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BACKGROUND: Reduction of vitamin A deficiency (VAD) in Malawi coincided with introduction of vitamin A-fortified staple foods, alongside continued biannual high-dose vitamin A supplementation (VAS). OBJECTIVE: We describe coverage of vitamin A interventions and vitamin A status in the 2015–2016 Malawi Micronutrient Survey. METHODS: Food samples and biospecimens were collected within a representative household survey across 105 clusters. Retinol was measured using ultraviolet excitation fluorescence (sugar) and photometric determination (oil). Preschool children (PSC, aged 6–59 mo, n = 1102), school-age children (SAC, aged 5–14 y, n = 758), nonpregnant women (n = 752), and men (n = 219) were initially assessed for vitamin A status using retinol binding protein (RBP) and modified relative dose response (MRDR). Randomly selected fasted MRDR participants (n = 247) and nonfasted women and children (n = 293) were later assessed for serum retinol, retinyl esters, and carotenoids. Analyses accounted for complex survey design. RESULTS: We tested sugar and oil samples from 71.8% and 70.5% of the households (n = 2,112), respectively. All of the oil samples and all but one of the sugar samples had detectable vitamin A. National mean retinol sugar and oil contents were 6.1 ± 0.7 mg/kg and 6.6 ± 1.4 mg/kg, respectively. Receipt of VAS in the previous 6 mo was reported by 68.0% of PSC. VAD prevalence (RBP equivalent to 5% of total serum vitamin A as retinyl esters, and 1.7% (0.0, 4.1) and 4.9% (0.0, 10.2) had >10% of total serum vitamin A as retinyl esters. Serum carotenoids indicated recent intake of vitamin A-rich fruits and vegetables. CONCLUSIONS: Near elimination of VAD in Malawi is a public health success story, but elevated levels of vitamin A among children suggests that vitamin A interventions may need modification.

Background In low-resource settings, urbanization may contribute to the individual-level double burden of malnutrition (DBM), whereby under- and overnutrition co-occur within the same individuals. Objective We described DBM prevalence among Malawian women by urban-rural residence, examined whether urban residence was associated with DBM, and assessed whether DBM prevalence was greater than the prevalence expected by chance given population levels of under- and overnutrition, which would suggest DBM is a distinct phenomenon associated with specific factors. Methods We analyzed nationally representative data of 723 nonpregnant women aged 15-49 y from the 2015-2016 Malawi Micronutrient Survey. DBM was defined as co-occurring overweight or obesity (OWOB) and ≥1 micronutrient deficiency or anemia. We used Poisson regression models to examine the association between urban residence and DBM and its components. The Rao-Scott modified chi-square test compared the observed and expected DBM prevalence. Results Nationally, 10.8% (95% CI: 7.0, 14.5) of women had co-occurring OWOB and any micronutrient deficiency and 3.4% (95% CI: 1.3, 5.5) had co-occurring OWOB and anemia. The prevalence of co-occurring OWOB and any micronutrient deficiency was 2 times higher among urban women than rural women [urban 32.6 (24.1, 41.2) compared with rural 8.6 (5.2, 11.9), adjusted prevalence ratio: 2.0 (1.1, 3.5)]. Co-occurring OWOB and anemia prevalence did not significantly differ by residence [urban 6.9 (0.6, 13.2) compared with rural 3.0 (0.8, 5.3)]. There were no statistically significant differences in observed and expected prevalence estimates of DBM. Conclusions This analysis shows that co-occurring OWOB and any micronutrient deficiency was higher among women in urban Malawi compared with rural areas. However, our finding that co-occurring OWOB and any micronutrient deficiency or anemia may be due to chance suggests that there may not be common causes driving DBM in Malawian women. Thus, there may not be a need to design and target interventions specifically for women with DBM.

