Estimating the Micronutrient Adequacy of the Food Supply Using Food Balance Sheets for Targeted Nutrition-sensitive Agricultural Approaches: Example of Bangladesh.

Objectives: To estimate the micronutrient availability and adequacy of the food supply of Bangladesh and estimate the additional agricultural output needed to achieve nutrient adequacy. Methods: We estimated micronutrient availability of the food supply using an average of 5 years of Food and Agricultural Organization (FAO) food balance sheet data. We estimated nutrients for non-specific food commodities (e.g., other vegetables) using FAO production data supplemented with known consumption information from a dietary survey. We estimated the probability of adequacy of the food supply using a method similar to the cut-point method of estimating nutrient intake adequacy. Then, we estimated the target level of nutrient needed in the food supply to achieve 80% adequacy and amounts of micronutrient-rich foods and land needed to meet the nutrient shortfall. Results: The current food supply in Bangladesh provides very low amounts (0-1% adequacy) of calcium and vitamins A, C, and folate; and low-moderate amounts of several other micronutrients. Using vitamin A as an example, the food supply would need to provide an additional 570 mcg RAE/capita/d to achieve 80% adequacy. This could be accomplished by adding ~67g/capita/d of carrots or ~73g/capita/d of orange-flesh sweet potatoes, requiring ~4 and 6% of the country's total agricultural land, respectively. Conclusions: National food balance sheets can be used to guide agricultural policies to ensure nutrient adequacy of the food supply, recognizing the need to consider other factors like climate, season, economics, and behavior change to drive food production decisions.

An Economic Model for Optimizing Effective Coverage of MN interventions: A Case Study of Cameroon.

Objectives: Micronutrient (MN) interventions are generally undertaken at national scale. New spatially disaggregated data on MN deficiencies in Cameroon suggest that subnational strategies may be more efficient, but methods to choose among alternative interventions are needed. We developed a tool to plan and manage sub-national MN interventions for Cameroon. Methods: Data from a nationally representative multi-stage cluster survey were used to determine the spatial distribution of MN deficiencies among population sub-groups at greatest risk. Macroregion-specific data (North, South, Douala/Yaoundé) on food intake were used to predict the effects of alternative MN intervention strategies on the prevalence of inadequate MN intake and absorption. MN supplements, fortified and biofortified foods, deworming and behavioral change communication to promote breastfeeding are among the interventions examined. Costs of alternative interventions were prepared. The costs and nutritional benefits of alternative interventions are included in an economic optimization model that chooses the best combination of MN interventions to ensure adequate MN intake, at regional level, over a ten-year planning horizon, given funding and other constraints. Results: Preliminary results indicate large spatial differences in MN deficiencies, e.g., estimated prevalence of vitamin A deficiency varied from ~62% (North region) to ~22% (Northwest region). Consumption of VA-rich foods and fortifiable foods also varies spatially. Hence, program efficiency may be enhanced by adopting targeted sub-national MN intervention strategies. Conclusions: Given spatial patterns in MN deficiencies, diet-driven effectiveness of alternative MN interventions, and costs of these interventions, sub-national MN interventions may offer efficiency gains that exceed the costs of planning and implementing them.

Relationships between Plasma Zinc Concentrations and Clinical Signs of Zinc Deficiency.

Objectives: To evaluate the relationship between plasma zinc concentrations (PZC) and clinical signs of zinc deficiency, and to determine a cut-off for PZC below which individuals would have an increased likelihood of having clinical signs associated with zinc deficiency. Methods: Electronic bibliographic searches were performed to identify literature from experimental zinc depletion studies and case reports of individuals with acrodermatitis enteropathica (AE). Data extracted from relevant literature included demographic characteristics, PZC and the presence or absence of clinical signs likely associated with zinc deficiency. Results: PZC were significantly lower among experimentally depleted individuals with clinical signs than those who remained asymptomatic (zinc depletion studies: (36.0+16.8 vs. 67.9+13.3μg/dL, P<0.034) and among patients with clinical signs of AE before undergoing highdose therapeutic zinc supplementation (35.0 (24.1, 47.4) μg/dL) compared with post-treatment values (108.0 (79.3, 127.0) μg/dL; P<0.01). Among individuals with restricted dietary Zn intake, PZC predicted clinical signs with 88% sensitivity and 75% specificity when using a cutoff of 60μg/dL, and 71% and 92% when applying a cutoff of 40μg/dL. Among individuals with AE, PZC predicted clinical signs with 88% sensitivity and 88% specificity when using a cutoff of 60μg/dL, and 63% and 95% when applying a cutoff of 40μg/dL. Conclusions: These analyses demonstrate a clear relationship between PZC and the presence of clinical signs associated with zinc deficiency among presumably healthy individuals undergoing periods of dietary zinc restriction, as well as individuals with AE pre- and post-treatment, further validating the utility of PZC as a biomarker of severe Zn deficiency.

