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Objective: Few studies have examined the effects of the COVID-19 pandemic on mental health among young people in sub-Saharan Africa and particularly pregnant and parenting adolescents exposed to multiple stressors. Our study addresses this gap by examining self-report of mental health challenges among pregnant and parenting adolescent girls during the pandemic. Methods: We undertook a cross-sectional survey involving 666 girls aged 13-19 in Blantyre district, southern Malawi, between March and May 2021. We recruited eligible respondents from households in 66 randomly selected rural (26) and urban (40) enumeration areas. Mental distress was assessed using nine symptoms including worry, restlessness, fear, anxiety, sadness, loneliness, frustration, fear, stress, and boredom. Girls were asked whether they experienced more of these symptoms after the start of the COVID-19 pandemic. Any girl experiencing one of these symptoms was considered to have experienced mental distress. Bivariate and multivariable regression models were used to examine correlates of mental distress. Findings: Girls’ median age was 18 years with a range of 13-19 years. Most girls (68.3%) reported having experienced somewhat more or much more mental distress, with 17.6% indicating all nine symptoms. In the adjusted model, pregnant and parenting girls aged 19 were more likely to report having experienced more mental distress (OR=1.79; 95% CI 1.15 – 2.77) during the pandemic compared to those aged 13-17 years. Similarly, girls who had ever worked had a higher likelihood of experiencing more mental distress (AOR:1.65; 95% CI 1.12 – 2.41) than before the pandemic. On the contrary, perceived neighborhood safety was protective against mental distress (OR=0.81 95% CI 0.69 – 0.95 pConclusion: Pregnant and parenting adolescent girls' mental health was adversely affected by the COVID-19 pandemic, thereby exacerbating their vulnerabilities and increasing risk of poor mental health. Our findings could inform interventions targeting adolescents’ mental health during pandemics.

Background High fertility rates and low modern contraceptive use put African youth and adolescents at high risk for health complications, including maternal mortality. Mainstreaming youth-friendly health services (YFHS) into existing services is one approach to improve access to reproductive health services for youth and adolescents. The objective of the evaluation was to assess the effects of a Population Services International (PSI)-sponsored YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and trained healthcare providers in Malawi. Methods In 2018, a mixed-methods convergent parallel design was used to assess relevant monitoring and evaluation documents and service statistics from PSI Malawi and qualitative data on perceptions of service quality from Malawian youth and healthcare providers. The data were assessed through separate descriptive and thematic analysis and integrated to generate conclusions. Results Results show that the number of family planning clients ages 15–24 increased from 72 to 2278 per quarter during the implementation of the YFHS training packages, however, positive trends in client numbers were not sustained after youth outreach activities ended. Focus group discussions with 70 youth and adolescents indicated that clinics were perceived as providing high-quality services to youth. The main barriers to accessing the services were cost and embarrassment. Interviews with ten healthcare providers indicated that many made efforts to improve clinic accessibility and understood the barrier of cost and importance of outreach to youth and the broader community. Conclusions The findings support research showing positive effects of mainstreaming YFHS when training for healthcare staff is combined with additional YFHS programming components. Furthermore, the findings provide evidence that provider training alone, though beneficial to perceived service quality, is not sufficient to sustain increases in the number of adolescent and youth family planning clients.

To address the increase in overweight and obesity among mothers and children in sub-Saharan Africa, an understanding of the factors that drive their food consumption is needed. We hypothesized food consumption in Malawi is driven by a combination of factors, including season, food accessibility (area of residence, convenience of purchasing food, female autonomy), food affordability (household resources, food expenditures, household food insecurity), food desirability (taste preferences, body size preferences), demographics, and morbidity. Participants in Lilongwe and Kasungu Districts were enrolled across three types of mother-child dyads: either the mother (n = 120), child (n = 80), or both (n = 74) were overweight. Seven-day dietary intake was assessed using a quantitative food frequency questionnaire during the dry and rainy seasons. Drivers associated with intake of calories, macronutrients, and 11 food groups at p

Overweight in mothers and children in sub-Saharan Africa is rapidly increasing and may be related to body size perceptions and preferences. We enrolled 268 mother-child (6-59 months) pairs in central Malawi; 71% of mothers and 56% of children were overweight/obese, and the remainder were normal weight. Interviewers used seven body silhouette drawings and a questionnaire with open- and closed-ended questions to measure mothers' perceptions of current, preferred and healthy maternal and child body sizes and their relation to food choices. Overweight/obese and normal weight mothers' correct identification of their current weight status (72% vs. 64%), preference for overweight/obese body size (68% both) and selection of an overweight/obese silhouette as healthy (94% vs. 96%) did not differ by weight status. Fewer overweight/obese than normal weight mothers' preferred body silhouette was larger than their current silhouette (74% vs. 29%, p < .001). More mothers of overweight than normal weight children correctly identified the child's current weight status (55% vs. 42%, p < .05) and preferred an overweight/obese body size for the child (70% vs. 58%, p < .01), and both groups selected overweight/obese silhouettes as healthy for children. More than half of mothers in both groups wanted their child to be larger than the current size. Mothers said that increasing consumption of fruits, vegetables, meat, milk, grains, fizzy drinks and fatty foods could facilitate weight gain, but many cannot afford to purchase some of these foods. Their desired strategies for increasing weight indicate that body size preferences may drive food choice but could be limited by affordability.

Objective:To derive dietary patterns (DP) among women of reproductive age (WRA) and older women in urban Sub-Saharan Africa (SSA), and to examine their association with body mass index (BMI), overweight and obesity.Design:We used principal component analysis to derive DP. Their association with BMI, overweight and obesity was assessed using linear and multinomial logistic regression models controlling for age, marital status, education and wealth.Setting:Cross-sectional data from prospective studies in Accra, Ghana (2008–2009), Dar es Salaam, Tanzania (2014) and Lilongwe and Kasungu, Malawi (2017–2018) were used.Participants:We compared WRA in Ghana (18–54 years, n 1762) and Malawi (19–48 years, n 137), and older women in Ghana (≥55 years, n 514) and Tanzania (≥50 years, n 134).Results:Among WRA, protein and healthy DP were identified in both Ghana and Malawi. In Ghana, the protein DP was associated with higher odds of overweight or obesity (adjusted OR 1·82, 95 % CI 1·27, 2·60 for quintile 2). Among older women, three DP were identified in Ghana (cereal, protein and healthy) and two DP in Tanzania (protein and healthy). The protein DP was associated with higher BMI in Ghana (adjusted mean difference 2·83, 95 % CI 0·95, 4·71 for quartile 3).Conclusions:Higher quintiles of the protein DP were associated with higher BMI and odds of overweight or obesity among women in urban Ghana, but not in Malawi or Tanzania. Further research is needed to understand how DP influence overweight and obesity among adult women in urban SSA.

