Dietary Diversity is a Good Indicator of Micronutrient Intake among Kenyan Women, Moderated by Season.

Objectives: Determining that dietary diversity can be used as indicator of micronutrient adequacy irrespective of season, we examined seasonal variations in dietary diversity, nutrient adequacy, and their association among Kenyan women (reproductive age). Methods: Repeated non-consecutive 24hr-recalls data collected during pre-harvest (period 1, Oct 2007, n=73), post-harvest (period 2, April 2008, n=203) and pre-harvest (period 3, Oct 2008, n=192) seasons. We constructed dietary diversity scores (DDS) based on 13 food groups, minimum intake of 15 g and calculated mean probability of adequacy (MPA) for 11 micronutrients. Correlations / regression analysis tested association between DDS and MPA and effects of season. Sensitivity/specificity analysis detected cut-off values of DDS indicating low nutrient adequacy. Results: DDS ranged from 4.5±1.2 period 1 to 3.2±1.3 period 3, indicating low diverse diet, based on starchy staples, without consumption of organ meat and fish. MPA ranged from 0.36±0.07 period 1 to 0.11±0.08 period 3. DDS and MPA were significantly associated in all seasons, the strength of association varied slightly per season, being stronger in the post/pre-harvest periods 2 and 3. DDS cut-off of 4 (MPA≤40%) periods 1 and 2, and DDS cut-off of 3 (MPA≤20%) period 3, maximized sensitivity/specificity detecting low adequacy. Conclusions: DDS can be used as a simple indicator for micronutrient adequacy, but strength of association and cut-off level of DDS indicating inadequacy is moderated by season.

Can local Diets Meet the Nutrient Adequacy of Young Children in Ethiopia? Evidence from the National Food Consumption Survey.

Objectives: Infants from 6 months onwards need energy- and nutrient dense complementary foods. This is a challenge in Ethiopia, where monotonous diets of poor nutrient density are fed to young children. We used data of the National Food Consumption Survey to determine nutrient adequacy of young children's diet and develop local food-based complementary feeding recommendations (CFR). Methods: Representative data were used on food intakes of children 12-23 months, from four regions. Linear goal programming (Optifood) was applied to develop population specific local foodbased CFR based on local foods and identify critical nutrients, for which local foods cannot meet recommendations. Results: Data were available from 1544 children. 40-47 different foods were frequently consumed by(>5%of children) and >85% still received breast milk. Portion sizes were small: 62-73% of the consumed foods were eaten in daily portion sizes below 15 gram. Foods consumed in larger quantities (>100 gram) differ per region. Dairy Milk was consumed in large quantities in each region. Wheat was consumed in all regions but in moderate quantities (25 grams per day in SNNP to >100 gram in Tigray). Due to low overall intakes micronutrient deficiencies are likely. Promising foods to contribute to micronutrient intake are chickpeas (iron), millet (iron and calcium) and teff (iron), but there are no local foods with meaningful zinc contents. Conclusions: The findings indicate that improved CFR can probably meet the nutrient requirements of some nutrients in Ethiopian young children. However, additional interventions will be required to meet requirements of zinc and probably others.

Monitoring and Evaluation of Complex Market-based Approaches to Improve Micronutrient Malnutrition: The Case of Amsterdam Initiative against Malnutrition (AIM).

Objectives: AIM is a partnership of 20 organizations in Europe and Africa. It includes 7 projects that combine assurance of sufficient and affordable quality of food supply (‘push') with stimulation of demand for nutritious foods (‘pull'). AIM provides the opportunity to assess the effectiveness of different market-based solutions and extract lessons for up-scaling and replication. The publicprivate and multi-strategy character of the AIM programme requires a monitoring and evaluation (M&E) system that addresses the complexity of the AIM partnership and its interventions. Methods: Through participatory consultation result pathways and M&E plans for each project were developed. These laid the basis for the AIM overall programme logic and M&E framework. Results: Building the M&E system involved (re)defining project impact pathways; identifying indicators; further landscape analysis; investment in baseline studies and evaluations; designing monitoring and reflection processes; formulation of project overarching learning questions and specific research questions within the projects. Conclusions: Building a meaningful M&E system for a complex programme like AIM's requires: bridging a development perspective (government, NGOs) with a production perspective (business); addressing reluctance to cover extra costs for M&E; finding creative solutions for building evidence, including rigorous designs for complex interventions; and reaching agreement on sharing results in the public domain which is not always desirable from a production perspective. Building capacity and trust coupled with good governance forms the basis for this process.

Designing Rigorous Program Evaluations to Assess the Impact on Child Growth of Integrated IYCN Programs in Burkina Faso and Ethiopia.

Objectives: The Micronutrient Initiative and academic partners have designed two program impact evaluations of Infant and Young Child Nutrition (IYCN) interventions in Ethiopia and Burkina Faso. The programs include enhanced behavioral change interventions on IYCN, improved quality of local complementary feeding, provision of Multiple Micronutrient Powders (MNPs) to children 6 to 23 months, and ensuring an integrated preventive and community-based management of moderate acute malnutrition. The objective is to critically review key elements for consideration in the design of future IYCN program evaluations. Methods: Evaluation designs were based on 1) selection of primary and secondary outcome indicators based on the Program Impact Pathways (PIP), 2) Considerations for assignment of intervention and comparison groups; 3) Considerations on designs in the context of integrated programs; 4) Ability to monitor adverse events within a program. Results: Following PIP, both impact and process indicators were identified. In Ethiopia, a matched-control cluster design and in Burkina Faso a cluster randomized matched-control design was used with repeated cross-sectional surveys. Sample size calculations took into account the selection of age-appropriate cohorts for the different impact indicators, and a population based sampling scheme. Following recent discussions around the safety of iron-containing supplements in young children without iron deficiency, the evaluations also included practical methods to assess potential adverse events in program settings. Conclusions: The complexity of measuring impact on child nutrition in an integrated programmatic context is often underestimated, leading to evaluations with inconclusive results or impacts that are difficult to attribute to program. Careful design could help avoid such pitfalls.