Comparison of Methods to Assess Adherence to Small-quantity Lipid Based Nutrient Supplements (SQ-LNS) and Dispersible Tablets among Young Burkinabe Children Participating in a Community-based Intervention Trial.

Objectives: Adherence to supplementation provided during an intervention trial can affect study outcomes. We compared different approaches for estimating adherence to SQ-LNS and dispersible tablets in a randomized clinical trial in Burkina Faso to evaluate concordance among results and factors associated with reported non-adherence. Methods: 2453 children (9-18 mo) were randomly assigned to receive daily 20 g SQ-LNS with varying contents of zinc and a dispersible tablet (0 or 5mg zinc). During weekly home visits, reported adherence to SQ-LNS and tablets was collected through caregiver interview and disappearance rate was calculated based on unused packages. In a randomly selected subgroup (n=192), 12-h home observations were completed when children were 11 and 16 mo of age, to assess supplement consumption. Results: Average daily reported SQ-LNS and tablet adherence was 97%±6%. SQ-LNS and tablet disappearance rate also showed high weekly adherence (98%±5%). By contrast, home observation found that only 68% and 58% of children at 11 and 16-mo, respectively, received SQLNS during the observation periods (Rho=0.06, P=0.294 reported vs. observed), and fewer (36 and 28%) received a tablet at 11 and 16-mo (Rho=0.11, P=0.05). Fever, diarrhea, malaria, vomiting and loss of appetite reduced significantly reported consumption of SQ-LNS and, to a lesser extent, tablet (P<0.0001). Conclusions: Discrepancies among observed and reported results suggest possible overreporting of adherence to products and/or that consumption occurs outside the 12h home observation period. Child morbidity may change child acceptance or caregiver perceptions regarding the suitability of supplementation. Better methods are needed to assess adherence in community supplementation trials.

Impact of Small-quantity Lipid-based Nutrient Supplements on Infant and Young Child Feeding Practices.

Objectives: Lipid-based nutrient supplements (LNS) are energy-dense and could change infant and young child feeding (IYCF) practices by changing caregiver perceptions of needs and/or child appetite and demand for breast milk and local complementary foods. We hypothesized that LNS (10-40g/day) would not have significant impacts on IYCF practices. Methods: Infants in three randomized controlled trials were assigned to receive either LNS from 9- 18 mo (Burkina Faso) or 6-18 mo (Ghana and Malawi) or a delayed intervention (DI). All caregivers were given brief didactic messages promoting continued breastfeeding and diverse diets at first distribution of LNS; messages were repeated periodically in Ghana and Malawi (all groups) and not repeated systematically in Burkina Faso. IYCF practices were assessed at 18 mo by caregiver recall of the preceding day and week. Results: The reported prevalence of continued breastfeeding did not vary by intervention group in any site, and was 97%, 74%, and 89% in Burkina Faso, Ghana, and Malawi. Reported frequency of breastfeeding yesterday also did not vary. The proportion of infants meeting the WHO recommendation for minimum dietary diversity (4+ food groups) did not differ by intervention group and was 37%, 75%, and 68% in Burkina Faso, Ghana and Malawi. In Burkina Faso, infants in the LNS group were more likely to meet the WHO recommendation for number of meals/snacks yesterday (79%, vs. 66% in DI group). Conclusions: Provision of LNS did not change most IYCF practices but increased frequency of feeding in one site.

Prevalence of and Risk Factors for Zinc Deficiency among Young Children in Rural Burkina Faso.

