In an effort to extend the findings of a study in Nepal that reported a 44 percent decrease in maternal mortality resulting from vitamin A or beta carotene supplementation in pregnancy, researchers conducted a large randomized controlled trial in Bangladesh, providing the same dosages that were used in the Nepal study. Supplements were provided from the identification of pregnancy through 12 weeks postpartum. In the study in Bangladesh, however, no differences from control were observed for all-cause maternal, fetal, or infant mortality. While these results differ dramatically from the Nepal study, they concur with those from a similar large-scale trial in Ghana, which also showed no mortality reduction from weekly vitamin A or beta carotene supplementation. The authors suggest a variety of factors that may account for the discrepancy between the Nepal and Bangladesh results, including a lower prevalence of vitamin A deficiency, higher proportion of attended births, and much lower mortality among mothers in Bangladesh.

Effects of Vitamin A or Beta Carotene Supplementation on Pregnancy-Related Mortality and Infant Mortality in Rural Bangladesh: A Cluster Randomized Trial

The authors of a paper published in a supplement to the Food and Nutrition Bulletinin March 2011 make a case for approaching agriculture as an ecological system serving human nutrition. They argue that the same factors that enhance a farm’s ecological performance can enhance the nutritional value it produces.

Greater species diversity enhances the performance of ecological systems, the authors claim, for two reasons: as the richness of species diversity increases, the likelihood increases that at least one of the species will survive a change in the environment, and diverse species interact to facilitate each other’s success. Applying these principles to agriculture and nutrition, they introduce the concept of “functional biodiversity,” where “function” refers to the nutrients the species provides to humans, and suggests that richer functional biodiversity improves both the nutritional and ecological performance of a farm system.

To illustrate their point, they contrast two farms, each growing five species: one with functionally diverse species (maize, beans, squash, sweet potato, and guava), and one with functionally similar species (maize, rice, wheat, sorghum, and millet). Simple species biodiversity is the same for both farms (five species), but the functionally biodiverse system would supply a more diverse diet, providing a greater variety of nutrients. The functionally biodiverse system would perform better ecologically as well, since the mix of functionally dissimilar crops is more likely to have at least one survivor if growing conditions change, and because the crops facilitate each other’s success (e.g., beans fix nitrogen in the soil, benefiting the maize).

To test their concept, the authors compared hemoglobin levels in a Kenyan village based on the level of functional species biodiversity and simple species biodiversity on an individual’s farm. They found that higher functional biodiversity was associated with higher hemoglobin concentration, but detected no relationship with simple species diversity. They suggest that ecological knowledge, tools, and models have an important role to play in efforts to direct food systems at improved human nutrition.

Ecological approaches to human nutrition

Results of a community-based cluster-randomized trial, published in The Lancet in July 2011, demonstrated the impact of peer counseling and support on exclusive breastfeeding (EBF) and diarrhea prevalence in Burkina Faso, Uganda, and South Africa. Peer counselors provided information and home-based support and encouragement for six months of EBF. Mothers participating in the study were offered at least five visits, including one antenatal visit. Comparisons between groups showed higher EBF prevalence at 12 and 24 weeks (assessed by both 24-hour and 7-day recall) among mothers who received peer support in all countries. EBF prevalence was lower at 24 weeks than at 12 weeks in both groups, but the difference between groups was greater at the later assessment.

Although EBF prevalence among mothers receiving peer counseling in Burkina Faso and Uganda was 50 percent or higher at both assessments (7-day recall), in South Africa, prevalence reached only 8 percent at 12 weeks and fell to 2 percent at 24 weeks. The authors attribute this to mixed messages received by South African mothers resulting from promotion of infant formula under the Department of Health’s protein energy malnutrition scheme, previous provision of infant formula by the National Programme for Prevention of Mother-to-Child Transmission of HIV-1, and uncontrolled marketing of infant formula due to the lack of legislation enforcing the International Code of Marketing of Breast-milk Substitutes.