Background Chronic malnutrition, as manifested by linear growth faltering, is pervasive among rural African children. Improvements in complementary feeding may decrease the burden of environmental enteric dysfunction (EED) and thus improve growth in children during the critical first 1000 d of development. Objective We tested the hypothesis that systematically including common bean or cowpea into complementary feeding would reduce EED and growth faltering among children in rural Malawi. Methods This was a double-blind clinical trial in which children 12-23 mo of age were randomly assigned to receive complementary feeding with 1 of 3 foods: roasted cowpea or common bean flour, or an isoenergetic amount of corn-soy blend as a control food for 48 wk. Children aged 12-23 mo received 155 kcal/d and thereafter until 35 mo received 200 kcal/d. The primary outcomes were change in length-for-age z score (LAZ) and improvements in a biomarker of EED, the percentage of lactulose (%L) excreted as part of the lactulose:mannitol dual-sugar absorption test. Anthropometric measurements and urinary %L excretion were compared between the 2 intervention groups and the control group separately with the use of linear mixed model analyses for repeated measures. Results A total of 331 children completed the clinical trial. Compliance with the study interventions was excellent, with >90% of the intervention flour consumed as intended. No significant effects on LAZ, change in LAZ, or weight-for-length z score were observed due to either intervention legume, compared to the control. %L was reduced with common bean consumption (effect estimate was -0.07 percentage points of lactulose, P = 0.0007). The lactulose:mannitol test was not affected by the legume intervention. Conclusion The addition of common bean to complementary feeding of rural Malawian children during the second year of life led to an improvement in a biomarker of gut health, although this did not directly translate into improved linear growth. This trial was registered at clinicaltrials.gov as NCT02472301.

Background Chronic childhood malnutrition, as manifested by stunted linear growth, remains a persistent barrier to optimal child growth and societal development. Environmental enteric dysfunction (EED) is a significant underlying factor in the causal pathway to stunting, delayed cognitive development, and ultimately morbidity and mortality. Effective therapies against EED and stunting are lacking and further clinical trials are warranted to effectively identify and operationalize interventions. Methods/design A prospective randomized placebo-controlled parallel-group randomized controlled trial will be conducted to determine if a daily supplement of lactoferrin and lysozyme, two important proteins found in breast milk, can decrease the burden of EED and stunting in rural Malawian children aged 12–23 months old. The intervention and control groups will have a sample size of 86 subjects each. All field and laboratory researchers will be blinded to the assigned intervention group, as will the subjects and their caregivers. The percentage of ingested lactulose excreted in the urine (Δ%L) after 4 h will be used as the biomarker for EED and linear growth as the measure of chronic malnutrition (stunting). The primary outcomes of interest will be change in Δ%L from baseline to 8 weeks and to 16 weeks. Intention-to-treat analyses will be used. Discussion A rigorous clinical trial design will be used to assess the biologically plausible use of lactoferrin and lysozyme as dietary supplements for children at high risk for EED. If proven effective, these safe proteins may serve to markedly reduce the burden of childhood malnutrition and improve survival. Trial Registration Clinicaltrials.gov, NCT02925026. Registered on 4 October 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2278-8) contains supplementary material, which is available to authorized users.

BACKGROUND Environmental enteric dysfunction (EED) and linear growth stunting affect many rural agrarian children in the developing world and contribute to the persistently high rates of stunting that are observed worldwide. Effective interventions to consistently ameliorate EED are lacking. OBJECTIVE We tested whether a bundle of safe and affordable interventions would decrease EED and stunting over 12-24 wk in a cohort of rural Malawian children 12-35 mo old. METHODS This was a randomized, double-blind, placebo-controlled clinical trial in which the intervention group received a single dose of albendazole and 14 d of zinc at enrollment and after 20 wk. The intervention group also received a daily multiple micronutrient powder throughout the 24 wk of study. The primary outcomes were improvements in EED, as measured by the urinary lactulose-to-mannitol ratio (L:M ratio) from dual-sugar absorption testing, and linear growth. Urinary L:M ratios and anthropometric measurements were evaluated after 12 and 24 wk of intervention and compared with a placebo group that did not receive any of these interventions. RESULTS A total of 254 children were enrolled at a mean age of 24 mo; 55% were female. Their mean weight-for-age z score was -1.5, and their mean length-for-age z score was -0.9. After 12 and 24 wk of study, increases in the L:M ratio did not differ between the intervention group (0.071 and 0.088 units, respectively) and the placebo group (0.073 and 0.080 units, respectively) (P = 0.87 and 0.19, respectively). Relative changes in length and weight also did not differ significantly between groups at any time point. CONCLUSION The combined usage of albendazole, zinc, and a daily multiple micronutrient powder did not decrease EED or stunting in this population of agrarian children 12-35 mo old in rural Malawi. Alternative interventions to improve these diseases should be investigated. This trial was registered at clinicaltrials.gov as NCT02253095.

Objective:To validate digitally displayed photographic portion-size estimation aids (PSEA) against a weighed meal record and compare findings with an atlas of printed photographic PSEA and actual prepared-food PSEA in a low-income country.Design:Participants served themselves water and five prepared foods, which were weighed separately before the meal and again after the meal to measure any leftovers. Participants returned the following day and completed a meal recall. They estimated the quantities of foods consumed three times using the different PSEA in a randomized order.Setting:Two urban and two rural communities in southern Malawi.Participants:Women (n 300) aged 18–45 years, equally divided by urban/rural residence and years of education (≤4 years and ≥5 years).Results:Responses for digital and printed PSEA were highly correlated (>91 % agreement for all foods, Cohen’s κw = 0·78–0·93). Overall, at the individual level, digital and actual-food PSEA had a similar level of agreement with the weighed meal record. At the group level, the proportion of participants who estimated within 20 % of the weighed grams of food consumed ranged by type of food from 30 to 45 % for digital PSEA and 40–56 % for actual-food PSEA. Digital PSEA consistently underestimated grams and nutrients across foods, whereas actual-food PSEA provided a mix of under- and overestimates that balanced each other to produce accurate mean energy and nutrient intake estimates. Results did not differ by urban and rural location or participant education level.Conclusions:Digital PSEA require further testing in low-income settings to improve accuracy of estimations.