Objectives: To determine the prevalence and risk factors of zinc deficiency among young children in rural south-western Burkina Faso. Methods: We collected socio-economic, demographic, feeding practice and morbidity information from a sample of 473 children 6-18 mo of age residing in southern Orodara health district; and measured plasma zinc concentration (PZC) by ICP-AES and C-reactive protein and alpha-1 acid glycoprotein by ELISA to adjust PZC for inflammation. Zinc deficiency was defined as PZC ˂ 65μg/L. Associations between selected risk factors and low PZC were screened in bivariate analyses and assessed by generalized multivariable logistic regression. Results: Mean adjusted PZC was 68.4±13.1 ug/L, and the prevalence of zinc deficiency was 43.5% [95%CI: 38.4-48.7]. The odds of zinc deficiency was significantly higher in households with no livestock ownership as compared to the two highest quintiles of livestock ownership (OR= 2.4- 2.5, p<0.05) and when more households shared the family compound (OR= 1.8, p<0.026 for 3-4 households as compared to 1 household per compound). Religion was also associated with zinc deficiency, but recent child morbidity history and feeding practices were not. Conclusions: There is a high prevalence of zinc deficiency among young children in rural southwestern Burkina Faso, especially among children living in large family compounds. Homestead livestock rearing and possibly some religious/cultural habits may reduce the risk of zinc deficiency.

Vitamin A and Iron Status of Women and Young Children in Major Cities of Cameroon before and after Vitamin A Fortification of Vegetable Oil and Iron Fortification of Wheat Flour.

Objectives: Few data are available on the effectiveness of large-scale food fortification programs. We conducted representative surveys 2 y before and 1 y after introduction of vitamin A (VA)- fortified cooking oil and iron-fortified wheat flour to assess program impact on VA and iron status in urban Cameroon. Methods: In each survey, 10 different households were selected within each of the same 30 clusters in Douala and Yaoundé (n=~300/survey). Indicators of VA (retinol-binding protein, pRBP) and iron (ferritin; soluble transferrin receptor, sTfR) status, adjusted for presence of inflammation (CRP, AGP) and malaria, were assessed among women 15-49 y and children 12-59 mo. Staple food intake was measured by 1-week FFQ, and post-fortification oil and flour samples were collected. Results: Oil and flour were each consumed by >80% of participants. Post-fortification, 44% of oil (85% of "branded" oil) and 76% of flour samples were fortified. Controlling for inflammation and malaria, there was no change in pRBP between pre- and post-fortification values among women (1.41 to 1.40 μmol/L) and children (0.87 to 0.88 μmol/L), but ferritin increased (women: 37 to 47 μg/L; children: 39 to 51 μg/L, both P < 0.05) and sTfR decreased (7.7 to 6.2 and 10.6 to 8.2 mg/L, P < 0.01). Prevalence of anemia decreased among women (46 to 38%, P < 0.05) but not children. Conclusions: After 1 year of a national program, adequately-fortified products are available. Iron status indicators have increased since the initial survey; plausibility analyses will determine whether these changes are attributable to the fortification program.

Consumption of Red Palm Oil and Relationships with Vitamin A Status, Region, and Household Characteristics in a National Survey of Women and Young Children in Cameroon.

Objectives: Red palm oil (RPO) is an important plant source of vitamin A (VA) in Cameroon, where ~210,000 tons were produced in 2011. We conducted a national survey of children and women to assess the prevalence of VA deficiency, frequency and amount of RPO consumption and factors associated with RPO consumption. Methods: 1002 households, each with a child 12-59 mo and a woman 15-49 y, were enrolled in a nationally-representative cluster survey with 3 strata (North, South, Cities). VA status was assessed by inflammation-adjusted plasma retinol-binding protein (RBP). RPO consumption was measured by FFQ and 24 h recall. Results: 35% of children had low adjusted RBP. 54.9% of children and 57.8% of women consumed RPO the previous week, with a mean frequency of 12.2 times/week and 8.7 times /week among consumers, respectively. Median RPO consumption (among consumers) on the previous day was 10.7 g/d for children and 21.4 g/d for women, contributing ~1/3 of total VA intake nationally. RPO consumption was greater among women and children in the South compared with the North and Cities, but did not vary by socio-economic group. Weekly frequency of RPO intake was positively correlated with adjusted RBP among women and children nationally; however, at the regional level, the relationship was significant only among women in the South. Conclusions: Promoting RPO consumption is a potential strategy to increase VA intakes in Cameroon without increasing the risk of excessive intake. Formative research is needed to understand barriers to RPO consumption.

Malaria Infection Affects the Interpretation of Biomarkers of Iron and Vitamin A Status, Even After Adjusting for Systemic Inflammation, but Does Not Affect Plasma Zinc Concentrations.

