Making a Case for Calcium Supplementation for Prevention of Pregnancy Hypertension in Ethiopia.

Objectives: Calcium supplementation significantly reduces the risk of pre-eclampsia, a major cause of maternal death and pre-term birth. The World Health Organization recommends preventive elemental calcium supplementation for all pregnant women living in areas with low calcium intake. Currently, no intake data is available in Ethiopia to inform the policy decision to include calcium supplementation in the existing antenatal care program. We used data from the 2011 Ethiopian National Food Consumption Survey (ENFCS) to identify regions with low dietary calcium intake and to determine factors associated with calcium intake. Methods: Nationally and regionally representative ENFCS data from 7549 women of 15-45 y, weighted for relative population sizes,) were analyzed. ANOVA was used to determine which regions were consuming low calcium levels (defined as <900 mg). Univariate general linear model was used to identify determinants of calcium intake. Results: All regions were found to consume below 900 mg of calcium per day, with women in the Afar region consuming the highest levels (416.87±1.002 mg; p<0.05). Women with a higher educational status, socio-economic status, and those living in rural areas were associated with higher calcium consumption (p<0.05). The mean intake of women below the age of 30 y (276.06 ±1.00 mg) was significantly higher than women between 30-40 y (251.77±1.00 mg) and above 40y (262.42±1.002 mg) (p<0.05). Conclusions: Calcium supplementation is recommended for antenatal care in all regions of Ethiopia. Improving women's education and socioeconomic status may help to increase the calcium intake of women.

Diet Diversity is Negatively Associated with Stunting among Ethiopian Children 6-35 Months of Age.

Objectives: In 2011, the Ethiopian Demographic and Health Survey reported 44% of children under five years-of-age were stunted (i.e., height-for-age z-score (HAZ) below -2) and 11% were consuming minimum diet diversity (DD), a World Health Organization core indicator for infant and young child feeding. DD has been found to be negatively associated with stunting among children 6-23 months-of-age. Our objective was to determine the association between DD and stunting among Ethiopian children. Methods: We used nationally and regionally representative data from the 2011 Ethiopian National Food Consumption Survey, weighted for relative population sizes (N=6819 children 6-35 monthsof- age). A DD score was calculated for each child by categorizing individual foods consumed in quantities > 5 g in the past 24-hours into the United Nations Children's Fund seven food groups for DD. We used Chi-square to determine in which regions children were consuming minimum DD, defined as ≥4 food groups. We used logistic regression to determine the association between DD and stunting, including all potential socioeconomic, demographic and physiological confounders. Results: DD was negatively associated with stunting (OR= 0.965, p<0.0001). Nationally, 14.9% of children consumed adequate DD, with highest rates observed in the Addis Ababa (27.7%) and Harari (23.9%) region (p<0.0001). Conclusions: As with other populations, our Ethiopian findings suggest that increasing DD may be one method of reducing child stunting rates. Due to broad variations in regional dietary consumption in Ethiopia, future research will include more specific validation exercises of DD as a marker of dietary consumption in this population.

The Prevalence of Zinc Deficiency among Vulnerable Populations in Ethiopia.

Objectives: Widespread zinc deficiency is likely to exist in developing countries where staple diets are predominantly plant based and intakes of animal source foods are low. In Ethiopia, there are no data which reflect the current prevalence of zinc deficiency at the national and regional levels. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional prevalence of Zinc deficiency among children 6-59 months old and non-pregnant women 15-49 years of age. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates of zinc deficiency. The prevalence of zinc deficiency will be determined by measuring serum zinc in venous blood samples using Atomic Absorption Spectrophotometry (AAS). Time of day for blood sampling, time of last meal, time of centrifugation, and other appropriate variables will be collected to assist in interpretation of data. The zinc deficiency cut-off defined by WHO is <70 μg/dL for all target groups will be used to analyze the results. Acute phase proteins alpha-1-acid-glycoprotein (AGP) and C-reactive protein (CRP) will be measured by immunoassay technique to account for the effects of inflammation when interpreting zinc deficiency. Results: The national and regional prevalence of zinc deficiency will be presented among children 6-59 months and non-pregnant women 15-49 years of age with and without inflammation in Ethiopia. Conclusions: This survey will provide national and regional data for zinc supplementation and fortification programs in Ethiopia.

