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.

The Prevalence of Iodine Deficiency (IDD) among Vulnerable Populations in Ethiopia.

Objectives: IDD is a common cause of preventable mental retardation and brain damage in the world. In Ethiopia, there are no data which reflect the current status of IDD at the national or regional levels. The 2014 Ethiopia National Micronutrient Survey (ENMS) will estimate the national and regional prevalence of IDD among children 5-14 years of age 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 iodine deficiency. Urine samples will be collected from children aged 5-14 years of age and from all non-pregnant womenof reproductive age. Approximately 10 ml of urine will be stored at -20ºC until analyzed for urinary iodine excretion by the Sandell-Kolthoff reaction. WHO/UNICEF/ICCIDD urinary iodine criteria (among school-age children and non-pregnant women of reproductive age) will be used to interpret the findings. Results: The national and regional iodine status will be presented based on median urinary iodine levels for children 5-14 years old and non-pregnant women 15-49 years of age in Ethiopia. Conclusions: This survey will provide national and regional datafor monitoring the progress toward the elimination of IDD in Ethiopia.

Assessment of Status of Infant and Young Child Feeding (IYCF) Practice, Policy and Programs: Achievements and Gaps, in Ethiopia.

Objectives: · To find achievements and gaps in the existing policy, program and practices in reference to Infant and Young Child Feeding in Ethiopia. · To build a consensus among all partners on the way forward to improve the existing IYCF practice. Methods: National publications, guidelines and reports were collected and assessed based on the 15 indicators modified by International Baby Food Action Network (IBFAN) to identify the current situations in the country in reference to the infant and young child feeding policy, program and practices. Participants from government and non-government reviewed and compiled the report. There was an elaborate discussion on each indicator before consensus was reached. The document was also validated by participants from different organizations on February 13, 2013. Results: In this assessment gaps were identified and recommendations were also forwarded. The main gaps include the absence of National Code of Marketing of Breast milk Substitutes and Baby Friendly Hospital Initiative, Idequate maternity leave conditions , lack of knowledge and experience by mothers about optimal complementary feeding practiceand the risk of bottle feeding. Conclusions: Key recommendations are the need of Implementation of the Baby Friendly Hospital Initiative and the International Code of Marketing of Breast milk Substitutes and capacitating of ealth workers in giving IYCF support skills for mothers. There is the needto review labour regulations s. This calls for the attention of policy makers and partners to promote optimal breastfeeding for the well being of infants and children in the country.

Iodine and other Nutritional Predictors of Infant and Young Child Development: Results from a Cluster Randomized Trial in Amhara, Ethiopia.

Objectives: The objective was to examine nutritional, health, and social predictors of early child mental development in the Amhara region of Ethiopia Methods: Using a cluster randomized design, iodized salt was forced early into the markets of 30 villages (intervention group) before it became available in the 30 control villages following national salt iodization legislation. A total of 1880 infants 6 to 10 mo old in the 60 villages were administered Bayley Scales of Infant and Toddler Development (BSID-III) at baseline and when they were 20-29 mo of age (86% of sample) Results: The two groups had similar socioeconomic, nutrition, and mental development scores at baseline. These variables were significant predictors of endline cognitive and language development scores: length-for-age z-score (p<0.001), weight-for-age z-score (p<0.001), psychosocial stimulation (p<0.001), water/sanitation (p<0.001), mother's education (p<0.01), family assets (p<0.001), recent deworming (p<0.05), and maternal depression (p<0.05). The intervention group had significantly higher mental development scores, and a multiple regression analysis revealed that the intervention effect was positively partially mediated by length-for-age z-score (std β= 0.16 to 0.21, p<0.01) and water/sanitation score (std β= 0.09 to 0.10, p<0.01). Conclusions: In conclusion, iodized salt improved children's mental development both directly and indirectly by its effect on growth. The indirect effect through water/sanitation may be because water and sanitation improve health.

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.

Iodine and Other Nutritional Predictors of Preschool-Aged Children's Development in Amhara, Ethiopia.

Objectives: The study examined nutritional and other predictors of mental development of preschool-aged children in northern Ethiopia. The current analysis of older children from the iodized salt project (see Infant study) included the effects of iodized salt, along with other determinants. Methods: Using a cluster randomized design, 1550 children in 60 villages in Amhara, Ethiopia were given tests of School Readiness and Wechsler verbal and nonverbal reasoning, twice at 54- 60 months and again at 69-78 months. Between these assessments, iodized salt was distributed early in the markets of 30 randomly assigned villages (intervention group) before it became available in 30 control villages. Results: The two groups were largely comparable at baseline. In addition to the effects of iodized salt on School Readiness (p=0.01) and nonverbal reasoning (p<0.10) seen at the endline, the following predictors were positively and significantly associated with cognitive outcomes: heightfor- age z-score (HAZ; p<0.0001), weight-for-age z-score (p<0.0001), family assets (p<0.0001), recent deworming (p=0.01), improved water/sanitation (p<0.01), and mother's education (p<0.05). Although over two-thirds had palpable goiter, hemoglobin status was good (M=134 g/L). Children overall performed relatively better on the School Readiness test (M=6.66 Intervention and 6.25 Control) than nonverbal reasoning (M= 4.15 Intervention and 3.95 Control)(theoretic ranges 0-19). A multiple regression, following the Baron and Kenny mediation analysis, on School Readiness scores revealed that the intervention effect was partially mediated by HAZ (std β= 0.37 , p<0.0001). Conclusions: In conclusion, iodized salt improved children's School Readiness skills and nonverbal reasoning, both directly, and indirectly by way of its effect on growth.