Background Small-quantity lipid-based nutrient supplements (SQ-LNS) are efficacious in controlled settings; data are scarce on the effectiveness utilizing health care delivery platforms. Objective We evaluated the impact of an infant young child feeding (IYCF)–SQ-LNS intervention on anemia and growth in children aged 6–18 mo in the Democratic Republic of Congo following a quasi-experimental effectiveness design. Methods An intervention health zone (HZ) received enhanced IYCF including improved counseling on IYCF during pregnancy until 12 mo after birth and daily use of SQ-LNS for infants 6–12 mo; the control HZ received the standard IYCF package. We analyzed data from 2995 children, collected in repeated cross-sectional surveys. We used adjusted difference-in-difference analyses to calculate changes in anemia, iron and vitamin A deficiencies, stunting, wasting, and underweight. Results Of mothers, 70.5% received SQ-LNS at least once in the intervention HZ, with 99.6% of their children consuming SQ-LNS at least once. The mean number of batches of SQ-LNS (28 sachets per batch, 6 batches total) received was 2.3 ± 0.8 (i.e., 64.4 ± 22.4 d of SQ-LNS). The enhanced program was associated with an 11.0% point (95% CI: −18.1, −3.8; P

Anaemia is a public health problem in Ghana. We sought to identify factors associated with haemoglobin concentration (Hb) and anaemia among school-attending adolescents. We analysed data from 2948 adolescent girls and 609 boys (10–19 years) selected from 115 schools from regions of Ghana as a secondary analysis of baseline surveys conducted at two time-points. We measured Hb, malaria from capillary blood, anthropometry and used a modified food frequency questionnaire to assess diet. Multivariable linear and Poisson regression models were used to identify predictors of Hb and anaemia. The prevalence of anaemia, malaria and geophagy were 24, 25, and 24 %, respectively, among girls and 13, 27 and 6 %, respectively, among boys. Girls engaging in geophagy had a 53 % higher adjusted prevalence of anaemia and 0⋅39 g/dl lower Hb. There were similar results among those who tested positive for malaria (+52 % anaemia; −0⋅42 g/dl Hb). Among girls, lower anaemia prevalence and higher Hb were associated with consumption of foods rich in haeme iron (−22 %; +0⋅18 g/dl), consumption of iron-fortified cereal/beverages consumed with citrus (−50 %; +0⋅37 g/dl) and being overweight (−22 %; +0⋅22 g/dl). Age was positively associated with anaemia among girls, but negatively associated among boys. Boys who tested positive for malaria had 0⋅31 g/dl lower Hb. Boys who were overweight or had obesity and consumed flour products were also more likely to be anaemic (119 and 56 %, respectively). Factors associated with Hb and anaemia may inform anaemia reduction interventions among school-going adolescents and suggest the need to tailor them uniquely for boys and girls.

Background Anemia is a moderate public health problem among adolescent girls in Ghana. Objectives We aimed to evaluate the barriers to and facilitators of program fidelity to a school-based anemia reduction program with weekly iron and folic acid (IFA) supplementation. Methods Authors analyzed directly observed weekly IFA consumption data collected longitudinally and cross-sectional data from a representative survey of 60 secondary schools and 1387 adolescent girls in the Northern and Volta regions of Ghana after 1 school year (2017-2018) of the intervention (30-36 wk). A bottleneck analysis was used to characterize the levels of IFA coverage and used adjusted generalized linear mixed-effects models to quantify the school and student drivers of IFA intake adherence. Results Of girls, 90% had ever consumed the tablet, whereas 56% had consumed ≥15 weekly tablets (mean: 16.4, range: 0-36), indicating average intake adherence was about half of the available tablets. Among ever consumers, 88% of girls liked the tablet, and 27% reported undesirable changes (primarily heavy menstrual flow). School-level factors represented 75% of the variance in IFA consumption over the school year. Total IFA tablets consumed was associated with the ability to make up missed IFA distributions (+1.4 tablets; 95% CI: +0.8, +2.0 tablets), junior compared with senior secondary school (+5.8; 95% CI: +0.1, +11.5), educators' participating in a program-related training (+7.6; 95% CI: +2.9, 12.2), and educator perceptions that implementation was difficult (-6.9; 95% CI: -12.1, -1.7) and was an excessive time burden (-4.4; 95% CI: -8.4, -0.4). Conclusions Although the program reached Ghanaian schoolgirls, school-level factors were barriers to adherence. Modifications such as expanded training, formalized make-up IFA distributions, sensitization (awareness promotion), and additional support to senior high schools may improve adherence. Spreading the responsibility for IFA distribution to other teachers and streamlining monitoring may reduce the burden at the school level. Strengthening the health education component and improving knowledge of IFA among students may also be beneficial.