OBJECTIVES: Overweight in mothers and children in sub-Saharan Africa is rapidly increasing and may be related to body size preferences. The objective of this study was to measure mothers’ preferences for their own and their child's body size and how they relate to food choices. METHODS: We enrolled 271 mothers and their children (6–59 months) in Lilongwe and Kasungu Districts. Based on standard body-mass index and weight-for-height z-score cutoffs, 78 mothers (29%) were normal weight and 193 (71%) were overweight; 120 children (44%) were normal weight and 151 (56%) were overweight. Interviewers used a set of 7 adult female and 7 child body silhouette drawings and a semi-structured question guide to measure mothers’ perceptions of their own and their child's preferred and healthy body sizes and how their preferences affected food choices. We performed chi-squared tests comparing body size perceptions and grouped open-ended responses by weight status. RESULTS: Mothers’ selection of silhouettes that represented their body size preferences (67% normal weight, 68% overweight preferred overweight) and perceptions of a healthy body size (96% normal weight, 94% overweight selected overweight as healthy) did not differ by their weight status. A higher percentage of mothers of overweight than normal weight children preferred overweight child body sizes (70% vs. 48%, P = 0.003). Mothers’ perceptions of a healthy child body size (89% normal weight, 94% overweight selected overweight as healthy) did not differ by the child's weight status. To attain a larger body size, mothers said they could eat or feed the child larger quantities or more frequently and increase consumption of fatty/oily foods and drinks (such as sodas, sweetened yoghurt, and milk), but many cannot afford to do this. CONCLUSIONS: Malawian mothers had strong preferences for overweight body sizes for themselves and mixed preferences for their children. Their desired strategies for increasing weight indicate that body size preferences may drive food choice but could be limited by cost. FUNDING SOURCES: Drivers of Food Choice (DFC) Competitive Grants Program, funded by the UK Government's Department for International Development and the Bill & Melinda Gates Foundation, and managed by the University of South Carolina, Arnold School of Public Health.

OBJECTIVES: Obesity is an increasing problem among women of reproductive age (WRA) in urban sub-Saharan Africa (SSA), yet population-specific information on dietary risk factors is limited. The objective of this study was to derive dietary patterns (DPs) among WRAs in urban SSA and to examine their association with overweight and obesity. METHODS: We used baseline data from two prospective studies conducted among WRAs in Accra, Ghana (n = 2307, year = 2008–9) and Lilongwe, Malawi (n = 103, year = 2017–18). Diet was assessed using locally adapted food frequency questionnaires. Overweight was defined as body mass index (BMI) ≥25 kg/m2 and BMI 0.05) associated with overweight or obesity in either Ghana or Malawi. CONCLUSIONS: Healthy and protein DPs characterized diets of urban WRA in Ghana, and protein and modern DPs in Malawi. Higher education and wealth were associated with higher DP quartiles/quintiles in both samples. The healthy DP in Ghana may reflect an earlier stage of the nutrition transition compared to the modern DP in Malawi (data collected ten years apart), or different food cultures and food varieties in the two countries. Further research is needed to understand the lack of association between DPs and obesity among urban WRAs in SSA. FUNDING SOURCES: None. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

Linear growth faltering, caused by insufficient diet, recurrent infections and environmental enteric dysfunction (EED), continues to plague young children in low- and middle-income countries (LMICs). Diets in LMICs are primarily plant based, and thus have poor-quality protein and low levels of essential micronutrients. The aim of this study was to assess the association of the type and protein quality of food consumed with stunting, EED and acute malnutrition in children aged 6–36 months in Limera and Masenjere, two rural Southern Malawian communities. This is a secondary analysis of two randomized controlled trials that tested the effects of common bean and cowpea flour on stunting in children aged 6–36 months. We used data from two interactive 24-h dietary recalls conducted 12 weeks after enrolment into each trial. Food intakes were compared between the regions using Chi-square and Student’s t-test. There were 355 children that participated in the dietary recalls. The diets of children were of poor quality, but the children from Limera consumed more fish (54% vs. 35%, p = 0.009) and more bioavailable protein (26.0 ± 10.3 g/day vs. 23.1 ± 8.1 g/day, p = 0.018, respectively) than children in Masenjere. Food type and protein quality were not associated with any of the outcomes except an association between animal protein consumption and improvement in height-for-age z scores in children aged 12–36 months (p = 0.047). These findings support the notion that animal-source food (ASF) consumption in this vulnerable population promotes linear growth.

BACKGROUND The utility of dairy ingredients in the supplementary foods used in the treatment of childhood moderate acute malnutrition (MAM) remains unsettled. OBJECTIVE We evaluated the effectiveness of a peanut-based ready-to-use supplementary food (RUSF) with soy protein compared with a novel RUSF containing dairy ingredients in the form of whey permeate and whey protein concentrate in the treatment of children with MAM. DESIGN We conducted a randomized, double-blind clinical effectiveness trial involving rural Malawian and Mozambican children 6-59 mo of age with MAM treated with either soy RUSF or a novel whey RUSF treatment of ~75 kcal · kg(-1) · d(-1) for up to 12 wk. RESULTS The proportion of children that recovered from MAM was significantly higher in the group that received whey RUSF (960 of 1144; 83.9%) than in the group that received soy RUSF (874 of 1086; 80.5%; P < 0.04; risk difference 3.4%, 95% CI: 0.3%, 6.6%). Children who consumed whey RUSF also demonstrated better growth markers, with a higher mean midupper arm circumference (MUAC) at the time of discharge (P < 0.009), greater MUAC gain during the course of treatment (P < 0.003), higher mean weight-for-height z score at discharge (P < 0.008), and greater weight gain (P < 0.05). No significant differences were identified in length gain or time to recovery between the 2 groups. CONCLUSION This study highlights the importance of milk protein in the treatment of MAM, because the use of a novel whey RUSF resulted in higher recovery rates and improved growth than did soy RUSF, although the whey RUSF supplement provided less total protein and energy than the soy RUSF. This study was registered at clinicaltrials.gov as NCT01790048.

