High Levels of Iron Deficiency Anaemia (IDA) and Stunting by 6-11 Months of Age in Northern Zambia: Evidence of the Need for Early-Life Intervention Scale-Up.

Objectives: Anaemia and stunting are widespread in Zambia with developmental implications from the individual to the national level. To address these conditions, an integrated Home Fortification with Micronutrient Powders (MNP) and Infant and Young Child Feeding (IYCF) programme has been introduced in Mbala district, Northern Province, Zambia. Here we present key findings from a baseline survey conducted to inform the project and investigate relationships among morbidity, biochemical and anthropometrics in children 6-11 months. Methods: A convenience sample of 631 child-caregiver pairs was recruited from health centres and outposts in Mbala District. We collected demographic, health, biochemical and anthropometric data. Children with severe anaemia or severe acute malnutrition were excluded and referred for treatment. Results: Stunting was 30% and 57% of the children were anaemic (haemoglobin <110 g/L), 42% were iron deficient (serum ferritin <30 μg/L) and 22% had IDA. Children with fever in the previous two weeks had higher rates of anaemia (65% versus 49%, p <0.001) and lower mean haemoglobin (104 g/L versus 107 g/L; p =0.005). 5% were Vitamin A deficient based on retinol binding protein <0.7 μmol/L. Furthermore, 74% of children had signs of inflammation (C-reactive protein >5mg/L and/or alpha-1-glycoprotein >1 g/L). Conclusions: The high rates of anaemia, stunting, and inflammation all indicate a high burden of disease and/or malnutrition among these young children. Children with recent fever were more likely to be anaemic which might have implications for physical and cognitive development. Interventions must target early life to prevent irreversible consequences.

The Effects of Prenatal Corn-Soya Blend (CSB) Plus Supplementation on Maternal and Newborn Outcomes: A Cluster-Randomized Trial in Kampong Chhnang, Cambodia.

Objectives: CSB Plus, a dietary supplement that contains a mixture of macronutrients and micronutrients, is frequently used to assist nutritionally-vulnerable women and children. Little is known about the effectiveness of CSB Plus in pregnancy. The objective of this study was to assess the effects of CSB Plus on maternal weight gain, anemia, and birth size. Methods: Villages (n=75) were randomized to an intervention or comparison arm. Pregnant women (n=547) were recruited during the first 12 weeks of gestation. Supplementation began at enrollment and continued until delivery. The daily ration provided approximately 800kcal. Women in the comparison group did not receive a dietary supplement. Weight and hemoglobin were measured for all women throughout pregnancy and birth anthropometrics were measured within 72 hours of birth. Results: Women receiving CSB Plus had a 16% lower anemia prevalence (p=.001) at 36-38 weeks compared to the comparison group. Further, there was a 5.0% lower rate of preterm birth (p=.006) in the CSB Plus group. Low birth weight was 4.5% lower in the CSB Plus group (6.2 vs. 10.7), but this was not statistically significant. Mean birth weight was similar between the groups (3000 g). There were no significant differences in mean maternal weight gain, birth length, or head circumference between the groups. Conclusions: CSB Plus reduced the rate of anemia, lowered the preterm birth rate, and showed a trend toward reducing low birth weight. CSB Plus did not have effects on other maternal and birth outcomes.

Building Operational Capacity for Successful Implementation of HOME Fortification: Academic Institutional Support for MNP Implementation.

Objectives: Many countries are expressing interest in implementing Home Fortification programmes using Micronutrient Powders (MNP) because of their proven effectiveness and low cost. A gap exists, however, between evidence based guidelines for practical implementation. Therefore our objective was to make technical support globally accessible and build operational capacity for successful implementation of MNP. Methods: As an academic institution and project group we have identified gaps, partners, research needs, and evaluated and streamlined existing guidelines for the implementation of MNP. We developed and field-tested tools for formative research to guide the design of MNP interventions integrated into IYCF and other programmes in Rwanda, Zambia, Cameroon, Laos, Sierra Leone, and Mali. Communication and training strategies and materials were developed, utilized, and continuously improved by our teams in multiple countries followed by comprehensive reporting and recommendations. Results: Broad contextual experience was built and made available to governments in implementing countries, organizational partners, and stakeholders through our team support. We facilitated knowledge exchange through national and global conference presentations and workshops. Research methods, communication and training materials, and monitoring & evaluation tools are constantly improved and adjusted and country specific implementation strategies for MNP are based on our findings. Conclusions: Creating an enabling environment for micronutrient interventions requires collaborative efforts from multiple stakeholders. Our university's multi-disciplinary team has enabled countries to move forward cost-effectively with Home Fortification programmes. Lessons learned are being integrated into practice-oriented technical guidelines and shared with other countries to operationalize and scale-up MNP programmes efficiently and effectively.

