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We evaluated a poverty-reduction program that targeted ultra-poor women in rural Bangladesh to promote economic and social improvement through income-generating activities and strengthening socio-political awareness. We hypothesized that ultra-poor women participating in the program would have lower domestic violence and depressive symptoms and higher subjective well-being, household economic status, and food security than non-participants. A quasi-experimental design with program and comparison arms and assessments at two times (i.e., baseline and end-line) was used. Analysis of covariance with linear multilevel random-intercept models adjusted for available baseline variables was used to estimate program-comparison differences at end-line for economic status, perceived economy, food insecurity, domestic violence, depressive symptoms, and subjective well-being. We also estimated the benefits attributable to the program for subjective well-being, food insecurity, and domestic violence. Women in the program arm had greater subjective well-being with a decrease in negative affect of life by 33.5% and dissatisfaction with life by 42.5%. The women in the program arm encountered 12% or fewer incidences of domestic violence than did the women in the comparison arm. Food insecurity reduced by an average of 14% due to the program. This poverty-reduction program helped in improving women’s access to and control of resources and their social awareness, thus empowering them and promoting economic, social, and psychological well-being. Poverty-reduction programs that acknowledge and address the social complexity of extreme poverty have the potential to effectively reach the ultra-poor who otherwise are often missed by traditional microcredit programs.

OBJECTIVES: Iron deficiency (ID) and iron deficiency anaemia (IDA) remain a public health concern among women and girls globally, and have numerous impacts on health, nutrition and socioeconomic status. Our objective was to investigate the efficacy of consuming iron-fortified lentils on iron status among rural Bangladeshi adolescent girls. METHODS: In this community-based, double-blind, cluster-randomized controlled trial, girls (13.5 ± 2.0 years) were randomly assigned to three groups that received 1)cooked iron-fortified lentils (160 ppm Fe NaFeEDTA per kg of lentils); 2)cooked non-iron-fortified lentils; or 3)no lentils (usual intake group). We served 200 g of cooked lentils using a local daal recipe on five days/week, for 4 months. Iron status (sFer, sTfR, and Hgb) was assessed at baseline, 2 and 4 months. All analyses were adjusted for inflammation. RESULTS: There were no differences in baseline iron status among the three groups. sFer significantly increased by 21.9% (+5.7 μg/L, p

Panelists in Saskatoon, Canada (n= 45) and Dhaka, Bangladesh (n= 98) participated in sensory evaluations of the sensory properties of both cooked and uncooked dehulled red lentil dal fortified with FeSO4·7H2O, NaFeEDTA or FeSO4·H2O at fortificant Fe concentrations of 800, 1,600 (both cooked and uncooked), or 2,800 ppm. Appearance, odor, and overall acceptability of cooked and uncooked samples were rated using a 9‐point hedonic scale (1 = dislike extremely to 9 = like extremely). Taste and texture were rated for the cooked samples prepared as typical south Asian lentil meals. Significant differences in sensory quality were observed among all uncooked and cooked samples at both locations. Overall, scores for all sensory attributes and acceptability of uncooked lentil decreased with increasing concentration of Fe in the fortificant; however, Fe fortification (particularly with NaFeEDTA) had small effects on acceptability. Panelists from Saskatoon provided a wider range of scores than those from Bangladesh for all attributes of cooked lentil. Overall, sensory evaluation of Fe fortification using NaFeEDTA minimally affected consumer perception of color, taste, texture, odor, and overall acceptability of cooked lentil. Reliability estimates (Cronbach's alpha [CA]) indicated that consumer scores were generally consistent for all attributes of all lentil samples (mean CA > 0.80). NaFeEDTA was found to be the most suitable Fe fortificant for lentil based on consumer acceptability. Consumption of 45 to 50 g of NaFeEDTA‐fortified lentil (fortificant Fe concentration of 1,600 ppm) per day meets the estimated average requirements (EARs) of Fe for humans (10.8 to 29.4 mg). Iron fortification of dehulled lentil dal may change organoleptic attributes that can influence consumer acceptability. Sensory evaluation by consumers helps to determine the effect on appearance, odor, taste, texture, and overall acceptability of fortified lentils. In this study, consumer acceptability was evaluated with panelists who consume lentil regularly. Panelists provided significantly different scores for 5 sensory attributes for 10 uncooked and 3 cooked lentil samples. Panelists reliably preferred NaFeEDTA as the most suitable Fe fortificant for dehulled lentils for 5 attributes. Overall, lentil dal fortified with NaFeEDTA can offer a simple and low‐cost solution to human health problems associated with iron‐related malnutrition.