Background School-based iron and folic acid (IFA) supplementation is recommended for adolescent girls in countries with high burdens of anemia. Objectives We aimed to evaluate the context-specific effectiveness of a school-based, integrated anemia control program with IFA supplementation in Ghana. Methods Using data from a pre-post, longitudinal program evaluation, we evaluated the effectiveness of school-based weekly IFA supplementation in reducing the burden of anemia and increasing hemoglobin concentrations (Hb; primary outcomes) in 2 regions of Ghana. Generalized linear mixed effects models with schools (clusters) as random effects were used to quantify the change in the anemia prevalence and the mean Hb associated with cumulative IFA tablet consumption over 1 school year (30-36 weeks), controlling for participant-level potential confounders. A cut point for minimum effective cumulative IFA consumption that is reflective of adequate Hb was derived following logistic regression. This cut point was verified by a restricted cubic spline model of IFA consumption and Hb. Results The analytical sample included 60 schools and 1387 girls ages 10-19 years. The prevalence of anemia declined during 1 school year of the intervention, from 25.1% to 19.6% (P = 0.001). Students consumed a mean of 16.4 IFA tablets (range, 0-36). IFA consumption was positively associated with Hb and negatively associated with anemia. Each additional IFA tablet consumed over the school year was associated with a 5% (95% CI, 1-10%) reduction in the adjusted odds of anemia at follow-up, though the relationship is nonlinear. The cut point for minimum effective consumption was 26.7 tablets over a 30-36-week school year, with tablets provided weekly. Conclusions School-based weekly IFA supplementation is effective in improving Hb and reducing the anemia prevalence among schoolgirls in Ghana, though most participants consumed fewer than the minimum effective number of IFA tablets. Increasing intake adherence may further improve anemia outcomes in this population.

To evaluate the impact of an infant, young child feeding practices-small-quantity lipid nutrient supplements (SQ-LNS) intervention on child development scores in children aged 6-18 months in the Katanga Province, Democratic Republic of Congo (DRC).We analyzed data of 2595 children from 2 health zones in a quasi-experimental design with preimplementation and postimplementation surveys to evaluate program impact on child development scores. Standard care was received in the comparison health zone and the intervention health zone received standard care plus enhanced infant, young child feeding practices with a monthly supply of 28 SQ-LNS sachets for up to 1 year. Program exposure and communication and motor domains of the Ages and Stages questionnaire were collected to assess changes in child development scores. A quasi-intent-to-treat and adjusted difference-in-difference analyses were used to quantify impact of the enhanced compared with the standard package.In adjusted models contrasting endline with baseline, there was a greater relative increase in proportion of children with normal communication (difference-in-difference, +13.7% [95%CI, 7.9-19.6; P .001] and gross motor scores, +7.4% [95% CI: 1.3-13.5; P .001]) in the intervention vs comparison health zones. Further, in separate analyses among children of intervention health zone at endline, each additional SQ-LNS distribution was associated with +0.09 (95% CI, 0.03-0.16) z-score unit increase in gross motor scores (P .01).The integrated infant, young child feeding practice-SQ-LNS intervention was positively associated with larger relative improvements in measures of child communication and motor development in the Katanga province of DRC.