The Nutritional Status of Vulnerable Populations in Ethiopia.

Objectives: According to the Ethiopia Demographic and Health Survey 2011, the prevalence of stunting, wasting, and underweight among children 6-59 months old was 44%, 12% and 29% respectively. The proportion of non-pregnant women with a Body Mass Index (BMI) below 18.5 kg/m2, indicating chronic energy deficiency was 27%. This survey will measure anthropometric status among children 6-59 months of age, school age children 5-14 years of age, non-pregnant women 15-45 years old, and men 15-54 years old at national and regional levels. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates of nutritional status. Anthropometry measurements will be conducted for all target groups using standard methods. Anthropometric indicators of length/heightfor- age, weight-for-height, and weight-for-age will be determined for children 6-59 months. Thinness, normal, overweight and obesity will be assessed according to BMI among other target groups. Results: The national and regional prevalence of stunting, wasting, and underweight among children 6-59 months of age will be presented. The national and regional proportions of thinness, overweight and obesity among all target groups will also be presented. Conclusions: This survey will provide national and regional data to guide nutrition programs in Ethiopia.

The Prevalence of Iron Deficiency Anemia (IDA) and Associated Factors among Vulnerable Populations in Ethiopia.

Objectives: In Ethiopia, there are no data which reflect the current prevalence of iron deficiency (ID) or iron deficiency anemia (IDA) at national or regional levels. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional prevalence of ID and IDA among children 6-59 months old and non-pregnant women 15-49 years of age in Ethiopia. Methods: The prevalence of ID will be determined by measuring serum ferritin (SF) and soluble transferrin receptor (sTfR) from venous blood samples using an automated electrochemiluminescence immunoassay (ELISA) and immuno-turbidimetry technique. Iron deficiency will be defined by SF<12.0 μg/L and sTfR>6.0 mg/L for children 6-59 months of age and SF<15.0 μg/L and sTfR>5.33 mg/L for non-pregnant women. Acute phase proteins alpha-1-acidglycoprotein (AGP) and C-reactive protein (CRP) will be measured to account for the effects of inflammation. The prevalence of anemia will be determined from hemoglobin levels in venous blood samples using a Hemocue® photometer. Anemia will be defined as hemoglobin <11.0 and <12.0 g/dL for children 6-59 months of age and non-pregnant women, respectively. IDA will be defined as either: 1) low serum ferritin levels and low hemoglobin (anemia) or 2) elevated sTfR (iron deficiency) and low hemoglobin (anemia). Results: The national and regional prevalence of iron deficiency and IDA will be presented with and without inflammation among children 6-59 months and non-pregnant women 15-49 years of age in Ethiopia. Conclusions: This survey will provide national and regional data for anemia control and fortification programs in Ethiopia.

The Prevalence of Vitamin A Deficiency (VAD) and Associated Factors among Vulnerable Populations in Ethiopia.

Objectives: There are no data which provide information on the current prevalence of VAD at the national and regional levels in Ethiopia. The 2014 Ethiopia National Micronutrient Survey (ENMS) will provide these estimates among children 6-59 months old and non-pregnant women 15-49 years of age in Ethiopia. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates of vitamin A deficiency. The retinol concentration of venous blood serum will be determined by HPLC. Mild VAD will be defined as a serum retinol concentration <0.70 μmol/L and severe VAD as <0.35 μmol/L. Acute phase proteins alpha-1-acidglycoprotein (AGP) and C-reactive protein (CRP) will be measured by immunoassay technique to account for the effects of inflammation when interpreting VAD. Results: The national and regional prevalence of vitamin A deficiency will be presented among children 6-59 months and non-pregnant women 15-49 years of age with and without inflammation in Ethiopia. Conclusions: This survey will provide national and regional data for vitamin A supplementation and fortification programs in Ethiopia.

Prevalence of Anemia and Associated Factors among Vulnerable Populations in Ethiopia.

