Home Fortification with a Small-quantity, Lipidbased Nutritional Supplement to Improve Complementary Feeding and Child Nutritional Status in Kasenga (DR Congo).

Objectives: To address the high prevalence of anemia and chronic malnutrition (71% and 43% among children <5 respectively), UNICEF and CDC supported the Ministry of Public Health to develop an integrated IYCN pilot program in October 2012, which includes the distribution of a small-quantity, lipid-based nutrition supplement (SQ-LNS), through the routine health system. The program targets 16,500 children 0-12 months and their mothers. Methods: The program involves i) monthly individual and group IYCN counseling by trained health workers and volunteers, and ii) a monthly distribution of SQ-LNS (locally known as Kulabora) to children 6-12 months through the health system, for daily consumption. Formative research was conducted to generate culturally acceptable key counseling messages and product branding. Routine health system reporting and bi-annual Lot Quality Assurance Surveys (LQAS) are used for program monitoring. Results: After 10 months of intervention, LQAS data showed 65% of mothers received the Kulabora at the last monthly health center visit, 53% received IYCN counseling at this visit, and additionally 55% received counseling by volunteers at home. Routine monitoring data reports that 3,100 women have enrolled in the program and approximately 2,000 children receive Kulabora monthly. Results from two rounds of LQAS show improvements in several IYCN indicators. LQAS data has allowed for targeted corrective action and further formative work will be used for program strengthening. Conclusions: Formative research has been important for program success, and program implementation is possible even in difficult settings. The impact assessment in October 2014 will inform a possible scaling up of the program.

Evidence of Effectiveness of Flour Fortification on Iron Status and Anemia: A Literature Review.

Objectives: The effectiveness of wheat- and maize-flour fortification for improving iron status and anemia in real-world situations has not been documented. The objective was to review published and grey literature on the public-health impact of flour fortification. Methods: A systematic literature review was undertaken, including a search of 17 databases and an e-mail appeal for unpublished reports. Two researchers reviewed 1881 documents. Only studies on government-supported, large-scale fortification programs with anemia or iron outcomes measured prior to and > 12 months after initiation of fortification were included. Results: Twelve studies describing 25 sub-groups (n=13 for children < 15 years, n=12 for women of reproductive age (WRA)) were analyzed. Eight studies used a pre-post design, 4 included a control population, and none adjusted for possible confounding factors. From the pre- to the postfortification periods (and as difference-in-difference for those that included a control group), hemoglobin increased significantly in 4 of 11 studies with children and 5/11 studies with WRA; hemoglobin decreased significantly in 1/11 studies with children and 2/11 with WRA. Anemia prevalence decreased significantly in 4/8 studies with children and 3/10 studies with WRA; anemia prevalence increased significantly in 1/8 studies with children and 2/3 studies with WRA. The prevalence of low serum ferritin statistically decreased in 1/6 studies with children and 3/3 studies with WRA.Conclusions: Available studies confirm that large-scale fortification can positively impact iron and anemia status in children and women of reproductive age; however there is not enough evidence yet to understand under what conditions such impact is greatest.

Formative Work to Design the Packaging of a Lipid-based Nutrient Supplement for a Home Fortification Program in the Democratic Republic of Congo (DRC) .

Objectives: To determine a culturally appropriate product name and package design that would communicate important usage instructions for a lipid-based nutrient supplement (LNS) for a target population with diverse languages and low literacy. Methods: Formative work was conducted in two locations in Katanga region, DRC: Mabaya, a rural village and Kipushi, a peri-urban area. In each site, focus group discussions with parents of children aged 0-24 months (3 with mothers, and 1 with fathers) were conducted. Additionally, two key informant interviews with mothers and health workers were conducted in each location. Two sets of 7 images, one for each LNS sachet in the strip, were tested to assess perceptions of use. Different color options and product names were tested to identify culturally appropriate packaging. Results: The majority of participants read the different images on the multi sachet strip as a story line. Participants retained the main messages that the strip should convey: Optimal child feeding and care, product use, target group and potential product benefits. All participants recognized the mother and children in the images as "Congolese". Green and brown were identified as suitable colors for the packaging and were associated with qualities such as growth, and healthy development. The names Kulazuri (eating well) and Afiabora (good health) were preferred. A combination of the first two name proposals "Kulabora" (eating better) was decided upon. Conclusions: The results from this formative assessment were used to finalize the design of the LNS product, which is currently being distributed in Kasenga health zone.

Micronutrient Supplementation during Pregnancy among Mildly and Non-anemic Women: Effects on Iron Status and Hemoglobin.

Objectives: Universal prenatal iron-folic acid and other micronutrient supplements are recommended to prevent anemia during pregnancy, but the evidence of their effect on iron status among women with mild or no anemia is limited. This study is to describe the iron status [serum ferritin (SF), serum transferrin receptor (sTfR), and body iron (BI)] before and after micronutrient supplementation during pregnancy. Methods: Among 834 pregnant women with mild or no anemia (Hb >110 g/L) from a subset of participants in a randomized, double-blind trial in China, women were randomly assigned to daily 400 µg folic acid (FA) (control), folic acid plus 30mg iron (IFA,), or folic acid, iron, plus 13 additional multiple micronutrients (MM) provided before 20 weeks gestation to delivery. Venous blood was collected during study enrollment (<20 weeks gestation) and at 28-32 weeks gestation. Results: At 28-32 weeks gestation , compared to FA group, both the IFA and MM group showed significantly lower prevalence of iron deficiency (ID) no matter which indicator (SF, sTfR, or BI) was used for defining ID. The prevalence of ID at 28-32 weeks gestation for IFA, MM, and FA were 35.3%, 42.7%, and 59.6% respectively using low SF; were 53.6%, 59.9%, and 69.9% respectively using high sTfR; and were 34.5%, 41.2%, and 59.6% respectively using low BI. However, there was no difference on anemia prevalence between FA and IFA or MM groups. Conclusions: Compared to FA alone, prenatal IFA and MM supplements provided to women with no or mild anemia improved later pregnancy iron status but did not affect perinatal anemia.