Low nutritional value of complementary foods is associated with high incidence of childhood growth stunting in low-income countries. This study was done to test a hypothesis that dietary complementation with lipid-based nutrient supplements (LNS) promotes linear growth and reduces the incidence of severe stunting among at-risk infants. A total of 840 6-month-old healthy infants in rural Malawi were enrolled to a randomised assessor- blinded trial. The participants received 12-month supplementation with nothing, milk-LNS, soy-LNS, or corn- soy blend (CSB). Supplements provided micronutrients and approximately 280 kcal energy per day. Outcomes were incidence of severe and very severe stunting (length-for-age z-score, (LAZ) < -3.00 and

Nutrition interventions have an effect on growth, energy and nutrient intake, and development, but there are mixed reports on the effect of supplementation of energy-dense foods on dietary intake. This substudy aimed at assessing the effect of supplementation with corn–soy blend (CSB) or lipid-based nutrient supplement (LNS) on energy and nutrient intake in moderately underweight children participating in a clinical trial. A total of 188 children aged 8–18 months participated and received daily either 284 kcal from CSB or 220 kcal from LNS and no supplements (control). An interactive 24-h recall method was used to estimate energy and nutrient intakes in the groups. Total mean energy intake was 548 kcal, 551 kcal and 692 kcal in the control, CSB and LNS groups, respectively (P = 0.011). The mean (95% confidence interval) intake of energy and protein were 144 (37–250; P

Factors associated with relapse among children who are discharged after reaching a threshold denoted ‘recovered’ from moderate acute malnutrition (MAM) are not well understood. The aim of this study was to identify factors associated with sustained recovery, defined as maintaining a mid-upper-arm circumference≥12·5 cm for 1 year after release from treatment. On the basis of an observational study design, we analysed data from an in-depth household (HH) survey on a sub-sample of participants within a larger cluster randomised controlled trial (cRCT) that followed up children for 1 year after recovery from MAM. Out of 1497 children participating in the cRCT, a subset of 315 children participated in this sub-study. Accounting for other factors, HH with fitted lids on water storage containers (P=0·004) was a significant predictor of sustained recovery. In addition, sustained recovery was better among children whose caregivers were observed to have clean hands (P=0·053) and in HH using an improved sanitation facility (P=0·083). By contrast, socio-economic status and infant and young child feeding practices at the time of discharge and HH food security throughout the follow-up period were not significant. Given these results, we hypothesise that improved water, sanitation and hygiene conditions in tandem with management of MAM through supplemental feeding programmes have the possibility to decrease relapse following recovery from MAM. Furthermore, the absence of associations between relapse and nearly all HH-level factors indicates that the causal factors of relapse may be related mostly to the child’s individual, underlying health and nutrition status.

OBJECTIVES Ready-to-use therapeutic food (RUTF) is the preferred treatment for uncomplicated severe acute malnutrition. It contains large amounts of linoleic acid and little α-linolenic acid, which may reduce the availability of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) to the recovering child. A novel high-oleic RUTF (HO-RUTF) was developed with less linoleic acid to determine its effect on DHA and EPA status. METHODS We conducted a prospective, randomized, double-blind clinical effectiveness trial treating rural Malawian children with severe acute malnutrition. Children were treated with either HO-RUTF or standard RUTF. Plasma phospholipid fatty acid status was measured on enrollment and after 4 weeks and compared between the 2 intervention groups. RESULTS Among the 141 children enrolled, 48 of 71 receiving HO-RUTF and 50 of 70 receiving RUTF recovered. Plasma phospholipid samples were analyzed from 43 children consuming HO-RUTF and 35 children consuming RUTF. The change in DHA content during the first 4 weeks was +4% and -25% in the HO-RUTF and RUTF groups, respectively (P = 0.04). For EPA, the change in content was 63% and -24% in the HO-RUTF and RUTF groups, respectively (P

Objective This study tested the hypothesis that Malawian children at risk for zinc deficiency will have reduced endogenous fecal zinc (EFZ) and increased net absorbed zinc (NAZ) following the addition of high amylose maize resistant starch (RS) to their diet. Methods This was a small controlled clinical trial to determine the effects of added dietary RS on zinc homeostasis among 17 stunted children, aged 3–5 years consuming a plant-based diet and at risk for perturbed zinc homeostasis. Dual zinc stable isotope studies were performed before and after 28 d of intervention with RS, so that each child served as their own control. The RS was incorporated into fried wheat flour dough and given under direct observation twice daily for 28 d. Changes in zinc homeostatic measures were compared using paired Student's t-tests and linear regression analysis. Results Children had a mean height-for-age Z-score of −3.3, and consumed animal source foods ≤twice per month. Their habitual diet contained a phytate:zinc molar ratio of 34:1. Children avidly consumed the RS without complaints. EFZ was 0.8 ± 0.4 mg/d (mean ± SD) both before and after the intervention. Fractional absorption of zinc was 0.38 ± 0.08 and 0.35 ± 0.06 before and after the RS intervention respectively. NAZ was 1.1 ± 0.5 and 0.6 ± 0.7 before and after the RS intervention. This reduction of NAZ corresponded with diminished dietary zinc intake on the study day following intervention with RS. Regression analysis indicated no change in zinc absorption relative to dietary intake as a result of the RS intervention. Conclusion Consumption of RS did not improve zinc homeostasis in rural African children without zinc deficiency. RS was well tolerated in this setting.

OBJECTIVES: Children with moderate acute malnutrition (MAM) have a high rate of relapse and death in the year following recovery. In this pilot study we evaluate the long-term benefits of an extended course of nutritional therapy for children with MAM. METHODS: Rural Malawian children 6 to 59 months old with MAM defined as a weight-for-height z score (WHZ) between -2 and -3 were provided supplementary feeding for a fixed duration of 12 weeks. The children were then studied for 12 months to assess long-term nutritional status and compared with children initially treated only until they first reached WHZ > -2. RESULTS: Compared with children treated until they reached WHZ > -2 children treated for 12 weeks were more likely to remain well nourished (71% vs 63% P = 0.0015) and maintain more normal anthropometric indices during 12 months of follow-up; there was also a trend towards lower rates of severe acute malnutrition (7% vs 10% P = 0.067) and death (2% vs 4% P = 0.082). Regression modeling showed that mid-upper arm circumference and WHZ at the end of supplementary feeding were the most important factors in predicting which children remained well nourished (P < 0.001 for each). CONCLUSIONS: The duration of supplementary feeding for children with MAM may not be as important as their anthropometry in terms of remaining well nourished after initial recovery. The presently accepted recovery criteria of WHZ of -2 may be insufficient for ensuring long-term nutritional health; consideration should be given to setting higher recovery criteria.