No differences due to the intervention were noted for the prevalence of diarrhea at age 12 weeks or 24 weeks. Since this finding contradicts the results of some similar studies, the authors speculate that breastfeeding may have less effect on diarrhea incidence than on its duration and severity, which were not measured in this study. They also note that in communities where predominant breastfeeding is common, such as Burkina Faso and Uganda, a shift to EBF may not result in large changes in diarrhea-associated morbidity.

The study demonstrates that fairly low-intensity peer counseling intervention may have the potential to significantly increase EBF in sub-Saharan Africa for infants aged up to 6 months.

Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial

A mother’s nutritional status prior to pregnancy and her nutrition during pregnancy can result in intrauterine growth restriction (IUGR), which is associated with poorer cognitive development during childhood and increased risk of cardiovascular, pulmonary, and renal diseases later in life. In a review published in Biomed Central Public Health in April 2011, researchers examined the evidence for the effect of balanced protein energy supplementation during pregnancy on birth outcomes to produce a point estimate for the intervention’s inclusion in the Lives Saved Tool (LiST, see http://www.jhsph.edu/dept/ih/IIP/list/). Balanced protein energy supplementation was defined as nutritional supplementation during pregnancy in which proteins provided less than 25 percent of the total energy content. From 11 studies selected from more than 4,000 potential studies, the primary outcomes examined were incidence of small for gestational age (SGA) birth, mean birth weight, and neonatal mortality.

The review’s meta-analysis found a 31 percent (95 percent confidence interval = 15 percent to 44 percent) reduction in the risk of delivering a SGA infant with balanced protein energy supplementation during pregnancy, with the effect more pronounced in malnourished women. In addition, mean birth weight increased significantly in infants of supplemented women. There was no statistically significant effect of supplementation on neonatal mortality. The authors recommend the 31 percent point estimate for inclusion in the LiST tool, and that balanced protein energy supplementation should be scaled up in developing countries to address IUGR and its negative long-term consequences.

Effect of balanced protein energy supplementation during pregnancy on birth outcomes

A recent special supplement of Maternal and Child Nutrition published in April 2011 is devoted to “Repositioning Children’s Right to Adequate Nutrition in the Sahel” and contains situational analyses of infant and young child nutrition activities in six Sahelian countries: Burkina Faso, Chad, Mali, Mauritania, Niger, and Senegal. The authors of the series compiled, analyzed, and interpreted available information on infant and young child feeding, and the nutrition and health situation of children less than two years of age. Based on this information, the authors determined: (i) whether national policies and activities match international recommendations; (ii) where activities have been successful, and why; and (iii) how international agencies can assist in filling gaps to speed progress in improving the feeding practices and nutritional status of infants and young children in the region. 

Across countries, they noted significant progress in the following areas: promotion of exclusive breastfeeding; countries with vitamin A supplementation reaching more than 80 percent of children; inclusion of zinc supplements for diarrhea treatment; management of acute malnutrition; and the creation of national behavior change communication strategies. Gaps identified included: too few nutrition programs reaching national coverage; lack of adequate monitoring and evaluation to assess program effectiveness; ineffective dissemination and integration of research findings into program activities; a need to expand efforts to prevent and treat zinc deficiency and reduce iron deficiency and anemia; unsystematic integration of screening and treatment for severe acute malnutrition; failure, in some countries, to institute comprehensive approaches for the prevention of HIV transmission through breastfeeding; inconsistent use of nutrition indicators across the region; poor access to documentation of nutrition program activities; and a need for high-level support to promote multi-sectoral activities. In the series summary, the authors propose a comprehensive set of key actions for overcoming these gaps in order to reach the goal of ensuring adequate nutrition for 80 percent of children in the region.