Formative Research: A Necessary Step for the Implementation of a Home Fortification Program in Cameroon.

Objectives: To understand caregivers' knowledge on anemia, barriers to optimal infant and young child feeding (IYCF) practices, and the acceptability and appropriate use of micronutrient powders (MNP) in households of children 6-23 months, in order to inform an implementation of MNP in Cameroon. Methods: The study was conducted in health districts of the North and South regions, areas with high prevalence of anaemia among young children. There were two steps: 1) situation analysis including focus group discussions and key informant interviews, 2) 30 day study to assess MNP acceptability and utilization. Caregivers (N=101) were interviewed at baseline, day 10, and day 30. Data were both qualitative and quantitative. Results: The situation analysis demonstrated that knowledge on anaemia and IYCF practices were not appropriate. Potential MNP food vehicles were identified. The 30 day study showed high rates of acceptability (100%). Adherence was challenging for the group on a rigid schedule (30 MNP sachets for 30 days) mainly due to child illness related interruption, which is why a flexible schedule (15 MNP sachets for 30 days) was found more feasible. Opposition to and rumours regarding MNP were observed in some cases. The main motivation factors for giving MNP cited by caregivers were: make child healthy, improve immune system and stimulate appetite. Conclusions: The formative research demonstrated the importance of a strong community sensitisation. A comprehensive communication strategy and community-based capacity building are essential to maximise acceptability, appropriate MNP utilization, adherence, and prevent rumour generation. Further, implementing MNP provides a great opportunity to strengthen IYCF.

Creating an Enabling Environment for Scaling-up MNP in Lao PDR: A Private-public Partnership.

Objectives: The Scaling-Up-Nutrition movement recognizes the importance of multi-stakeholder partnerships to deliver high-impact nutrition interventions. A private-public partnership in Lao PDR - supported by MMG Limited and involving the Ministry of Health (MoH), UNICEF, Population Services International (PSI) and University of British Columbia (UBC) - offers an opportunity to evaluate such a partnership and to develop an operational delivery model for Micronutrient Powders (MNP). Develop an effective, scalable and sustainable operational delivery model for MNP through a multistakeholder approach involving public and private sector partners. Methods: UBC, PSI, UNICEF and the MoH collaborated through telecommunications and in person, and conducted formative research in rural and urban areas to inform communication materials, food vehicles, packaging, and distribution channels for MNP. Input from all partners was provided for interview guides and other evaluation tools. Results: Individually the partners prepared reports on different research components and collectively provided input into findings. Together, a comprehensive communication strategy has been drafted that promotes MNP along with improved complementary feeding. The MoH and UNICEF, with technical input from UBC, is developing a free distribution model using health workers and volunteers to reach children aged 6-23 months. PSI is creating a social marketing model to complement public sector distribution and expand access to MNP for children aged 6-59 months. Conclusions: This private-public partnership has provided an opportunity to create an enabling environment for scaling-up MNP in Lao PDR. Processes to date highlight the value of different partner perspectives in the design and implementation of formative research, communication materials and programme activities.

Formative Research to Guide Successful Scale-up of Micronutrient Powder Programmes: Lessons Learned from a 4 Country Comparison.