Background Environmental enteropathy (EE) is subclinical, diffuse villous atrophy characterized by T cell infiltration of the small intestinal mucosa associated with nutrient malabsorption and stunting. EE is assessed by the lactulose:mannitol (L:M) test, whereby nonmetabolized sugars are ingested and quantified in the urine. Multiple micronutrient (MN) deficiency morphologically mimics EE, and ω-3 (n-3) polyunsaturated fatty acids reduce mucosal inflammation in Crohn disease. Objective We tested the hypothesis that supplementary MNs, with or without fish oil (FO), would improve L:M in rural Malawian children aged 1-3 y compared with a control (C) group receiving a placebo. Methods The MNs and FO provided the Recommended Dietary Intake for 26 vitamins, minerals, eicosapentaenoic acid, and docosahexaenoic acid. This was a 3-arm, randomized, double-blind, placebo-controlled clinical trial, with the primary outcomes being the change in L:M (ΔL:M) after 12 and 24 wk of supplementation. Comparisons were made for ΔL:M after 12 and 24 wk within each group by using a Wilcoxon matched pairs signed rank test, because the data are not normally distributed. Results A total of 230 children had specimens adequate for analysis; all had an abnormal baseline L:M, defined as >0.10. After 12 wk, children who received MNs + FO had a ΔL:M [mean (95% CI)] of -0.10 (-0.04, -0.15; P = 0.001), and children receiving only MNs had ΔL:M of -0.12 (-0.03, -0.21; P = 0.002). After 24 wk, children who received MNs + FO had a ΔL:M of -0.09 (-0.03, -0.15; P = 0.001); children receiving only MNs had a ΔL:M of -0.11 (-0.02, -0.20; P = 0.001), and the C group had ΔL:M of -0.07 (0.02, -0.16); P = 0.002). Linear growth was similar in all groups, ∼4.3 cm over 24 wk. Conclusion Although the effect was modest, these data suggest MNs can transiently ameliorate EE in rural African children. The trial was registered at clinicaltrials.gov as NCT01593033.

Background: Growth faltering is common in rural African children and is attributed to inadequate dietary intake and environmental enteric dysfunction (EED). Objective: We tested the hypothesis that complementary feeding with cowpea or common bean flour would reduce growth faltering and EED in 6-mo-old rural Malawians compared with the control group receiving a corn-soy blend. Design: A prospective, double-blind, randomized controlled clinical trial was conducted in which children received daily feeding for 6 mo (200 kcal/d when 6–9 mo old and 300 kcal/d when 10–12 mo old). The primary outcomes were change in length-for-age z score (LAZ) and improvements in EED, as measured by percentage of lactulose excretion (%L). %L

Background: Children who recover from moderate acute malnutrition (MAM) have high rates of relapse in the year after nutritional recovery. Interventions to decrease these adverse outcomes are needed to maximize the overall effectiveness of supplemental feeding programs (SFPs). Objective: We evaluated the effectiveness of a package of health and nutrition interventions on improving the proportion of children who sustained recovery for 1 y after MAM treatment. We further explored factors related to sustained recovery. Design: We conducted a cluster-randomized clinical effectiveness trial involving rural Malawian children aged 6–62 mo who were enrolled on discharge from an SFP for MAM. We enrolled 718 children at 10 control sites and 769 children at 11 intervention sites. In addition to routine health and nutrition counseling, the intervention group received a package of health and nutrition interventions that consisted of a lipid nutrient supplement, deworming medication, zinc supplementation, a bed net, and malaria chemoprophylaxis. A survival analysis was used to determine the effectiveness of the intervention as well as to identify factors associated with sustained recovery. Results: Of 1383 children who returned for the full 12-mo follow-up period, 407 children (56%) and 347 children (53%) sustained recovery in the intervention and control groups, respectively. There was no significant difference in relapse-free survival curves between the treatment and control groups (P = 0.380; log-rank test). The risk factors for relapse or death after initial recovery were a smaller midupper arm circumference on SFP admission (P = 0.01) and discharge (P < 0.001), a lower weight-for-height z score on discharge (P < 0.01), and the receipt of ready-to-use supplementary food as opposed to ready-to-use therapeutic food during treatment (P < 0.05). Conclusion: The provision of a package of health and nutrition services in addition to traditional SFP treatment has no significant effect on improving sustained recovery in children after treatment of MAM. This trial was registered at clinicaltrials.gov as NCT02351687.

Background: Malnutrition during pregnancy in sub-Saharan Africa is associated with poor birth outcomes. Objective: This study compared maternal and offspring anthropometry for moderately malnourished pregnant women receiving ready-to-use supplemental food (RUSF), a fortified corn-soy blend (CSB+) with a daily multiple micronutrient antenatal supplement [United Nations International Multiple Micronutrient Preparation (UNIMMAP)], or standard of care comprising CSB+ and iron and folic acid (IFA). Design: A single-blind randomized controlled clinical trial was conducted in southern Malawi among 1828 pregnant women with moderate malnutrition, defined as a midupper arm circumference (MUAC) ≥20.6 and ≤23.0 cm. Women received 1 of 3 dietary treatment regimens that provided ∼900 kcal/d and 33–36 g protein/d. Maternal and infant anthropometry were followed until the child was 3 mo old. Results: Newborns had a mean length-for-age z score of −1.3 ± 1.2 and 22% were stunted at birth. Mothers receiving RUSF had the highest weight gain during supplementation (3.4 ± 2.6, 3.0 ± 2.2, and 3.2 ± 2.4 kg for the RUSF, CSB+ with UNIMMAP, and CSB+ with IFA groups, respectively; P = 0.03). Newborn birth weights and lengths were similar across intervention groups, but the incidence of newborns with a birth weight

BACKGROUND: There is evidence to support the use of lipid-based nutrient supplements (LNSs) to promote child growth and development in low-income countries but there is also a concern regarding the safety of using iron-fortified products in malaria-endemic areas. OBJECTIVE: The objective of this study was to test the hypothesis that 6- to 18-mo-old rural Malawian children receiving iron-containing (6 mg/d) LNSs would not have excess morbidity compared with infants receiving no supplementation. METHODS: A randomized controlled trial allocated 840 children to receive daily supplementation with 54 g/d LNS with milk protein base (milk-LNS) 54 g/d LNS with soy protein base (soy-LNS) 71 g/d corn-soy blend (CSB) or no supplementation from 6 to 18 mo of age. Morbidity was compared using a non-inferiority margin set at 20% excess morbidity in supplemented groups compared with the nonsupplemented group. RESULTS: Baseline characteristics were similar across groups. The proportion of days with febrile illness between 6 and 18 mo was 4.9% and there were no differences between the groups: 4.9% (95% CI: 4.3 5.5%) 4.5% (95% CI: 3.9 5.1%) 4.7% (95% CI: 4.1 5.3%) and 5.5% (95% CI: 4.7-6.3%) in the milk-LNS soy-LNS CSB and control groups respectively. The proportion of days with respiratory problems and diarrhea between 6 and 18 mo also did not differ between groups. Compared with controls the incident rate ratio (95% CI) for clinical malaria was 0.80 (0.59 1.09) 0.77 (0.56 1.06) and 0.79 (0.58 1.08) in milk-LNS soy-LNS and CSB respectively with 95% CIs confirming non-inferiority. The incidence of febrile episodes diarrhea respiratory problems or admission to hospital prevalence of malaria parasitemia throughout the follow-up and mean change in hemoglobin concentration from baseline were also similar between the groups. CONCLUSIONS: Daily supplementation with 54 g of milk-based or soy protein-based LNS or 71 g of CSB did not result in increases in malaria or respiratory morbidity in children in a malaria-endemic setting. However we could not conclude whether LNSs did or did not increase diarrheal morbidity. This trial was registered at clinicaltrials.gov as NCT00524446. (c) 2014 American Society for Nutrition.