Objectives: To assess how asymptomatic malaria infection affects the interpretation of biomarkers of iron, vitamin A and zinc status after adjustment for elevated acute phase proteins (APP). Methods: Plasma ferritin (pF), transferrin receptor (sTfR), retinol binding protein (RBP) and zinc (pZn) concentrations were measured among 451 asymptomatic children aged 6-23 months in Burkina Faso, and adjusted for elevated APP (C-reactive protein ≥5 mg/L and/or alpha-1-acidglycoprotein ≥1g/L) based on a four-group categorical model, as per Thurnham. Histidine-rich protein II (HRP2) concentrations >0.75 ng/mL were considered indicative of current or recent malaria parasitemia. Results: 57.4% of children had at least one elevated APP, and 48.5% had elevated HRP2. After adjusting for APP, children with elevated HRP2 had higher pF (23.5+1.5 vs. 11.1+0.8 μg/L, P<0.001) and lower RBP (0.79+0.01 vs. 0.92+0.01 μmol/L, P<0.001) vs. those without. Controlling for APP, there were no differences in pZn among those with and without elevated HRP2 (62.9+0.8 vs. 62.9+0.8 μg/dL, P=0.98). sTfR did not differ by APP status when controlling for HRP2, but was increased in children with elevated HRP2 vs. those without (17.6+0.5 vs. 12.3+0.4mg/L, P<0.0001). After adjusting for HRP2, along with APP, the estimated prevalence of iron deficiency (pF<12 μg/L) increased from 38.7% to 50.6% and vitamin A deficiency (RBP<0.84μmol/L) decreased from 33.4% to 27.7%. Conclusions: Current or recent malaria parasitemia affects indicators of micronutrient status, even after adjusting for APP. Adjusting indicators of iron and vitamin A status based only on APP may inaccurately estimate the prevalence of micronutrient deficiencies in settings with a high prevalence of malaria and inflammation.

Small-quantity Lipid-based Nutrient Supplements, Together with Malaria and Diarrhea Treatment, Improve Growth and Development in Young Burkinabe Children.

Objectives: Small-quantity lipid-based nutrient supplement (SQ-LNS) is a promising home fortification product to supplement young children's diets, but the optimal zinc level to include is uncertain. We assessed growth and development in young Burkinabe children who received SQLNS without or with varied amounts of zinc. Methods: In a partially masked, placebo-controlled, randomized trial, 34 communities were assigned to immediate (II) or non-intervention (NI). 2469 eligible II children were randomly assigned to 1 of 4 groups to receive 20 g LNS/d containing 0, 5 or 10 mg of zinc (and placebo tablet) or LNS without zinc and 5 mg zinc tablet from 9-18 mo of age, along with treatment of malaria and diarrhea. Children in NI (n=797) received neither SQ-LNS, tablets nor morbidity treatment. At 9 and 18 mo, length, weight, and mid-upper arm circumference (MUAC) were measured in all children. In a randomly selected subgroup, motor, language, and personal-social development was assessed at 18 mo (n=747 II; n=376 DI). Results: Reported adherence was 97±5% for SQ-LNS and tablets. Length, weight, MUAC and developmental scores were significantly greater at 18 mo in children who received SQ-LNS and morbidity treatment (p<0.001) compared to NI, but did not differ by II group. Stunting prevalence at 18 mo was 39% in children in NI and significantly reduced to 24-33% in children in the II groups (p<0.0001). Conclusions: Providing daily 20 g LNS with or without zinc along with malaria and diarrhea treatment significantly improved growth and motor, language, and personal-social development in young children.

Iodine Status of Young Burkinabe Children Receiving Small-quantity Lipid-based Nutrient Supplements and Iodized Salt.

Objectives: To assess the impact of supplementing local complementary foods with LNS on iodine status in young Burkinabe children exposed to iodized salt. Methods: In a partially masked, placebo-controlled, randomized trial, 34 communities were assigned to immediate (II) or non-intervention (NI). II children were randomly assigned to receive 20 g LNS/d containing 90 μg iodine with 0 or 10 mg zinc, and NI children received no LNS. Urinary iodine (UI) was assessed in spot samples and thyroxin (T4) and thyroid-stimulating hormone (TSH) concentrations in dried blood spots at 9 and 18 mo among a subset of 123 II children and 56 DI children. Salt samples (n=106) were collected at homes of randomly selected participants for assessment of iodine content by titration. Results: Mean iodine content of salt samples was 37±15 ppm (range 5-86 ppm). 37% had an iodine content <30ppm. At baseline and 18 mo, UI, T4 and TSH did not differ among groups. At 18 mo, median (IQR) UI was 334.8 (193.9-555.7) μg/L, T4 114 (99-138) nmol/L and TSH 0.76 (0.49- 1.09) mU/L in all groups combined. While no child had elevated TSH at 18 mo, more children in NI (8.9%) had low T4 (<65 nmol/L) than in II (1.6%) (p=0.0325). Conclusions: Although the majority of household salt samples contained iodine above the target of 30 ppm, provision of iodine in LNS significantly reduced the percentage of children with abnormally low T4 concentrations at 18 mo.

