.15, P < 0.0001) and nonrice food expenditures (OR 0.93, 95% CI 0.90-0.96, P < 0.0001) were associated with maternal underweight. Households that spent a greater proportion on nonrice foods and less on rice had a lower prevalence of maternal and child malnutrition.

The global food supply system is facing serious new challenges from economic and related crises and climate change, which directly affect the nutritional well-being of the poor by reducing their access to nutritious food. To cope, vulnerable populations prioritize consumption of calorie-rich but nutrient-poor food. Consequently, dietary quality and eventually quantity decline, increasing micronutrient malnutrition (or hidden hunger) and exacerbating preexisting vulnerabilities that lead to poorer health, lower incomes, and reduced physical and intellectual capabilities. This article introduces the series of papers in this supplement, which explore the relationships between crises and their cumulative impacts among vulnerable populations, particularly through hidden hunger.

Vitamin A deficiency (VAD) is a major health problem, particularly in low-resource countries, putting an estimated 125-130 million preschool-aged children at increased risk of morbidity and mortality from infectious diseases. Vitamin A supplementation reduces VAD and increases child survival; it is complemented by fortifying foods with vitamin A. Concern over increased risk of bone fracture associated with vitamin A intakes below the tolerable upper intake level (UL) among populations in affluent countries conflicts with the need to increase intakes in less developed countries, where populations are at greater risk of VAD and intakes are unlikely to reach the UL as diets include fewer foods containing retinol while vitamin A from carotenoids poses no risk of overdose. With the implementation of recently developed risk management tools, vitamin A can be used safely in food fortification, including point-of-use fortification in the context of supplementation among specific target groups in low-resource countries.

Background: Oxidative stress has been implicated in the pathogenesis of chronic diseases related to aging such as cancer and cardiovascular disease. Carotenoids could be a part of a protective strategy to minimize oxidative damage in vulnerable populations, such as the elderly., Objective: Our aim was to determine the protective effect of carotenoids against DNA damage., Design: A randomized, double-blind, placebo-controlled intervention study was conducted. Thirty-seven healthy, nonsmoking postmenopausal women aged 50-70 y were randomly assigned to 1 of 5 groups and were instructed to consume a daily dose of mixed carotenoids (beta-carotene, lutein, and lycopene; 4 mg each), 12 mg of a single carotenoid (beta-carotene, lutein, or lycopene), or placebo for 56 d. Plasma carotenoid concentrations were analyzed by using HPLC, and lymphocyte DNA damage was measured by using a single-cell gel electrophoresis (comet) assay., Results: At day 57, all carotenoid-supplemented groups showed significantly lower endogenous DNA damage than at baseline (P < 0.01), whereas the placebo group did not show any significant change. Significantly less (P < 0.05) endogenous DNA damage was found as early as day 15 in the mixed carotenoid (P < 0.01) and beta-carotene (P < 0.05) groups., Conclusions: The results indicate that carotenoid supplementation decreases DNA damage and that a combination of carotenoids (4 mg each of lutein, beta-carotene, and lycopene), an intake that can be achieved by diet, or a larger dose (12 mg) of individual carotenoids exerts protection against DNA damage.

A robust database shows that dietary supplements of vitamins E and C are safe for the general population. Because these nutrients supply antioxidant and other functions for homeostasis and protection against free radical damage, supplementation has been intensively studied. Because of perceived benefits, many persons consume quantities of vitamins E and C well above the recommended dietary allowances. As safety guidance, tolerable upper intake levels have been established by the Food and Nutrition Board, Institute of Medicine, at 1000 mg for vitamin E and 2000 mg for vitamin C in adults. Many clinical trials with these vitamins have involved subjects with various diseases, and no consistent pattern of adverse effects has occurred at any intake. Numerous studies of vitamin C supplementation have provided no pattern of evidence to support concerns about safety other than occasional gastrointestinal upset or mild diarrhea resulting from the osmotic effects of unabsorbed quantities of vitamin C. Evidence of bleeding effects and other potential adverse effects of high vitamin E intakes in humans is not convincing. Evidence of adverse effects of vitamin C that result from its effects on iron absorption and metabolism has not been confirmed in clinical trials. Thus, we conclude from clinical trial evidence that vitamin E supplements appear safe for most adults in amounts

In human skin, highest alpha-tocopherol levels are found in facial sebum. We hypothesized that the bioavailability of vitamin E in human skin is, at least in part, dependent on sebaceous gland secretion. To test this, 24 volunteers were subjected to a randomized daily supplementation with either 400 mg RRR-alpha-tocopheryl acetate (RRR-alpha-toc) or 400 mg all-rac-alpha-tocopheryl acetate (all-rac-alpha-toc) for 14 days. Fasting blood samples, facial sebum samples, and lower-arm skin-surface lipids (SSL) were taken at time-points between 0-21 days. Samples were analyzed by HPLC for alpha-tocopherol and squalene concentrations. Increased serum alpha-tocopherol levels were detectable as early as 12 h after supplementation of RRR-alpha-toc or all-rac-alpha-toc and peaked on day 7. No significant changes were observed in lower-arm SSL. Remarkably, while unchanged until day 14, alpha-tocopherol sebum levels were increased on day 21 in both the RRR-alpha-toc and the all-rac-alpha-toc group by 87% and 92%, respectively. With respect to dietary supplementation of vitamin E and its bioavailability in human skin, these results suggest that (1) sebaceous gland secretion is a relevant delivery mechanism; (2) the bioavailabilities of RRR-alpha-toc and the all-rac-alpha-toc are similar; and (3) significant accumulation requires a daily supplementation period of at least 2-3 weeks.

Growing female obese Zucker (fa/fa) rats were treated (via intragastric gavage) for 21 d with either a (i) vehicle [corn oil; 0.9 g/kg body weight (BW)], (ii) CLA mixture [50:50; trans-10, cis-12 and cis-9, trans-11 CLA], (iii) cis-9,trans-11 CLA, or (iv) trans- 10, cis-12 CLA (CLA treatments at 1.5 g CLA/kg BW). Compared with controls, average daily gain (g/d) was reduced 24 and 44% by the CLA mixture and trans-10, cis-12 CLA, respectively. There was no treatment effect on average whole-body (minus heart and liver) composition (dry matter basis): fat (70.2%), protein (21.0%), and ash (4.3%). Compared with animals treated with cis-9,trans-11 CLA, obese Zucker rats treated with trans-10, cis-12 and the CLA mixture had 7.8% more carcass water. Treatment had no effect on heart or liver weights or on heart or liver weights as a percentage of body weight, but compared with the other treatments trans-10, cis-12 CLA increased liver lipid content by 33%. Hepatic lipid ratios of 16:1/16:0 and 18:1/18:0 (a proxy for delta9-desaturase capability) were not affected by treatment (0.1 and 0.6, respectively). Similar to previous reports, CLA increased hepatic lipid content and altered both liver and carcass FA composition (i.e., reduced arachidonic acid content), but the ability of CLA to manipulate body composition in obese Zucker rats remains questionable.