OBJECTIVES: Easy-to-use tools to facilitate portion size estimation in low-income countries are needed. The objective of this study was to validate digitally displayed photographic portion size estimation aids (PSEAs) against a weighed meal record and compare findings with an atlas of printed photographic PSEAs and actual prepared food PSEAs in a low-income country. METHODS: In Blantyre and Chikwawa Districts, Malawi, we enrolled 300 women 18–45 years of age equally divided by urban/rural residence and years of education (≤4 years and >4 years). Participants served themselves water and five prepared foods, which were weighed separately before the meal and again after the meal to measure any leftovers. Participants returned the following day and completed a meal recall. They estimated the quantities of foods consumed three times using the different PSEAs in a randomized order. RESULTS: Responses for digital and printed PSEAs were highly correlated (>91% agreement for all foods, Cohen's κ = 0.78–0.93). Overall, digital and actual-food PSEAs had a similar level of agreement with the weighed meal record at the group level. The proportion of participants who estimated within 20% of the weighed grams of food consumed ranged by type of food from 30–45% for digital PSEAs and 40–56% for actual food PSEAs. Digital PSEAs consistently underestimated grams and nutrients across foods, whereas actual-food PSEAs provided a mix of under- and overestimates that balanced each other to produce accurate mean energy and nutrient intake estimates. Results did not differ by urban and rural location or participant education level. CONCLUSIONS: Digital PSEAs require further testing in low-income settings to improve accuracy of estimations because they offer several logistical advantages over other PSEAs. FUNDING SOURCES: RTI International.

OBJECTIVES: As obesity increases in sub-Saharan Africa, information is needed about factors influencing food choices in households with overweight members. The objective of this study was to assess women's food purchasing decisions in overweight mother-child dyads in Malawi. METHODS: We enrolled 50 mother-child (age 6–59 months) dyads in which either the mother, the child, or both were overweight in Lilongwe and Kasungu Districts. Research assistants accompanied each woman on a food shopping trip and filled out a structured observation form on the types of food purchased and locations of purchases. Upon returning to the woman's home, research assistants conducted an in-depth interview about the factors that influenced the woman's purchases, including asking them to sort 12 factors into piles that always, sometimes, or never influence their food purchasing choices. RESULTS: Observations showed that women most often purchased small quantities of foods needed to prepare relish (the dish accompanying the staple food), such as tomatoes (76%), green leafy vegetables (66%), cooking oil (56%), onions (44%), and fish (41%) at outdoor markets. Pile sorts and open-ended responses revealed that taste, cost, and food quality were the strongest factors influencing food purchases. Women explained that if a food is too expensive, they buy a smaller quantity or buy something else (e.g., fish instead of meat). Cooking food that their family enjoys eating influenced the foods women bought. Adding tomatoes, onions, and oil to relish was commonly described as making the food tastier. To make the child happy, >50% of the women said they buy food, such as sweets, packaged snacks, fruit, or fried food (e.g., doughnuts), specifically for their child. CONCLUSIONS: Cost, taste, and food quality were the most important drivers of women's food purchasing choices. Women used some of their minimal funds to buy unhealthy foods for their children, despite their overall emphasis on food cost and quality. These findings can be used by programs to reinforce healthy and decrease unhealthy food purchases. FUNDING SOURCES: Drivers of Food Choice (DFC) Competitive Grants Program, funded by the UK Government's Department for International Development and the Bill & Melinda Gates Foundation, and managed by the University of South Carolina, Arnold School of Public Health.

Linear growth faltering, caused by insufficient diet, recurrent infections and environmental enteric dysfunction (EED), continues to plague young children in low- and middle-income countries (LMICs). Diets in LMICs are primarily plant based, and thus have poor-quality protein and low levels of essential micronutrients. The aim of this study was to assess the association of the type and protein quality of food consumed with stunting, EED and acute malnutrition in children aged 6&ndash, 36 months in Limera and Masenjere, two rural Southern Malawian communities. This is a secondary analysis of two randomized controlled trials that tested the effects of common bean and cowpea flour on stunting in children aged 6&ndash, 36 months. We used data from two interactive 24-h dietary recalls conducted 12 weeks after enrolment into each trial. Food intakes were compared between the regions using Chi-square and Student&rsquo, s t-test. There were 355 children that participated in the dietary recalls. The diets of children were of poor quality, but the children from Limera consumed more fish (54% vs. 35%, p = 0.009) and more bioavailable protein (26.0 &plusmn, 10.3 g/day vs. 23.1 &plusmn, 8.1 g/day, p = 0.018, respectively) than children in Masenjere. Food type and protein quality were not associated with any of the outcomes except an association between animal protein consumption and improvement in height-for-age z scores in children aged 12&ndash, 36 months (p = 0.047). These findings support the notion that animal-source food (ASF) consumption in this vulnerable population promotes linear growth.

Aim To assess whether using lipid-based nutrient supplements (LNS) to complement the diets of infants and young children affected when they achieved selected developmental milestones. Methods In rural Malawi, 840 6-month-old healthy infants were enrolled to a randomised trial. Control participants received no supplements, others were provided with milk-containing LNS, soy-containing LNS or corn–soy blend (CSB) for 12 months. Outcomes were the age at which they achieved key milestone: motor (walking with assistance, standing and walking alone, running), social (drinking from a cup and eating by themself) and language (saying single comprehensible words and waving goodbye). Results The mean age at which the subjects walked with assistance was 42.5, 42.3, 42.7 and 43.2 weeks in the control, milk-LNS, soy-LNS and CSB groups, respectively (p = 0.748). There were also no significant differences in the mean age at standing alone (45.0, 44.9, 45.1 and 46.3 weeks), walking alone (54.6, 55.1, 55.3, 56.5 weeks), running (64.6, 63.7, 64.8, 65.9 weeks) or any other social or language milestones (each p > 0.10). Conclusion The findings do not support a hypothesis that providing tested formulations and doses of micronutrient-fortified LNS or CSB would have an impact on when young children in rural Malawi achieved selected developmental milestones.