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

Widely consumed daal (lentils) in Bangladesh are an ideal vehicle for iron (Fe) fortification, however, an acceptable portion size in meals needs to be determined to carry out a community feeding study in at-risk adolescent girls. A non-randomized crossover trial was conducted with n = 100 Bangladeshi girls (12.9 ± 2.0 years of age). Two recipes (thin and thick) and three portion sizes (25 g, 37.5 g, 50 g of raw lentil) of daal were served with 250 g of cooked white rice in a counter-balanced manner over 12 weeks. Each meal was fed to participants 5 days/week for two weeks. Ratings of hunger, satiety, and palatability were measured before and after each meal using Visual Analog Scales (VAS). The thick preparation in the 37.5 g portion (~200 g cooked) elicited higher VAS ratings of hunger, satiety, and palatability compared to all other meals. The 50 g portion of the thin preparation had VAS ratings similar to those of the 37.5 g thick preparation. Consuming the 37.5 g portion of fortified daal would provide 6.9 mg Fe/day to girls in a community-based effectiveness study. This would meet ~86% and ~46% of the Recommended Dietary Allowance (RDA) for Fe for girls aged 9–13 and 14–18 years, respectively.

Condiments and seasonings have been considered as potential vehicles for fortification in place of, or in addition to, fortifiable staple foods. Methodologies for establishing fortification programs focus primarily on use of staple foods, which are consumed in larger portions than condiments and seasonings. Some fortification models assume self-limiting consumption relative to the maximum energy consumed by target populations. However, this assumption may prove incorrect for estimating fortification concentrations of condiments and seasonings because they may only provide negligible energy. Although flavor or color may limit consumption, these limits would vary across each condiment or seasoning vehicle. In addition, the small volume of condiments and seasonings consumed relative to staple foods can lead to proportionally larger potential errors than with staple foods when measuring usual dietary intakes for establishing safe and effective fortification concentrations. This paper reviews available methods for setting fortification levels, whether or how available methods or conceptual frameworks could be adapted to condiments and seasonings, and gaps in knowledge for appropriately using condiments and seasonings as vehicles for fortification in public health.

OBJECTIVES: Despite all efforts, iron deficiency (ID) and iron deficiency anaemia (IDA) among adolescent girls remains a public health concern for Bangladesh. The objective of the current analysis was to examine baseline data from an effectiveness trial with the aim to compare prevalence of anemia, ID and IDA with Bangladesh's National Micronutrients Status Survey 2011–12. METHODS: A community-based, double-blind, cluster randomized controlled trial is being conducted among n = 1260 Bangladeshi adolescent girls (10–17 years). Treatment groups include: 1) Fe-fortified lentils; 2) unfortified lentils and 3) usual intake (no intervention). Within the lentil groups, participants are being served 250 g cooked lentils with half a cup of cooked rice 5 days/week for 85 feeding days. All Fe-fortification and processing of lentils were carried out at the University of Saskatchewan. Anemia, ID and IDA were defined according to WHO (2011) cut-off values. RESULTS: At baseline, age of participants was 13.5 ± 2.0 years; BMI 18.2 ± 3.0 kg/m2 (or 38th percentile BMI-for-age); hemoglobin 12.4 ± 1.1 g/dL, serum ferritin 54.2 ± 36.3 ng/mL, sTfR 3.7 ± 2.6 µg/mL, and CRP 1.2 ± 3.9 mg/L. 26.6% girls were clinically anemic (non-pregnant-Hb

Mapping pathways of how interventions are implemented and utilized enables contextually grounded interpretation of results, differentiates poor design from poor implementation, and identifies factors that might influence the utilization of interventions. Few studies in nutrition have comprehensively examined the steps of implementation and utilization in behavior change communication (BCC) interventions, thus limiting the interpretation of variable impacts of BCC interventions. A program impact pathway (PIP) analysis was used to study a BCC intervention implemented in Bangladesh to improve infant and young child feeding (IYCF) practices. The PIP was developed through an iterative process with the program implementation team; the PIP then guided the choice of methods and tools. Using mixed methods, we reviewed the content of training materials for implementation staff, measured their IYCF knowledge (n = 100), observed their communication with mothers (n = 37), and examined factors influencing promotion of IYCF practices and their trial and adoption by mothers (n = 64). Implementation staff demonstrated good knowledge and maintained fidelity to the intervention to a large extent. Mothers identified them as their primary sources of information, and a majority of mothers tried recommended IYCF practices. Key facilitators included family support and availability of resources, whereas lack of time, maternal and family perceptions of age-appropriate feeding, and lack of resources were salient barriers to adopting recommended practices. Using a PIP analysis identified critical issues pertaining to implementation (e.g., the role of paid and volunteer staff) and utilization (e.g., resource and time constraints that require complementary interventions) and the need for further research and programmatic attention. J. Nutr. doi: 10.3945/jn.113.179085.