Objectives: Micronutrient Powders (MNP) have been shown to reduce anaemia among young children and are reportedly easy-to-use for home fortification of complementary foods. Many countries are considering implementing MNP. However, to facilitate optimal implementation, formative research must be conducted to address country-specific household barriers such as cultural practices, knowledge and beliefs. 1. Compare findings from 4 countries where formative research was conducted to inform MNP protocols and communication materials. 2. Evaluate tools and share lessons learned to inform country-specific MNP programmes. Methods: In Rwanda, Zambia, Cameroon and Lao PDR, focus groups were conducted with caregivers; and individual caregivers, health workers and community leaders were interviewed on IYCF knowledge, attitudes and practices, anaemia and beliefs. Home-based MNP trials then followed children 6-23 months over 14-30 days with caregivers interviewed to evaluate acceptability and adherence at baseline, midpoint and endline. Formative research tools, MNP and IYCF communication and training materials were tested. Results: Practices varied considerably by country and important barriers identified, particularly regarding complementary feeding. Age at introduction, suitable food vehicle availability and consistency were frequently not concordant with recommendations. For example, in Rwanda porridge was too liquid and in Laos sticky rice too dense for delivering MNP. Whereas, home fortification was universally accepted and tools developed were highly usable. Conclusions: Formative research was indispensible as knowledge, attitudes and practices varied widely between countries with implications for usage, training and communication materials. Tailoring global guidelines using our research tools will help ensure optimal development of country-specific protocols and ultimate effectiveness of MNP home fortification scale-up.

Increased Availability of Micronutrient Rich Foods and Income among Women Farmers Participating in a Cluster Randomized Control Trial of Homestead Food Production (HFP) in Cambodia.

Objectives: Household food insecurity and under-nutrition are prevalent in Cambodia where there is a lack of dietary diversity and reliance on rice. To address these issues, HKI has implemented HFP to increase the availability and consumption of micronutrient-rich foods. We are currently integrating household level fishponds to enhance plant-based HFP; small nutrient-rich fish, consumed whole, are raised together with large fish, which can be eaten or sold. We aim to improve household food security, micronutrient intake and status. To report on the progress of our 24-month cluster RCT after one year intervention in Prey Veng Province. Methods: 90 clusters were established each consisting of a village model farm and 10 families headed by women farmers (n=990). Each cluster was randomly assigned to either: 1) HFP, 2) HFP plus aquaculture, or 3) control. A baseline survey was completed and process monitoring onging with production, and income data among other variables. Results: Median vegetable and fruit production increased by 8 kg and 4 kg, respectively in households receiving any HFP. Income generation from the sale of fruit and vegetables in HFP farms increased by 55%. Small and large fish production increased by 1 and 5 kg, respectively. Conclusions: Early in the intervention we are observing increased fish, fruit and vegetables production as well as income generation. We hope that this will translate into an improvement in nutritional and in in particular micronutrient status.

Informing National Scale-up of Micronutrient Powders: Evidence from a 12-month Effectiveness Study in Rural Rwanda.

Objectives: While the efficacy of Micronutrient Powders (MNP) at reducing anaemia is known, effectiveness within a Community-Based Nutrition Programme (CBNP) in Rwanda is needed to inform scale-up and policy. 1. Determine the acceptability and effectiveness of MNP on the reduction of anaemia in children aged 6-23 months in Nyaruguru and Musanze districts. 2. Investigate the feasibility of national scale-up of MNP within a CBNP. Methods: A 12-month quasi-experimental control trial was conducted with 1049 mother/child pairs (intervention: n=569; control: n=480). Information on household demographics, IYCF knowledge, attitudes and practices, and morbidity, as well as children’s anthropometry and hemoglobin (Hb) were collected at baseline, 6 and 12 months. Caregivers were interviewed on the acceptability and perceived benefits of MNP at midline and endline. Results: At endline, 98% of caregivers were willing to continue using MNP. A high percentage of mothers perceived benefits of MNP, including improved appetite (84%), increased activity levels (87%), and improved health (88%) of their child. Hb levels of children with moderate to severe anemia significantly improved in the intervention group compared to children in the control group (P<0.05). Conclusions: Our results illustrate nearly universal acceptance of MNP among mothers. Together with the reduction in anemia, these findings demonstrate the feasibility of implementing national scale-up of MNP within Rwanda’s CBNP and will help achieve sustainable improvements in infant and young children’s health.

Qualitative Research to Inform the Implementation of Home Fortification with Nutrition Education with Seasonal Malaria Chemoprevention through Early Childhood Development Centres for Children Aged 6-59 Months in Sikasso, Mali.