Effect of Provitamin A-biofortified Cassava on Vitamin A Status of Kenyan Children: A Randomised Controlled Trial.

Objectives: To measure the effect of daily consumption of provitamin A-biofortified cassava on vitamin A status in children aged 5-13 years. Methods: Mild-to-moderate vitamin A deficient children (n=342) were randomly allocated to groups receiving: 1) 375 g of white cassava and placebo supplement; 2) 375 g of white cassava and a supplement of β-carotene (1,054 μg); 3) 375 g of biofortified cassava and placebo supplement. Children received the intervention 6 days/week for 18.5 weeks. Field staff and participants were blinded to supplementation. Cooked cassava was mashed with salt and 4 g of oil per portion. Biofortified cassava supplied 208 μg RAE, which is ~50% of the age-specific estimated average requirement for vitamin A for children. The primary endpoint was serum retinol concentration and secondary endpoint was serum β-carotene concentration, both at end of intervention; in the analysis, we adjusted for sex and serum concentrations at baseline of retinol, C-reactive protein and α1-acid-glycoprotein. Results: Complete data were collected for 337 children. Compliance to cassava feeding was similar between treatment groups. Preliminary results showed that consumption of biofortified cassava and β-carotene supplementation resulted in a similar increase in retinol concentrations (for both interventions, mean: 0.81 μmol/L versus 0.77 μmol/L; difference, 95% CI: 0.04 μmol/L, 0.00─0.07 μmol/L) but in a different increase in serum β-carotene concentration (for β-carotene supplement group, mean: 0.25 μmol/L (95% CI: 0.17─0.33), for biofortified cassava group, mean: 0.81 μmol/L (95% CI: 0.73-0.88)) Conclusions: Provitamin A-biofortified cassava improves the vitamin A status of primary school children in Kenya.

Proxy Markers of Serum Retinol Concentration, Used Alone and in Combination, to Assess Population Vitamin A Status in Kenyan Children.

Objectives: To assess the diagnostic performance of serum concentrations of retinol-binding protein (RBP), transthyretin, retinol concentration measured by fluorometry and RBP:transthyretin molar ratio, either alone or in combination, to estimate the prevalence of vitamin A deficiency (serum retinol concentration <0.70 μmol/L measured by high-performance liquid chromatography(HPLC)). Methods: A cross-sectional study was conducted in 15 primary schools in Kibwezi and Makindu districts in Eastern province, Kenya in June 2010 with 375 schoolchildren (6-12 years), 25 randomly selected from each school by lot quality assurance sampling. Results: Complete data were collected for 372 children. Mean serum concentration of retinol (HPLC), RBP and transthyretin were 0.87 (SD 0.19) µmol/L, 0.67 (SD 0.17) µmol/L and 3.0 (SD 0.62) µmol/L. The mean RBP: Transthyretin molar ratio was 0.23. The prevalence of vitamin A deficiency measured with HPLC was 18%. Transthyretin and RBP showed the largest area under the curve (AUCs 0.96 and 0.93, respectively). Logistic regression resulted in a model predicting vitamin A deficiency based on RBP, transthyretin and C-reactive protein (AUC: 0.98) and prevalence depending cutpoints for the linear predictor were calculated. Conclusions: Combination of transthyretin, RBP and C-reactive protein in a linear predictor showed excellent diagnostic performance in assessing vitamin A status, and has great potential to eventually replace serum retinol concentration measured by HPLC as the preferred method to assess the population burden of vitamin A deficiency. Further research is needed to confirm whether this linear predictor yields similar results in different populations and laboratories. Our methodology can be widely applied for other diagnostic aims.

Efficacy of Amaranth Grain Flour or Multi-micronutrient Fortified Maize Porridge on Iron of Kenyan Pre-school Children: A Randomized, Controlled Intervention.

Objectives: Adding iron-rich foods or multi-micronutrients powder (MNP) could be options to control iron deficiency anaemia (IDA) in children. Data evaluating the impact of fortification with iron-rich foods such as amaranth grain and MNP containing low doses of highly bio-available iron to control IDA is limited. We assessed the efficacy of maize porridge enriched with amaranth grain or MNP to reduce IDA in Kenyan pre-school children. Methods: In a 16-week intervention trial, children (n=279; 12-59 months) were randomly assigned to: unrefined maize porridge (control; 4.1 mg of iron/meal); unrefined maize (30%) and amaranth grain (70%) porridge (amaranth group; 23 mg of iron/meal); or unrefined maize porridge with MNP (MNP group; 6.6 mg iron/meal; 2.5 mg iron as NaFeEDTA). Primary outcomes were anaemia and iron status with treatment effects estimated relative to control. Results: At baseline, 38% were anaemic and 30% iron deficient. Consumption of MNP reduced prevalence of anaemia [-46% (95% CI= -67,-12)], ID [-70% (95% CI=-89,-16)], IDA [-75% (95% CI= -92,-20)] and soluble transferrin receptor [-10% (95% CI=-16,-4)] concentration while significantly increasing haemoglobin [2.7 g/L (95% CI= 0.4, 5.1)] and plasma ferritin [40% (95% CI=10, 95)] concentration. There was no significant change in haemoglobin or iron status in the amaranth group. Conclusions: Consumption of maize porridge fortified with low dose highly bio-available iron MNP can reduce the prevalence of IDA in pre-school children. In contrast, fortification with amaranth grain even when shown to have high iron concentration without reduction of phytic acid may not show significant improvement in iron status.