To examine acceptability and feeding practices associated with different supplementary food items and identify practices associated with weight gain.Caregivers (n = 409) whose children had been enrolled in a trial comparing a fortified corn-soy blended flour (CSB++), soy ready-to-use supplementary food (RUSF), and soy/whey RUSF answered a questionnaire administered by health workers in their homes.No significant differences in acceptability of food types were found. CSB++ was more likely than soy RUSF or soy/whey RUSF to be shared (21% vs 3% vs 8%, respectively, P .001). Children who received soy/whey RUSF were more likely to feed themselves than children who received soy RUSF or CSB++ (11% vs 4% vs 3%, respectively, P .05). Refusing food was associated with slower weight gain.Despite similar acceptability, feeding practices differed among food types. Increased nonstaple food consumption is associated with weight gain.

Moderate acute malnutrition (MAM) affects 11% of children −2. The median duration of feeding was 2 wk, with a maximum of 12 wk. The hypothesis tested was that children treated with either RUSF would be more likely to remain well-nourished than those treated with CSB++. The primary outcome, remaining well-nourished, was defined as mid-upper arm circumference ≥12.5 cm or WHZ ≥−2 for the entire duration of follow-up. During the 12-mo follow-up period, only 1230 (63%) children remained well-nourished, 334 (17%) relapsed to MAM, 190 (10%) developed severe acute malnutrition, 74 (4%) died, and 139 (7%) were lost to follow-up. Children who were treated with soy/whey RUSF were more likely to remain well-nourished (67%) than those treated with CSB++ (62%) or soy RUSF (59%) (P = 0.01). A seasonal pattern of food insecurity and adverse clinical outcomes was observed. This study demonstrates that children successfully treated for MAM with soy/whey RUSF are more likely to remain well-nourished; however, all children successfully treated for MAM remain vulnerable.

The aim of the present study was to investigate the relation of environmental enteropathy, as measured by the dual sugar absorption test, to linear growth faltering in 2- to 5-year-old Malawian children. Dietary quality, food insecurity, anthropometry, and site-specific sugar testing were measured in 418 children, and anthropometry was reassessed 3 months later. A linear regression model predicting linear growth was created. Better growth was associated with less urinary lactulose excretion, more clean water usage, not sleeping with animals, and no previous history of malnutrition. Eighty-seven percent of children studied demonstrated evidence of environmental enteropathy. In conclusion, abnormal gut integrity is associated with reduced linear growth in a population of rural African preschool-age children.

Next-generation sequencing has expanded our understanding of the viral populations that constitute the mammalian virome. We describe a novel taxon of viruses named Statoviruses, for Stool associated Tombus-like viruses, present in multiple metagenomic datasets. These viruses define a novel clade that is phylogenetically related to the RNA virus families Tombusviridae and Flaviviridae. Five distinct statovirus types were identified in human, macaque, mouse, and cow gastrointestinal tract samples. The prototype genome, statovirus A, was frequently identified in macaque stool samples from multiple geographically distinct cohorts. Another genome, statovirus C1, was discovered in a stool sample from a human child with fever, cough, and rash. Further experimental data will clarify whether these viruses are infectious to mammals or if they originate from another source present in the mammalian gastrointestinal tract.

Background: Children with moderate acute malnutrition (MAM) are often treated with fortified blended flours, most commonly a corn-soy blend (CSB). However, recovery rates remain ,75%, lower than the rate achieved with peanut paste‐based ready-to-use supplementary foods (RUSFs). To bridge this gap, a novel CSB recipe fortified with oil and dry skim milk, “CSB++,” has been developed. Objective: In this trial we compared CSB++ with 2 RUSF products for the treatment of MAM to test the hypothesis that the recovery rate achieved with CSB++ will not be .5% worse than that achieved with either RUSF. Design: We conducted a prospective, randomized, investigatorblinded, controlled noninferiority trial involving rural Malawian children aged 6‐59 mo with MAM. Children received 75 kcal CSB++ kg 21 d 21 , locally produced soy RUSF, or an imported soy/whey RUSF for 12 wk. Results: The recovery rate for CSB++ (n = 763 of 888; 85.9%) was similar to that for soy RUSF (795 of 806, 87.7%; risk difference: 21.82%; 95% CI: 24.95%, 1.30%) and soy/whey RUSF (807 of 918, 87.9%; risk difference: 21.99%; 95% CI: 25.10%, 1.13%). On average, children who received CSB++ required 2 d longer to recover, and the rate of weight gain was less than that with either RUSF, although height gain was the same among all 3 foods studied. Conclusions: A novel, locally produced, fortified blendedflour (CSB++) was not inferior to a locally produced soy RUSF and an imported soy/whey RUSF in facilitating recovery from MAM. The recovery rate observed for CSB++ was higher than that for any other fortified blended flour tested previously. This trial is registered at clinicaltrials.gov as NCT00998517. Am J Clin Nutr 2012;95:212‐9.

This study aimed to compare the nutritional intake values among 15-month-old rural Malawian children obtained by weighed food record (WFR) with those obtained by modified 24-hour recall (mod 24-HR), and to develop algorithm for adjusting mod 24-HR values so as to predict mean intake based on WFRs. The study participants were 169 15-month-old children who participated in a clinical trial. Food consumption on one day was observed and weighed (established criterion) by a research assistant to provide the estimates of energy and nutrient intakes. On the following day, another research assistant, blinded to the direct observation, conducted the structured interactive 24-hour recall (24-HR) interview (test method). Paired t-tests and scatter-plots were used to compare intake values of the two methods. The structured interactive 24-HR method tended to overestimate energy and nutrient intakes (each P < 0.001). The regression-through-the-origin method was used to develop adjustment algorithms. Results showed that multiplying the mean energy, protein, fat, iron, zinc and vitamin A intake estimates based on the test method by 0.86, 0.80, 0.68, 0.69, 0.72 and 0.76, respectively, provides an approximation of the mean values based on WFRs.