Situational analysis of infant and young child nutrition activities in the Sahel – executive summary

Current WHO/UNICEF diarrhea management guidelines include 10- to 14-day zinc treatment as an adjunct therapy during acute childhood diarrhea based on earlier trials showing substantial reductions in both the duration of the current episode and in preventing diarrhea in the three months post supplementation. However, challenges arose in implementing this policy, as mothers would often stop giving zinc after three to five days as their child’s symptoms went away. Even with intensive campaigns and motivation, studies have shown that adherence lasts only 7 of the intended 14 days. In February 2011, the Journal of Nutrition published findings from a randomized trial conducted in Bangladesh. The authors determined that a shorter course of zinc therapy (five days) is as effective as the standard zinc therapy (ten days) on the incidence and duration of diarrhea among young children (ages 4–59 months). In this study of over 1,600 children, the mean number of repeat episodes did not differ between five days or ten days of zinc treatment, nor did the proportion of children having at least one episode of diarrhea during the 90-day observation period. This study has practical significance because zinc supplementation has been shown to be associated with increased vomiting in young children, suggesting that a shorter course of zinc therapy may be desirable to avoid unnecessary vomiting. Moreover, it cuts treatment costs by 50 percent. While these data strongly suggest using a five-day regime, larger-scale effectiveness studies are needed to assess the preventive efficacy in a less-controlled environment.

Zinc Treatment for 5 or 10 Days Is Equally Efficacious in Preventing Diarrhea in the Subsequent 3 Months Among Bangladeshi Children

Responsive feeding (RF), or the interaction between caregiver and child during feeding, has become an important issue for scientific inquiry—and a component of nutrition programming—in response to studies showing an association between caregiver feeding behaviors and child acceptance of food. To assess evidence concerning the role of feeding behaviors and style, a paper published in the Journal of Nutrition in March 2011 reviewed 21 observational and intervention studies addressing the relationship between RF and child eating behaviors, dietary intake, and growth outcomes. Each of the handful of intervention studies that assessed the relationship between RF and dietary intake showed associations, as did the eight (six observation, two intervention) studies assessing RF and eating behaviors. A preponderance of studies (four of six observational studies; six of seven intervention studies) also showed a positive association between RF and child growth outcomes. Despite these findings, the authors found that lack of uniformity in definitions of RF, and the methods for measuring and coding it, complicates interpretation of results and limits the potential for comparisons across studies. Moreover, in intervention studies, the embedding of RF into broader approaches to address child feeding in many cases prevents isolation of the effect of RF.

Based on their review, the authors emphasize the need for a standard definition of RF to allow comparability among studies, and they call for longitudinal studies to account for caregiver modifications of feeding behaviors in response to changing child characteristics (e.g., temperament or weight status). Also needed, according to the authors, are studies highlighting the role of factors that influence caregivers’ ability to practice optimal feeding behaviors, such as maternal nutritional status and time allocation. They conclude that much additional research still is needed to establish an in-depth understanding of how, when, and why caregivers feed as they do.

Responsive Feeding and Child Undernutrition in Low- and Middle-Income Countries

Infants and young children are particularly vulnerable to iron and zinc deficiency, especially in low-resource settings where they are unreached by fortified products. Targeted use of micronutrient powders (MNP), which contain a variety of nutrients mixed with an inert carrier, is a promising approach to reducing deficiencies in such settings, but the high dose of iron normally found in MNPs raises concerns about increased incidence and intensity of malaria and other infections and prevents their widespread use. One reason that MNPs contain a relatively high amount of iron is that they often are added to cereals that are high in phytic acid that inhibits both iron and zinc absorption. 

A study, published in the Journal of Nutrition in February 2011, aimed to test whether a new MNP formulation containing less but more-absorbable iron, more vitamin C (to enhance iron absorption), and a phytase (an enzyme that breaks down phytic acid) would improve iron and zinc status and growth. The formulation substituted highly absorbable “ferric sodium EDTA” for the less-absorbable iron normally used in MNP. While the use of phytase to break down phytic acid in high-phytate foods is not new, its use at the time of consumption was previously untested. In this double-blind controlled trial, 200 South African school children (ages 5–11) with low iron status received a high-phytate maize porridge to which either MNP or the unfortified carrier was added at consumption for 5 days per week for 23 weeks. Despite the low iron and zinc dose (2.5 mg for each), the formulation was efficacious, resulting in iron and zinc deficiency reductions of 31 percent and 12 percent, respectively, reduced serum transferrin receptor concentration (a measure of iron-deficient red blood cell production), increased serum ferritin concentration (a measure of iron stores), and increased weight-for-age Z-score.