Short-term, Daily Supplementation with Vitamin A, But Not Beta-carotene, Increases Plasma and Breast Milk Retinol Concentration in Lactating Filipino Women.

Objective: To assess the usefulness of breast milk vitamin A (BMVA) for evaluating the impact of food-based vitamin A (VA) interventions. Methods: We assessed the effect of daily supplementation with 600 ug VA activity as either retinyl palmitate or β-carotene (BC) or 0 ug VA activity as corn oil (CO) on BMVA and BC concentrations in lactating women (n=83) who were randomly assigned to receive one of the three treatments, 6 d/wk for 3 wk. Treatments were administered as capsules (containing either 300 ug or 0 ug VA ), 2 times/d, with morning and noon meals consisting of low VA foods. Plasma and milk concentrations of VA and BC were measured before and after the intervention. Results: Initial mean plasma retinol concentration was 1.29±0.41 umol/L, and the mean change in plasma retinol was greater in the VA group than in the BC and CO groups (0.13, 0.03, -0.04 umol/L, respectively, P<0.01). Initial mean BMVA was 28.0±14.6 nmol/g fat, and the mean change in BMVA was greater in the VA group than in the BC and CO groups (4.6, 0.5, -3.6 nmol/g fat, respectively, P<0.001). Initial plasma BC concentration was 0.33±0.22 umol/L, and the mean change in plasma BC was greater in the BC group than in the VA and CO groups (0.74, 0.02, 0.07 umol/L, respectively, P<0.0001). Conclusions: Both BMVA and plasma retinol concentrations increased in response to supplementation with retinyl palmitate, but bioconversion of BC to VA is limited in this population.

Cost-Effectiveness of Zinc Supplementation for the Prevention or Treatment of Diarrhea among Young Children in Rural Burkina Faso.

Objectives: Zinc supplements may decrease incidence of diarrhea among young children at risk of zinc deficiency. We estimated the cost-effectiveness of three approaches for delivery of preventive and therapeutic zinc supplements in rural Burkina Faso. Methods: Cost estimates were derived from data collected during a community-based randomized zinc trial, information on ongoing child-health days to distribute public health services, and an indepth study of the current health care system. Diarrhea incidence reduction is based on intent-totreat analysis of zinc trial data. Activity-based costing using an ingredients approach accounts for the costs of mutually exclusive inputs related to defined program activities for each approach. Cost-effectiveness is analyzed and compared across an intermittent preventive zinc (IPZ) approach (quarterly delivery of 10-days of 10 mg/d supplements to childrens’ homes), and a therapeutic approach (10-days of 20 mg/d supplements delivered during an ill-child consultation at a local clinic (TZ-CSPS) or via community-based health worker (TZ-CHW)). We assume 81.6% of children are reached with IPZ and .06% and 52% of diarrhea cases treated with TZ-CSPS and TZCHW, respectively. Results: Estimated annual program cost per additional child reached is $3.52 (IPZ), $3.49 (TZCSPS) and $17.59 (TZ-CHW). Cost per death averted in the first program-year is estimated to be $3164 (IPZ), $7363 (TZ-CSPS), and $14068 (TZ-CHW), assuming a diarrhea case fatality rate of 0.3% and 2.64 episodes of diarrhea/child/year. Estimated cases of diarrhea averted per year are 11.5% (IPZ), 0.9% (TZ-CSPS), and 8.2%(TZ-CHW). Conclusions: IPZ is the most cost-effective approach for a zinc program among our study population.

Predicted Impact of Large-scale Fortification on Adequacy of Vitamin A Intakes among Women and Young Children in Cameroon: Simulations Using Nationally-representative 24-h Recall Data.