To investigate a Florida manatee (Trichechus manatus latirostris) mortality event following a red tide bloom in Southwest Florida, an RNA sequencing experiment was conducted. Gene expression changes in white blood cells were assessed in manatees rescued from a red tide affected area (n = 4) and a control group (n = 7) using RNA sequencing. The genes with the largest fold changes were compared between the two groups to identify molecular pathways related to cellular and disease processes. In total, 591 genes (false discovery rate

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P

Demand for national-level micronutrient status data continues to grow, yet little is known about the implementation of different approaches for collecting these data. We conducted an evaluation of the process of linking the 2015-2016 Malawi Demographic and Health Survey (MDHS) and 2015-2016 Malawi Micronutrient Survey (MNS). We conducted 24 in-depth interviews with stakeholders from the Malawi government and international agencies and field staff. Interview questions explored perceptions of what worked and what was challenging during three phases of implementation: preparation; data collection; and data analysis, reporting, and dissemination. Data were analysed using thematic analysis. Results showed that there was strong government interest to integrate the MDHS and MNS. Perceived benefits included potential cost savings and lower respondent burden. However, government and international agency stakeholders did not view the linkage of the surveys to be a fully integrated approach. The lack of full integration produced challenges throughout implementation, such as complex field logistics and duplication in nutrition indicators assessed and reported. Some stakeholders believed integration was not attainable primarily due to timing. The MDHS and MNS were originally designed as stand-alone surveys, and planning for each survey was at an advanced stage once the government sought to integrate the surveys. Additionally, the MNS could not be incorporated as a module within the MDHS given the complexity of the MNS data collection and short timeframe for planning. These findings can inform decisions about implementing the next MNS and may be transferable to other countries that are conducting micronutrient surveys to address data gaps.

Background Micronutrient powders (MNP) reduce anemia and improve iron status in children aged 6 to 23 months. Little is known about home fortification interventions in low-income and middle-income countries. Objective To describe highlights of the Global Assessment of Home Fortification Interventions 2011, new directions, and needed policy and programmatic guidance. Methods A cross-sectional survey of home fortification interventions was conducted. Staff at UNICEF and regional focal points at Home Fortification Technical Advisory Group partner agencies sent questionnaires to representatives in 152 low-income and middle-income countries. Included interventions met the following criteria: they were for prevention and used MNP, lipid-based nutrient supplements (LNS), or complementary food supplements (CFS); one recommended mode of use was mixing into food; they were implemented or planning to start within 12 months; and research interventions were directly linked to programs. Results This study identified 63 implemented interventions (36 countries) and 28 planned interventions (21 countries), including 34 implemented interventions (22 countries) and 25 planned interventions (20 countries) that used MNP. These interventions were expected to reach 17.2 million people in 2011, including 14.1 million participants in MNP interventions. Among implemented interventions, 16% distributed nationally. Most interventions used integrated approaches targeting young children. Recently, there was increasing expansion of interventions in Africa. The main challenges identified were monitoring and evaluation, adherence, product funding, and procurement. Conclusions Home fortification interventions, especially those that use MNP, are increasing and scaling up rapidly in regions with widespread problems of micronutrient deficiencies and stunting. Home fortification interventions contribute to global initiatives to reduce undernutrition.

ObjectiveTo assess the association of the acute-phase protein biomarkers, C-reactive protein (CRP) and α1-acid glycoprotein (AGP), with anaemia in children aged 6–59·9 months in Papua New Guinea.DesignA nationally representative household-based cross-sectional survey of children aged 6–59·9 months was used to assess the relationships between various combinations of elevated CRP (>5 mg/l) and AGP (>1·2 g/l) with anaemia. Logistic regression was used to determine if other factors, such as age, sex, measures of anthropometry, region, urban/rural residence and household size, modified or confounded the acute-phase protein–anaemia association.SettingPapua New Guinea.SubjectsA total of 870 children aged 6–59·9 months from the 2005 Papua New Guinea National Micronutrient Survey were assessed.ResultsThe following prevalence estimates were found: anaemia 48 %; elevated CRP 32 %; and elevated AGP 33 %. Children with elevated CRP had a prevalence of anaemia of 66 % compared with children with normal CRP who had a prevalence of 40 %. Corresponding estimates for AGP were 61 % and 42 %, respectively. Similar results were found with combinations of elevated CRP and AGP. The higher prevalence of anaemia in children with elevated CRP and/or AGP was still present after controlling for confounders.ConclusionsElevated levels of CRP and AGP were significantly associated with a higher prevalence of anaemia in the children surveyed. There are no expert group recommendations on whether to or how to account for markers of inflammation in presenting results on anaemia prevalence. Additional research would be helpful to clarify this issue.