Objectives: 93.4% of children aged 6-59 months old have malaria in Sikasso, Mali, and 83.5% have anemia. Our qualitative research sought to inform the home fortification with micronutrient powders (MNP) component of a malaria and anemia prevention project with seasonal malaria chemoprevention, delivered through early childhood development centers in 90 villages in Sikasso, Mali. We sought to understand the knowledge, attitudes and practices on infant and young child feeding, anemia prevention, and any opportunities and barriers for proper MNP use at the household level. Methods: 8 focus groups, and 46 in-depth interviews with stakeholders, beneficiaries and providers of the service, and 3 cooking and feeding observations were conducted in 4 villages, purposively selected to represent similar socio-economic status, accessibility to health centers and markets, agricultural and environmental climate as the remaining intervention villages. Results: Age-inappropriate feeding practices, and poor quality and quantity of complementary foods were identified. There is great awareness on the occurrence of anemia but knowledge on causes and preventive measures was lacking. All respondents showed positive interest in MNPs and additional stakeholders and potential barriers were identified, such as multiple family households and the intra-household sharing of meals. Conclusions: These results informed the creation of training materials and cooking demonstrations with MNPs as well as additional people to engage with to create a supportive and enabling environment. This helped guide the implementation of a malaria and anemia prevention project with seasonal malaria chemoprevention and MNP with nutrition education delivered through early childhood development centers in 90 villages in Sikasso, Mali.

Genetic Hemoglobin Disorders and Anemia in Cambodian Women of Reproductive Age.

Objectives: To examine associations between anemia (Hb <120 g/L) and genetic hemoglobin disorders in Cambodian women (18-45 y). Methods: Blood samples of 450 women from Prey Veng province were analyzed with consent. A complete blood count was performed and the presence and typing of hemoglobin disorders was carried out by PCR and hemoglobin electrophoresis. Serum ferritin, serum transferrin receptor, c-reactive protein and other micronutrients were also assessed. Results: Overall, the prevalence of anemia in women was 33.1%, of which 61% was microcytic (Hb <120 g/L and MCV <80 fl). The prevalence of genetic hemoglobin disorders was > 55% (most commonly alpha-thalassemia, Hb E and Hb Constant Spring) and were significantly correlated with anemia. Of women with anemia, over two-thirds had an abnormal genetic hemoglobin type. Less than 5% of women had a low serum ferritin (< 15 µg/L). Conclusions: The most common form of anemia in Cambodian women is microcytic anemia. Genetic Hb disorders are major contributors to anemia in this region. Low serum ferritin was uncommon suggesting that iron deficiency is not a major problem. However, genetic Hb disorders and concurrent infections may be confounding the interpretation of ferritin and leading to an underestimation of iron-deficiency anemia. Other indicators of iron status and other micronutrients involved in anemia are being examined.

Suboptimal Thiamin Status is Common in Women of Childbearing Age in Rural and Urban Cambodia.

Objectives: Thiamin deficiency causes beriberi, which is often fatal in infants who do not receive rapid treatment. Infantile beriberi appears to be common in Cambodia, likely because thiamin deficient mothers produce breast milk low in thiamin. Strategies may be needed to improve thiamin status; however, population representative thiamin data is required. Therefore, we measured erythrocyte thiamin diphosphate (TDP) concentration to assess thiamin status in Cambodian women of childbearing age. Methods: A representative sample of non-pregnant and non-lactating women of childbearing age (20-45 y) in urban Phnom Penh (n=146) and rural Prey Veng (n=156), and for comparison purposes, a convenience sample of urban women in Vancouver, Canada (n=49) were recruited. TDP was measured using HPLC. Results: The response rates were 91% in Phnom Penh and 98% in Prey Veng. Mean ± SD erythrocyte TDP was 100±38 and 87±26 nmol/L in Phnom Penh and Prey Veng, respectively; which were lower than in Canadian women, [128±38 nmol/L (P<0.001)]. Among Cambodian women, thiamin deficiency (TDP < 70 nmol/L) was more prevalent in Prey Veng (24%) than Phnom Penh (12%). Similarly, insufficient thiamin status (TDP < 90 nmol/L) was more prevalent among women living in Prey Veng (59%) than Phnom Penh (39%). Of Canadian women, 84% were thiamin sufficient (TDP > 90 nmol/L). Conclusions: We found a high prevalence of suboptimal thiamin status in Cambodian women of childbearing age, particularly in rural Prey Veng. Supplementation, fortification, and/or food-based strategies may be required to improve thiamin intake in Cambodian women. Funding: UBC Vitamin Research Fund.