Background Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. Objective To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. Methods From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. Results Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. Conclusions Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

Adolescent girls have high nutrient needs and are susceptible to micronutrient deficiencies. The objective of this study was to test the effect of a multiple-micronutrient-fortified beverage on hemoglobin (Hb) concentrations, micronutrient status, and growth among adolescent girls in rural Bangladesh. A total of 1125 girls (Hb > or = 70 g/L) enrolled in a randomized, double-blind, placebo-controlled trial and were allocated to either a fortified or nonfortified beverage of similar taste and appearance. The beverage was provided at schools 6 d/wk for 12 mo. Concentrations of Hb and serum ferritin (sFt), retinol, zinc, and C-reactive protein were measured in venous blood samples at baseline, 6 mo, and 12 mo. In addition, weight, height, and mid-upper arm circumference (MUAC) measurements were taken. The fortified beverage increased the Hb and sFt and retinol concentrations at 6 mo (P < 0.01). Adolescent girls in the nonfortified beverage group were more likely to suffer from anemia (Hb

Background Infant feeding and caregiving by adolescent girls and young women in rural Bangladesh remains relatively understudied despite high potential vulnerability of younger mothers and their children due to poverty and high rates of early marriage and childbearing. This key knowledge gap may hamper the effectiveness of maternal, infant and child health interventions not specifically tailored to teenage mothers. This study aimed to narrow this gap by documenting key barriers to optimal infant and young child feeding and caregiving perceived by adolescent girls and young women in rural Bangladesh. Methods Focus group discussions and in-depth semi-structured interviews were conducted with 70 adolescent girls and young women participating in a community-based adolescent empowerment program in two rural regions of northwestern Bangladesh. Participants were stratified into three groups: unmarried, married without child, and married with child(ren). Thematic analysis was performed to elucidate dominant ideas regarding challenges with child feeding and caregiving across participant strata. Results Participants in all three strata and in both geographical regions attributed actual and anticipated caregiving difficulties to five major contextual factors: early marriage, maternal time allocation conflicts, rural life, short birth intervals, and poverty. Indications are that many girls and young women anticipate difficulties in feeding and caring for their future children from an early age, and often prior to motherhood. Participants articulated both perceived need and unmet demand for additional education in infant and young child feeding, childcare, and family planning techniques. Conclusions Provision during adolescence of appropriate education, services and financial aid to support best practices for infant feeding and childcare could significantly improve maternal self-efficacy, mental health, nutrition security and young childcare, nutrition and health in rural Bangladesh. Lessons learned can be applied in future programs aimed at supporting adolescent women along a continuum of care.

Background The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. Objective We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. Design The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. Results When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). Conclusions The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.

Background: Poor psychosocial health is a major global burden. A challenge to improving psychosocial health is that its associations with risk factors are complicated, inadequately understood, and difficult to modify, and/or require action outside the health sector. Objective: We capitalized on the quasi-experimental assignment of a poverty-alleviation program for the ultra-poor in Bangladesh to investigate how this program affected 2 aspects of psychosocial health; distress, (i.e., the negative cognitive appraisal of stress) and subjective well-being (i.e., satisfaction with domains of life), and the importance of food insecurity as a mediator relative to other stressors and economic status. Methods: The study was conducted in 3 northern districts of Bangladesh where the program operated. The ultra-poor households were selected through a multistage selection process. The economically better-off households were excluded during the process and included as study controls. The program supported women by providing income-earning opportunities, strengthening sociopolitical livelihood, and building self-awareness and self-confidence. Data were collected in 2006 from 209 women on demography, psychosocial health, and stressors (i.e., domestic violence, food insecurity, economic status, perceived economy, and emotional social constraints). Data collected in 2002 from the same individuals were used to control for the baseline differences between groups. By using path analysis we showed the direct and indirect effects of the program on distress and well-being. Results: The program positively affected psychosocial health by alleviating stressors. The indirect effect of the program contributed 74% in reducing distress and 30% in improving well-being. Food insecurity was by far the most important mediator, explaining 50% of indirect effect on distress and 66% of the indirect effect on well-being. Conclusion: Food insecurity is modifiable and an appropriate target for poverty-alleviation and agricultural programs. These findings suggest programmatic and policy attention to the social dimensions of poor psychosocial health, particularly to food insecurity as a central cause. J Nutr doi: 10.3945/jn.115.210799.