The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles®) and a lipid-based nutrient supplement (Nutributter®), and to explore people's willingness to pay for these products in a resource-poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6–23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6–23 months were given either Sprinkles® or Nutributter® to use either for a period of 4 weeks, or they were given both products over the 4-week period, i.e. Sprinkles® for 2 weeks and Nutributter® for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4-week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter®. The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles® at a cost of US$0.03 or Nutributter® at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter® or Sprinkles® at a low or subsidized cost through a market-based system may be possible in Niger, if an appropriate distribution system can be identified.

Objectives: To determine a culturally appropriate product name and package design that would communicate important usage instructions for a lipid-based nutrient supplement (LNS) for a target population with diverse languages and low literacy. Methods: Formative work was conducted in two locations in Katanga region, DRC: Mabaya, a rural village and Kipushi, a peri-urban area. In each site, focus group discussions with parents of children aged 0-24 months (3 with mothers, and 1 with fathers) were conducted. Additionally, two key informant interviews with mothers and health workers were conducted in each location. Two sets of 7 images, one for each LNS sachet in the strip, were tested to assess perceptions of use. Different color options and product names were tested to identify culturally appropriate packaging. Results: The majority of participants read the different images on the multi sachet strip as a story line. Participants retained the main messages that the strip should convey: Optimal child feeding and care, product use, target group and potential product benefits. All participants recognized the mother and children in the images as "Congolese". Green and brown were identified as suitable colors for the packaging and were associated with qualities such as growth, and healthy development. The names Kulazuri (eating well) and Afiabora (good health) were preferred. A combination of the first two name proposals "Kulabora" (eating better) was decided upon. Conclusions: The results from this formative assessment were used to finalize the design of the LNS product, which is currently being distributed in Kasenga health zone.

Objectives: To address the high prevalence of anemia and chronic malnutrition (71% and 43% among children

The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles(®)) and a lipid‐based nutrient supplement (Nutributter(®)), and to explore people's willingness to pay for these products in a resource‐poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6–23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6–23 months were given either Sprinkles(®) or Nutributter(®) to use either for a period of 4 weeks, or they were given both products over the 4‐week period, i.e. Sprinkles(®) for 2 weeks and Nutributter(®) for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4‐week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter(®). The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles(®) at a cost of US$0.03 or Nutributter(®) at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter(®) or Sprinkles(®) at a low or subsidized cost through a market‐based system may be possible in Niger, if an appropriate distribution system can be identified.

Background Although much is known about risk factors for low birthweight, an important cause of neonatal death, little is known about how to reduce or prevent low birthweight. Objective This study aimed to verify a low rate in the incidence of low birthweight reported in the Bhutanese refugee camps in Nepal and, if true, to try to understand how this came about. Methods Medical records from 1994 to 2001 were recovered for half of the refugee population, and birthweight and other maternal factors were analyzed. The adequacy of the food ration provided to the general population was assessed by comparing it with the nutrient requirements of pregnant women. Results The rates of low birthweight were indeed low in the refugee camps, averaging 11% in the years reviewed. Between 1996 and 1998, the mean rate of low birthweight fell from 16% to 8% and mean birthweight increased from 2.84 kg (SE, 2.80–2.87) to 3.0 kg (SE, 2.97–3.03). The increase in birthweight occurred following improvements in the micronutrient-to-energy ratios of the general ration. Conclusions Rates of low birthweight comparable to those in developed countries were achieved in an ethnic Nepali population within 5 years of settlement in refugee camps. These low rates were probably achieved because basic needs of mothers were met, including both the quantity and the micronutrient content of food, water and sanitation, antenatal care, and education. The improvement from 1996 to 1998 coincided with increased availability of micronutrients in the food ration. We hypothesize that increased periconceptional micronutrient intake may be responsible for the increase in birthweight.