Objectives: According to Ethiopia Demographic and Health Survey 2011, the prevalence of anemia among children age 6-59 months and women of reproductive age is 44.2% and 16.6% respectively. The 2014 Ethiopia National Micronutrient Survey will provide national and regional estimates of the prevalence of anemia among children 6-59 months’ old and non-pregnant women 15-49 years of age in Ethiopia. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates of anemia. The prevalence of anemia will be determined from hemoglobin levels in venous blood samples using a Hemocue® photometer. Anemia will be defined by a hemoglobin <11.0 and <12.0 g/dL for children 6-59 months of age and non-pregnant women, respectively. Hemoglobin values will be adjusted for altitude and smoking status. Results: The national and regional prevalence of anemia will be presented for children 6-59 months old and non-pregnant women 15-49 years of age. Conclusions: This survey will provide national and regional data for anemia control and fortification programs in Ethiopia.

The Proportion of Households with Adequately Iodized Salt in Ethiopia.

Objectives: According to the Ethiopia Demographic and Health Survey 2011, the proportion of households using iodized salt (>15 parts per million [PPM]) was 15.4%. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional proportions of households using adequately iodized (>15 ppm) salt in Ethiopia. Methods: The ENMS is a cross-sectional household survey designed to produce national and regionally representative estimates. Samples of salt (20 gram) usually consumed will be collected from approximately 4,000households for qualitative testing using the rapid test kit. Salt samples will be sent to the Ethiopian Health and Nutrition Institute Laboratory where iodometric titration will be conducted. Results: The national and regional proportions of households with adequately iodized (>15 ppm) salt will be presented. Conclusions: This survey will provide national and regional data for monitoring and evaluating the progress of the Universal Salt Iodization (USI) program in Ethiopia.

Sensory Acceptability Trial for a Chickpea-based Ready-to-use Supplementary Food.

Objectives: To assess sensory acceptability of WFP developed, chickpea based and locally produced RUSF products for treatment of moderately malnourished (MAM) children aged from 6 to 59 months and assess the readiness of their caregivers to administer such food Methods: Mother to child pair of 129 numbers from 5 Woredas participated in a two phased acceptability and preference tests to first select two of the most preferred products out of 4 (Chickpea only; Chickpea+Soy; Chickpea+Maize+Soy; and Chickpea+Maize) and then went on assessing the sensory acceptability of the two selected RUSF products with a cohort type study design. Results: Out of the four products, chickpea only was selected to pass to the second phase evaluation of acceptability test and chickpea+soya joins it with random selection owing to the statistical similarity of the rest of the three products. Similarly, Chickpea only was better accepted product out of the two during the 6 days acceptability assessment of the study excelling in 8 of the 9 study variables/quality parameters. Both products has a mean value of more than 4 in most of the study parameter indicating that they were well accepted by the study participants. Conclusions: Chickpea only and chickpea+soya were well accepted and the study concluded that follow on effectiveness study should be carried out to assess the nutritional adequacy of the RUSF products so that it can be put in nutrition programs for MAM treatment.

Overview of the Ethiopian National Food Consumption Survey (NFCS): Implications for Fortification Programsv.

Objectives: NFCS was developed in response to a request by the Federal Ministry of Health to obtain evidence to inform the National Fortification Strategy (NFS). This is one of the first nationally and regionally representative surveys to be conducted using individual-level 24-hour dietary recall data. Methods: Approved survey protocols were used to collect information from 324 enumeration areas. The target population was young children (6-35 months), their closest female caregiver (15- 49 years) and (in 30% of urban households) their closest male caregiver (19-45 years of age). Data collection included 24-hour dietary recall, anthropometry and household characteristics. Results: Data were collected from 8267 households, 8079 children, 8133 women, and 380 men. In the NFCS 27% of children and 20% of women nationally, and 62% of children, 52% of women, 41% of men living in urban centers reported consuming potentially fortifiable wheat. The consumption of oil was much higher, with 70% and 50% of children and women nationally, respectively, and 82%, 72% and 66% of children, women and men living in urban centers. Geometric mean intake of wheat and oil (in consumers) was 28.3 g and 3.6 g per day for children; 64.8 g and 8.7 g per day for women; 53.0 g and 9.0 g per day for urban men, respectively. Conclusions: These data are being used to develop the NFS and number of other diet-related strategies and programs. Hence, it provides an extensive resource to inform and guide nutrition policy, strategy, educational messages and program development for many coming years.

Effective Modalities to Improve Pregnant Women’s Compliance to Daily Prenatal Iron Supplementation.