Background Poverty alleviation programs for the extreme poor improve participants' economic status and may impact other important outcomes that are seldom evaluated. A program targeted to the extreme poor by BRAC, a development organization in Bangladesh, has been successful in significantly alleviating extreme poverty. Objective We hypothesized that the program also improved the nutritional status of women and preschool children. Methods A nonequivalent control, pre- and posttest quasi-experimental design that was longitudinal at the village level was used to test the hypotheses. Data were collected from a random sample of 4,131 children and 3,551 women from 3,409 households in 159 villages of 3 northern districts of Bangladesh in 2002 and 2006. Linear mixed random-intercept models accounted for clustering effects and potential confounders. Results The weight-for-height of children between 24 and 35 months of age from program households was significantly higher ( p < .05) than that of children from control households. We found no significant differences between control and program households in three other growth and body-composition indicators in three other age categories of preschool children or in women. Conclusions These results are important, as this is a large-scale program that has already been extended to more than half the country. The findings will contribute to judging the cost-benefit and cost-effectiveness of the program and in garnering support for the expansion of such programs.

The WHO evidence-informed guidelines provide recommendations to Member States and their partners on interventions with vitamins and minerals. Evidence gathered and synthesized through systematic reviews contributes to the development of these guidelines, a process that is dependent on the availability and quality of evidence. Although the guideline development process is stringently governed and supervised to maintain clarity and transparency, the lack of adequacy and specificity of available evidence poses limitations to the formulation of recommendations that can be easily applied for policy and program decision making in diverse contexts. The symposium created a space for dialogue among scientists and public health practitioners to improve the understanding of how evidence fulfills the needs and reflect on mechanisms by which policy and program guidance and priorities for research could be better informed by policy and program needs. Ultimately, programmatic success depends not only on identifying efficacious agents but ensuring effective delivery to those with the potential to respond. To do this, we must understand the rationale for recommending interventions, the biological pathways by which interventions work, delivery systems required to make efficacious interventions work, and other contextual factors that might limit or facilitate successful implementation.

Background In Bangladesh, many programs and projects have been promoting breastfeeding since the late 1980 s. Breastfeeding practices, however, have not improved accordingly. Methods For identifying program-relevant issues to improve breastfeeding in infancy, quantitative data were collected through visits to households (n = 356) in rural Chittagong and urban slums in Dhaka, and qualitative data from sub-samples by applying semi-structured in-depth interviews (n = 42), focus group discussions (n = 28), and opportunistic observations (n = 21). Trials of Improved Practices (TIPs) (n = 26) were conducted in the above sites and rural Sylhet to determine how best to design further interventions. Our analysis focused on five breastfeeding practices recommended by the World Health Organization: putting baby to the breast within the first hour of birth, feeding colostrum and not giving fluids, food or other substances in the first days of life, breastfeeding on demand, not feeding anything by bottle, and exclusive breastfeeding for the first six months. Results The biggest gaps were found to be in putting baby to the breast within the first hour of birth (76% gap), feeding colostrum and not giving other fluids, foods or substances within the first three days (54% gap), and exclusive breastfeeding from birth through 180 days (90% gap). Lack of knowledge about dangers of delaying initiation beyond the first hour and giving other fluids, foods or substances, and the common perception of "insufficient milk" were main reasons given by mothers for these practices. Health workers had talked to only 8% of mothers about infant feeding during antenatal and immunization visits, and to 34% of mothers during sick child visits. The major providers of infant feeding information were grandmothers (28%). Conclusions The findings showed that huge gaps continue to exist in breastfeeding behaviors, mostly due to lack of awareness as to why the recommended breastfeeding practices are beneficial, the risks of not practicing them, as well as how to practice them. Health workers' interactions for promoting and supporting optimal breastfeeding are extremely low. Counseling techniques should be used to reinforce specific, priority messages by health facility staff and community-based workers at all contact points with mothers of young infants.