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.

An Adult Female Equivalent can be used to Estimate Average Individual Consumption of Wheat flour, oil, and Salt from Household Level Ethiopian consumption Survey Data.

Objectives: Individual-level food consumption data remains as the ideal source for national nutrition policy-makers to identify nutrient gaps among vulnerable groups to inform appropriate interventions. Collection of such data is resource and time consuming. The Ethiopian Household Consumption and Expenditure Survey (HCES) could be an alternative source for this information with minimum marginal cost. However, data comparability between the individual-level and the household-level remains uncertain. We hypothesized that data from the HCES would be comparable with individual-level Ethiopian National Food Consumption Survey (NFCS) data with regards to average adult female consumption of wheat flour, oil, and salt. Methods: The nationally and regionally representative HCES (July 2010 to July 2011) cluster survey included 27,844 households. The NFCS (June-September 2011) was conducted on a randomly selected subset of HCES clusters, and included 8,267 women between 15-45 years of age. Data were weighted for relative population sizes. We used the adult-female-equivalent of household fraction to convert household-level HCES data to average adult-female daily consumption of wheat flour, oil, and salt to compare with the NFCS average individual-level 24- hour dietary recall data. Differences between mean gram consumption of wheat flour, oil, and salt were assessed with a paired t-test. Results: No significant differences in average adult female consumption of wheat flour, oil, and salt were found between the two surveys. Conclusions: Findings from this initial analysis suggest that the HCES based estimates can be used to estimate average adult female consumption of wheat flour, oil, and salt.

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.

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.

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.