Objectives: Prenatal Iron Supplementation (PIS) has a paramount contribution for reducing maternal mortality. The coverage and compliance in Ethiopia is 17.3% and 0.4% respectively. The aim of this study was to determine the coverage of and adherence to prenatal PIS and to identify factors affecting utilization of the service. Methods: The formative research was conducted in eight selected woredas, namely Alamata, Enderta, Menze Mama, Menze Gera, Ada Berga, Meta Robi, Sankura and Meskan. The study applied descriptive cross-sectional design with quantitative and qualitative elements targeted at determining the coverage and adherence of PIS and identifying factors affecting utilization of PIS. Results: Among women who gave birth in the preceding year, 40.1% took iron tablets during the pregnancy. The coverage exceeded 50% in Sankura, Enderta and Alamata Woredas; whereas, only one-in-three and one-in-ten women were supplemented in Menze Gera and Menze Mama woredas respectively. However, only 3.6% of them took the supplement for the recommended 90 or more days. Conclusions: The coverage among women who gave birth in the preceding year and among women who were pregnant at the time of the survey was 40.1% and 38.5%, respectively. Lack of adequate stock and poor logistic system, lack of training for front line health workers on ANC, lack of BCC and job aid materials, fear of side effect, fear of taking medication during pregnancy, lack of awareness on the benefits of the supplement have contributed for the low coverage and adherence to PIS.

Daily Dietary Intake of Zinc is positively Associated With Height-for-Age Z-score (Haz) among Ethiopian Children 6-35 Months of Age.

Objectives: In Ethiopia, 44% of children under five years-of-age are stunted (i.e., height-for-age (HAZ) below -2SD). This is considered a major public health concern by the Ethiopian Ministry of Health’s National Nutrition Plan. Future efforts to reduce stunting depend largely on understanding the local determinants of stunting. Zinc deficiency is a recognized risk factor for stunting in this age group and we hypothesized this was also true in Ethiopia. Our objectives were to determine the association between daily dietary zinc intake (DDZI) and HAZ and to also identify determinants of DDZI among children 6-35 months of age. Methods: We used regionally representative data from the 2011 Ethiopian National Food Consumption Survey, weighted for relative population sizes (N=6752 children). Univariate general linear models served to assess the association between HAZ and DDZI and to identify determinants of DDZI. Models included potential socioeconomic, demographic and physiological confounders. Results: DDZI was positively associated with HAZ (p<0.0001). Socio-economic status, maternal education, and maternal age were positively associated with DDZI, while the number of children under 5 years-of-age in a household was negatively associated with DDZI (p<0.0001). Children from the Amhara and SNNPR regions, and those reportedly sick in the previous 2 weeks were most likely to report low DDZI (p<0.0001). Conclusions: Low height-for-age remains a major public health problem in Ethiopia. Our findings suggest that height-for-age is associated with low zinc intake in Ethiopia, providing evidence for Ethiopia’s National Nutrition Plan to emphasize increased consumption of zinc rich foods in young children.

Effects of Governance Structures in Ethiopia on Implementation of Nutrition Interventions.

Objectives: 1. Assess factors that enhance or constrain implementation of nutrition interventions at national and sub national levels. 2. Analyze how direct nutrition interventions and multi sector approaches are implemented at national, regional, zonal and woreda levels. 3. Identify models of effective governance for nutrition interventions. Methods: Key informants were interviewed using a structured questionnaire. National level interviews from the agricultural, health, education, finance, economic development, social protection sectors and UN agencies, civil society and donors were included. Parallel interviews were conducted in four regions - Amhara, Oromia, SNNPR and Tigray - and 16 woredas for a total of 312 interviews at the subnational level. Results: While there was general awareness of the Government's activities as part of the SUN movement, key individuals at the national level were, in general, not able to identify specific actions that had been launched as a result of the 2013 National Nutrition Programme. Linkages between policy and program initiatives between national and sub national levels varied. The vertical and horizontal collaborations were most active where a specific, coordinating body or mechanism had been established. Several models of effective implementation are identified and most often originate outside the health sector. Conclusions: Two dominant models of implementing a multi pronged strategy to alleviate malnutrition exist in Ethiopia. The appropriateness of these models and factors associated with each are discussed.