Variation of Serum Selenium (Se) in Children from Amhara Region, Ethiopia. Will Low Se Affect the Success of Salt Iodization in Ethiopia.

Objectives: To assess Se status of 54-60 month-old children in the Amhara region, Ethiopia Methods: Serum from 280 children from five zones of the Amhara regional state, Ethiopia, was analyzed by inductively coupled plasma mass spectrometry (ICP-MS). Results: The mean serum Se concentration was 65.89±38.4 μg/L (median: 54.54 μg/L). Individual values ranged from 10.66-255.45 μg/L. Overall, 77% of the study children were below the recommended cutoff. The mean serum Se varied by administrative zones (p<0.05). Mean serum Se concentrations from West Gojjam 44.13±11.37 μg/L; East Gojjam 60.03±26.06 μg/L; and South Gonder 61.76±24.34 μg/L were below the cutoff while mean Se concentrations for South Wollo 153.95±50.47 μg/L; Wagehmera 179.95±46.87 μg/L were adequate;. Means for children from East and West Gojjam and South Gonder were not different (p=0.42) from each other but they were different (p < 0.05) from means of children from South Wollo and Wagehmera. In addition, mean Se concentrations for children from South Wollo and Wagehmera were different (P<0.05) from each other. Conclusions: Our data illustrate the variability of serum Se in children by zones. Although, Ethiopia is making progress with salt iodization, low Se status in some areas may hamper iodine metabolism and success of the salt iodization program.

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.

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.

Modelling the Impact of Fortification on the Prevalence of Inadequate Micronutrient Intakes in Ethiopia: Results from the Ethiopian National Food Consumption Survey.

Objectives: To estimate the potential impact of national fortification of wheat flour and vegetable oil on inadequate intakes of vitamin A, zinc and iron in Ethiopian women of childbearing age. Methods: Nationally representative 24-hour dietary recall data were collected from children (6-35 months), women (15-45 years), and males (19-45 years, urban only). Prevalence of inadequate and excessive intakes of vitamin A, zinc and iron were analysed using IMAPP after adjusting usual intake distributions with external within-person variance estimates. Modelling was based on fortification of oil with vitamin A (2000 μg / 100g), and wheat with vitamin A (380 μg / 100 g), zinc (9 mg / 100 g) and iron (6 mg / 100 g). Results: Across 8267 households, 50% and 20% of women consumed oil and wheat, respectively. Vitamin A fortification of oil and wheat was estimated to reduce inadequacy from 59% to 36%. Zinc fortification of wheat could reduce inadequacy from 61% to 50%. For iron, <1% had inadequate current intakes. It was estimated that fortification would be more effective in urban areas, despite a similar initial prevalence of inadequacy, as higher proportions consumed fortifiable products (percentage change in vitamin A inadequacy: urban 65%, rural 24%; and zinc inadequacy: urban 51%, rural 12%). Fortification with vitamin A and zinc did not expose any population sub-group to >3% excessive intakes. Conclusions: Fortification of oil and wheat with vitamin A, and wheat with zinc could reduce inadequacy in Ethiopian women, with greatest impact in urban areas. Iron fortification is not justified as intakes appear high and fortification could expose the population to excessive intakes.

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.

Socio-Demographic Factors Affect Zinc Status of Infants and Preschool Children in East Gojjam, Amhara Region, Ethiopia.

Objectives: The main objective of this study was to assess the prevalence and risk factors of zinc deficiency among infants and preschool children. Methods: A community based, cross-sectional study was conducted in East Gojjam zone between October 2011 and April 2012. Sub-samples about 240 infants and preschool children were randomly selected in the study. Data on potential determinants of zinc deficiency were collected using a structured questionnaire. Serum zinc concentration was measured using Atomic Absorption Spectrometer. Statistical analysis was done using ANOVA and Student’s independent t-test and linear regression model. Results: The mean serum zinc concentration of infants and preschool children was 62.98 (±13.03) µg/dl (95% CI: 61.32, 64.63 µg/dl). About 57.1% of the subjects were zinc deficient. The main determinants of low serum zinc status of infants and preschool children were age and number of family members living on the same land. Zinc status of older children was 3.67 µg/dl (95% CI: -5.58,-1.77 µg/dl) lower than children who were aged 6-10 months. Serum zinc status of infants and preschool children is decreased by 0.83 µg/dl (95% CI:-1.36, -0.30 µg/dl) with each additional family member. Food insecurity, dietary diversity, sex, child health, anthropometric indices, maternal education and wealth index were not associated with serum zinc status. Conclusions: The prevalence of zinc deficiency was more than two-fold of the value set by International Zinc Nutrition Consultative Group. Such potential deficiencies require urgent attention including the endorsement of food fortification programs, complementary food preparation education and family planning implementation.