The authors contend that improvements in iron status occurred despite the relatively low iron dose because of the more-absorbable ferric sodium EDTA and the absorption-enhancing effects of vitamin C and the phytase. An MNP product containing a lower dose of highly absorbable iron with vitamin C and phytase to aid in absorption may hold promise for safe use in areas where malaria and other infectious diseases are common.

A Micronutrient Powder with Low Doses of Highly Absorbable Iron and Zinc Reduces Iron and Zinc Deficiency and Improves Weight-For-Age Z-Scores in South African Children

In the October 2010 issue of the Bulletin of the World Health Organization, researchers reported a reduction in episodes of diarrhea and acute lower respiratory infection (ALRI) as well as reduced hospitalizations among infants younger than 6 months after they received a diarrhea treatment intervention providing education on zinc together with access to zinc tablets and oral rehydration solution (ORS). The findings came out of a subgroup analysis of the authors’ previously reported cluster-randomized trial in India.

For children 6 months to 4 years of age, zinc supplementation with ORS for the treatment of acute diarrhea has been shown to reduce the duration and severity of a current diarrhea episode and to protect against diarrhea and ALRI morbidity for two to three subsequent months. For infants younger than 6 months, however, data about the efficacy of this intervention are limited.

The original trial showed that zinc and ORS intervention was more effective than ORS alone at reducing the prevalence of acute diarrhea, ALRI, and hospitalizations for diarrhea and pneumonia. Findings from the 0- to 5-month subgroup analysis were similar. After three months of intervention, the authors found episodes of diarrhea to be 34 percent and 40 percent fewer in the previous 24 hours and 14 days, respectively. After six months, they found 41 percent fewer ALRI episodes in the previous 24 hours, 28 percent fewer diarrhea episodes in the previous 14 days, and fewer hospitalizations due to diarrhea, ALRI, and all causes.

The authors suggested that the lower incidence of diarrhea and ALRI in the subgroup reflects carryover protection after treatment of a previous acute diarrhea episode. Although they acknowledged that retrospective subgroup comparisons should be interpreted with caution, they suggested additional research on this intervention because of the high proportion of diarrhea and ALRI deaths among infants younger than 6 months of age.

Effectiveness of zinc supplementation plus oral rehydration salts for diarrhoea in infants aged less than 6 months in Haryana state, India

Results from a study of an intervention that promoted improved infant diets with or without the introduction of a lipid-based nutrient supplement (LiNS) were published online in August 2010 in Maternal and Child Nutrition. Researchers used a formative research technique called Trials of Improved Practices (TIPs) with groups of mothers during the “hungry season” in a rural Zimbabwean community practicing primarily subsistence farming and market gardening. The TIPs approach, which involves the negotiation of new practices for participants to try and assessment of their experiences with them, identifies appropriate and feasible improved practices for promotion in a behavior change program. The authors conducted TIPs with two groups of mothers and compared the results: one group introduced LiNS (Nutributter®), while in the other group, LiNS was not discussed or provided. 

The most common feeding problem was poor dietary diversity, followed by low energy density of the diet. After TIPs, mothers in both groups were more likely to feed beans, leafy green vegetables, fruit, and peanut/seed butters. Feeding of meat increased, but not significantly. After TIPs, the majority of mothers gave thick and enriched porridge. These changes increased intake of energy, protein, vitamin A, folate, calcium, iron, and zinc in both groups, with greater increases in the LiNS group for fat, folate, iron, and zinc but not for energy and the other nutrients.

The authors attributed the positive results to the creation of barrier-specific messages about locally available foods (“prepare bean powder”) rather than general recommendations (“peas, beans, lentils…are good for children”), and to counseling from local nurses and village health workers rather than from facility-based nurses or  workers. They concluded that while improvements in iron and zinc intake are likely to require a fortified food, significant improvements to infant diets can and should be made using locally available resources.

Complementary feeding messages that target cultural barriers enhance both the use of lipid-based supplements and underlying feeding practices to improve infant diets in rural Zimbabwe