Objectives: WHO recommends using information on dietary intakes to design food fortification programs, but nationally-representative, individual dietary data are rarely available in low-income countries. Prior to initiating a fortification program in Cameroon, we assessed intakes of vitamin A (VA) and fortifiable foods (vegetable oil, sugar, wheat flour, and bouillon cube), to simulate the effects of fortification with different foods and VA levels on VA intakes. Methods: In a nationally-representative, cluster survey with 3 strata (North, South, Cities), we conducted 24-h dietary recalls among 912 women 15-49 y and 883 children 12-59 mo (with duplicates in a subset). Results: Among women, 50% had usual VA intakes < 500 μg RAE/d (17% South, 99% North, 44% Cities); 58% of non-breastfeeding children had VA intake < 210 μg RAE/d (41% South, 86% North, 60% Cities). Oil fortification with 12 mg VA/kg, as currently mandated, would decrease the prevalence of inadequate intakes to 33% among women and 34% among children (73% and 55% in the North region, where VA deficiency is most common). Increasing the VA in oil or fortifying a second food would further decrease the prevalence of inadequate intakes, but would also increase the prevalence of retinol intakes above the UL, mainly among children. Conclusions: The current food fortification program can be expected to improve dietary VA adequacy among women and children in Cameroon. Modifications to the program must balance the potential to further increase VA intakes with the risk of retinol intake above the UL among children.

Daily Zinc Supplementation, But Not Intermittent or Therapeutic Zinc Supplementation, Increases Plasma Zinc Concentration and Does Not Affect Iron and Vitamin A Status in Young Children.

Objectives: To assess the effect of three zinc supplementation strategies, provided with diarrhea and malaria treatment, on zinc, iron and vitamin A status. Methods: During a community-based, cluster-randomized, zinc supplementation trial, we collected venous blood at baseline and after 48 weeks in a random subsample of 451 rural Burkinabe children 6-18 mo old assigned to 4 groups: 7 mg zinc/d, ORS+placebo for diarrhea (DPZ); 10 mg zinc/d for 10d/16wks followed by daily placebo, ORS+placebo for diarrhea (IPZ); daily placebo, ORS+20mg zinc/d for 10d for diarrhea (TDZ); no intervention (NI). Supplemented children were treated for fever and malaria. Blood hemoglobin concentration (Hb) was measured by HemoCue®. Plasma zinc concentration (pZn), measured by ICP-AES, and plasma ferritin (pF), transferrin receptor (TfR) and retinol-binding protein (RBP) concentrations, measured by ELISA, were adjusted for inflammation. Results: High baseline rates of anemia (88.5% had Hb<11 g/dL), iron deficiency (50.5% had pF<12 ug/L; 89.9% had TfR>8.3 mg/L ), vitamin A deficiency (48.9% had RBP<0.83 umol/L) and zinc deficiency (43.5% had pZn<65 ug/dL) were not different by group. Over 48 weeks, pZn increased significantly more in DPZ (+5.8±1.9%) than in TDZ (-0.7±1.8%) and NI (-1.7±1.3%) but not than in IPZ (+2.3±1.7%). 48-week changes in Hb, pF, TfR and RBP did not differ by group. Conclusions: Daily preventive, but not intermittent preventive or therapeutic zinc supplementation, increased pZn over 48 weeks. Zinc supplementation with malaria and diarrhea treatment did not affect iron and vitamin A status.

Zinc added in Different Amounts to Small-quantity Lipid-based Nutrient Supplements (SQ-LNS) or provided as a Tablet did not affect Diarrhea or Malaria Morbidity in young, Rural Burkinabe Children.

Objectives: Meta-analyses find that supplemental zinc reduces the incidence of diarrhea and acute lower respiratory tract infections, but its effect on malaria is inconsistent. We assessed the effects of different amounts of zinc in SQ-LNS compared with zinc in a dispersible tablet on the incidence of diarrhea and malaria in young children in a community-based, double-blind, placebo controlled, randomized trial in rural, southwestern Burkina Faso. Methods: 2469 children 9 months of age, were assigned to receive one of four interventions: LNS without zinc and placebo tablet (LNS-Zn0; negative control), LNS with 5 mg zinc and placebo tablet (LNS-Zn5), LNS with 10 mg zinc and placebo tablet (LNS-Zn 10) and LNS without zinc and 5 mg zinc tablet (LNS-TabZn5; positive control). Children received 20 g of LNS and one placebo or zinc tablet daily for 9 months. Weekly morbidity surveillance was conducted at children's homes; malaria treatment was provided for confirmed malaria, and ORS provided for reported diarrhea. Results: Prevalence of malaria at baseline (59.4% overall) did not differ among groups. During the 9-month follow-up, the incidence of diarrhea was 1.15 (±1.18 SD) and the incidence of malaria was 0.55 (±0.54 SD) episodes per 100 child-days, and did not differ by treatment group (p=0.673 and p=0.535, respectively). Incidence of severe diarrhea and severe malaria also did not differ by treatment group. Conclusions: The inclusion of 5 or 10 mg zinc in SQ-LNS did not affect diarrhea or malaria morbidity compared to both positive and negative control groups in this population.