Although widely used, there is little information concerning the efficacy of corn-soy blend (CSB) supplementation in the treatment of moderate underweight in African children. Lipid-based nutrient supplements (LNS), which have proven to be beneficial treatment for severely wasted children, could offer benefits to less severely affected individuals. We conducted a clinical randomized trial to determine whether LNS or CSB supplementation improves weight gain of moderately underweight children. A total of 182 underweight [weight-for-age Z-score (WAZ) < -2] 6- to 15-mo-old children were randomized to receive for 12 wk a ration of 43 g/d LNS or 71 g/d CSB, providing 1189 and 921 kJ, respectively, or no supplementation (control). The primary outcome was weight change; secondary outcomes included changes in anthropometric indices, hemoglobin levels, and morbidity. The body weight increases (mean ± SD) did not differ and were 620 ± 470, 510 ± 350, and 470 ± 350 g in the LNS, CSB, and control groups, respectively (P = 0.11). Compared with controls, infants and children in the LNS group gained more weight [mean (95% CI) = 150 g (0-300 g); P = 0.05] and had a greater increase in WAZ [0.33 (-0.02-0.65); P = 0.04]. Weight and WAZ changes did not differ between the control and CSB groups. In exploratory stratified analysis, the weight increase was higher in the LNS group compared with the control group among those with lower initial WAZ [250 g (60-430 g; P = 0.01]. Supplementation with LNS but not CSB modestly increases weight gain among moderately underweight children and the effect appears most pronounced among those with a lower initial WAZ.

The effect of different energy densities of complementary foods on breast milk consumption is not well understood. In this study, we tested the hypothesis that provision of fortified spread (FS), a micronutrient fortified, energy-dense (22 kJ/g), ready-to-use food, to Malawian infants would not decrease their breast milk intake more than a traditional corn + soy blended flour (CSB). Forty-four healthy 6-mo-old infant and mother pairs were enrolled in a prospective, parallel group, investigator-blinded, randomized controlled complementary feeding trial. Infants were randomized to receive 25 g/d of FS, 50 g/d of FS, or 72 g/d of CSB. The primary outcome was the difference in breast milk intake after 1 mo of complementary feeding as measured by the dose-to-mother deuterium oxide dilution technique. Outcomes were compared using repeated measures ANOVA. A total of 41 mother-infant pairs completed the study. At enrollment, 88% of the infants had received corn porridge. At baseline, the infants consumed 129 +/- 18 g.kg body wt(-1) x d(-1) (mean +/- SD) of breast milk. After 1 mo of complementary feeding with 25 g/d FS, 50 g/d FS, or 72 g/d CSB, their breast milk consumption was 115 +/- 18 g.kg body wt(-1) x d(-1), a significant reduction; however, the effects of the complementary foods did not differ from one another (F-value model = 4.33, P = 0.0008 for effect of time and P = 0.69 for effect of type of food). The results suggest that complementary feeding of Malawian infants with FS has the same effect on their breast milk intake as complementary feeding with traditional CSB porridge.

OBJECTIVE: To compare the growth of HIV-exposed children receiving 1 of 2 complementary foods after prevention of mother-to-child HIV transmission through maternal lifelong antiretroviral therapy (ART). METHODS: In rural Malawi 280 HIV-infected pregnant women were consecutively identified and offered ART without consideration of their CD4 counts. Mothers were supported to exclusively breast-feed and children tested for HIV status at 1.5 and 5.5 months of age. From this group 248 HIV-exposed children were enrolled and randomized to receive micronutrients with either whole milk powder or a ready-to-use complementary food (RUF) until the child reached 12 months of age. Children were followed until 18 months of age. RESULTS: HIV-free survival at 12 months was 90% (95% confidence interval: 87% to 94%). Exclusive breast-feeding for the first 6 months of life was practiced in 97% of the children. At 12 months of age 89% of the children continued to be breast-fed. At 6 months of age infants had a weight-for-height z score of 0.7 +/- 1.1 (mean +/- SD) and length-for-age z score of -1.3 +/- 1.2. The decrease in length-for-age z score among children receiving RUF at 12 months of age was greater than that seen in those receiving milk powder (-0.3 +/- 0.8 vs -0.1 +/- 0.7 P = 0.04). Mean weight-for-height z score was >0 at 12 and 18 months of age in both groups. CONCLUSIONS: HIV-free survival >/=90% at 12 months was achieved with maternal ART while either milk powder or RUF as a complementary food preserved child anthropometry. Breast-feeding by mothers receiving ART was acceptable.

Environmental enteropathy (EE) is a subclinical condition among children in the developing world, characterized by T-cell infiltration of the small-bowel mucosa and diffuse villous atrophy. EE leads to macronutrient and micronutrient malabsorption and stunting, with a resultant increased risk for infection and reduced cognitive development. We tested the hypothesis that zinc and albendazole treatments would reduce the severity of EE in rural African children.In a randomized, double-blind, placebo-controlled trial in rural southern Malawi, asymptomatic children, 1 to 3 years old and at high risk for EE, received either a single dose of albendazole, a 14-day course of 20 mg zinc sulfate, or a placebo. Subjects were given the dual-sugar absorption test, and the ratio of lactulose to mannitol (L:M) in urine was used to determine the severity of EE at baseline and 34 days after completion of the assigned regimen. The primary outcome was the change in the L:M.A complete set of urine samples was obtained from 222 of 234 children enrolled and analyzed. The mean baseline L:M was 0.32 ± 0.18 among all children and did not differ among groups (normal L:M range,0.12). At the end of the study, the L:M ratio had increased more in the placebo group (0.12 ± 0.31) than in the zinc group (0.03 ± 0.20; P.03) or the albendazole group (0.04 ± 0.22; P.04).Treatment with zinc or albendazole protects against a significant increase in the L:M ratio, a biomarker for EE, in asymptomatic rural Malawian children. These findings could provide insight into the etiology and pathogenesis of EE. Clinicaltrials.gov Number: NCT01440608.

ObjectiveTo determine if supplementation with corn–soya blend (CSB) or lipid-based nutrient supplement (LNS) improved the weight gain of moderately underweight infants and children when provided through the national health service.DesignA randomised, controlled, assessor-blinded clinical trial. Infants and children were randomised to receive for 12 weeks an average daily ration of 71 g CSB or 43 g LNS, providing 1188 kJ and 920 kJ, respectively, or no supplement (control). Main outcome was weight gain. Secondary outcomes included changes in anthropometric indices and incidence of serious adverse events. Intention-to-treat analyses were used.SettingKukalanga, Koche, Katema and Jalasi health centres in Mangochi District, rural Malawi.SubjectsUnderweight (weight-for-age Z-score n 299).ResultsMean weight gain was 630 g, 680 g and 750 g in control, CSB and LNS groups, respectively (P = 0·21). When adjusted for baseline age, children receiving LNS gained on average 90 g more weight (P = 0·185) and their weight-for-length Z-score increased 0·22 more (P = 0·049) compared with those receiving no supplementation. No statistically significant differences were observed between the CSB and control groups in mean weight and length gain.ConclusionsLNS supplementation provided during the lean season via through the national health service was associated with a modest increase in weight. However, the effect size was lower than that previously reported under more controlled research settings.