Risk Factors Associated with Severe Underweight among Young Children Reporting to a Diarrhoea Treatment Facility in Bangladesh.

Protein-energy malnutrition (PEM) is a serious health problem among young children in Bangladesh. PEM increases childhood morbidity and mortality. Information is needed on the major risk factors for PEM to assist with the design and targeting of appropriate prevention programmes. To compare the underlying characteristics of children, aged 6-24 months, with or without severe underweight, reporting to the Dhaka Hospital of ICDDR,B in Bangladesh, a case-control study was conducted among 507 children with weightfor- age z-score (WAZ) <-3 and 500 comparison children from the same communities with WAZ >-2.5. There were no significant differences between the groups in age [overall mean±standard deviation (SD) 12.6±4.1 months] or sex ratio (44% girls), area of residence, or year of enrollment. Results of logistic regression analysis revealed that severely-underweight children were more likely to have: undernourished mothers [body mass index (BMI) <18.5, adjusted odds ratio (AOR)=3.8, 95% confidence interval (CI) 2.6-5.4] who were aged <19 years (AOR=3.0, 95% CI 1.9-4.8) and completed <5 years of education (AOR=2.7, 95% CI 1.9-3.8), had a history of shorter duration of predominant breastfeeding (<4 months, AOR=2.3, 95% CI 1.6-3.3), discontinued breastfeeding (AOR=2.0, 95% CI 1.1-3.5), and had higher birth-order (>3 AOR=1.8, 95% CI 1.2- 2.7); and fathers who were rickshaw-pullers or unskilled day-labourers (AOR=4.4; 95% CI 3.1-6.1) and completed <5 years of education (AOR=1.5; 95% CI 1.1-2.2), came from poorer families (monthly income of Tk <5,000, AOR=2.7, 95% CI 1.9-3.8). Parental education, economic and nutritional characteristics, child-feeding practices, and birth-order were important risk factors for severe underweight in this population, and these characteristics can be used for designing and targeting preventive intervention programmes.

Guías ACC/AHA 2006. Estado del arte de la evaluación cardiovascular perioperatoria para cirugía no cardiaca: Enfocado en la terapia perioperatoria con betabloqueadores / Guides ACC/AHA 2006. State-of-the-art of the cardiovascular evaluation perioperatoria for surgery noncardiac: Focused in the therapy perioperatoria with betabloqueadores

Reporte de la fuerza de Trabajo sobre Guías de Práctica del Colegio Americano de Cardiología ACC y la Asociación Americana del Corazón AHA (Comité de actualización de las Guías para la evaluación cardiovascular preoperatoria para cirugía no cardiaca). Desarrollado en colaboración con la American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Angiography and Interventions, Society for Cardiovascular Medicine and Biology. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Notas: Este documento fue aprobado por la Fundación Comité del Colegio Americano de Cardiología (ACC) en Marzo de 2006 y por el Consejo Asesor y Consultor de Ciencias de la Asociación Americana de Corazón (AHA) en febrero de 2006. Cuando cite este documento el Colegio Americano de Cardiología requiere el siguiente formato de citación: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular...

Encuesta sobre prácticas y creencias culturales de la población del callejón de Huaylas en relación a la alimentación de los niños durante la diarrea / Survey on cultural practices and beliefs at population of Callejon de Huaylas, relationed to children feeding due to diarrhoea

Para implementar un programa orientado a mejorar la alimentación de los niños durante y después de diarrea aguda, se obtiene información de las creencias culturales y prácticas alimenticias de la población. Se realizaron dos encuestas: Callejón de Huaylas y comunidades urbano-marginales de Lima. Se realizaron estudios antropológicos y un estudio longitudinal