Targeting strategies for balanced energy and protein (BEP) supplementation in pregnancy: study protocol for the TARGET-BEP cluster-randomized controlled trial in rural Bangladesh.

BACKGROUND: The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation be provided to all pregnant women living in undernourished populations, usually defined as having a prevalence > 20% of underweight women, to reduce the risk of stillbirths and small-for-gestational-age neonates. Few geographies meet this threshold, however, and a large proportion of undernourished women and those with inadequate gestational weight gain could miss benefiting from BEP. This study compares the effectiveness of individual targeting approaches for supplementation with micronutrient-fortified BEP vs. multiple micronutrient supplements (MMS) alone as control in pregnancy in improving birth outcomes. METHODS: The TARGET-BEP study is a four-arm, cluster-randomized controlled trial conducted in rural northwestern Bangladesh. Eligible participants are married women aged 15-35 years old identified early in pregnancy using a community-wide, monthly, urine-test-based pregnancy detection system. Beginning at 12-14 weeks of gestation, women in the study area comprising 240 predefined sectors are randomly assigned to one of four intervention arms, with sector serving as the unit of randomization. The interventions involving daily supplementation through end of pregnancy are as follows: (1) MMS (control); (2) BEP; (3) targeted BEP for those with pre-pregnancy body mass index (BMI) < 18.5 kg/m2 and MMS for others; (4) targeted BEP for those with pre-pregnancy BMI < 18.5 kg/m2, MMS for others, and women with inadequate gestational weight gain switched from MMS to BEP until the end of pregnancy. Primary outcomes include birth weight, low birth weight (< 2500 g), and small for gestational age, defined using the 10th percentile of the INTERGROWTH-21st reference, for live-born infants measured within 72 h of birth. Project-hired local female staff visit pregnant women monthly to deliver the assigned supplements, monitor adherence biweekly, and assess weight regularly during pregnancy. Trained data collectors conduct pregnancy outcome assessment and measure newborn anthropometry in the facility or home depending on the place of birth. DISCUSSION: This study will assess the effectiveness of targeted balanced energy and protein supplementation to improve birth outcomes among pregnant women in rural Bangladesh and similar settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05576207. Registered on October 5th, 2022.

Maternal misperception of under-five children weight status and associated factors: A cross-sectional study.

Maternal perceptions, about the nutritional status of their children, may have implications for timely health care seeking and feeding behaviour. Shreds of evidence are limited in this area that assessed maternal perception about the nutritional status of the children in the context of Bangladesh. The objective of this study is to assess the differences in mothers' perceptions about their children's nutritional status who are less than 5 years of age and their associated factors in the context of urban slum areas. A cross-sectional study (Quantitative approach) was conducted in two of the largest urban slums of Dhaka city. A total of 437 mother-children dyads were included in the final analysis. The outcome of interest was the mother's 'varied perceptions' regarding the nutritional status of their children under five. 'Varied perception' refers to the difference between a mother's subjective assessment of her child's nutritional condition and the anthropometrically measured nutritional status. The prevalence of mother's varied perceptions was around 46%, and among them, 37% of mothers underestimated and 9% overestimated their child's nutritional status. 'The child doesn't want to eat' (AOR = 3.69; 95% CI: 2.34-5.85; p < 0.001) and 'Feels light when carried' (AOR = 3.39; 95% CI: 1.69-6.81; p = 0.001) were the significant reasons behind the mother's perception about the nutritional status of their under-five children. About one in two mothers' perceptions about their children varied from the anthropometry-derived status. Various research findings indicate that providing health education on proper feeding practices for children, along with anthropometric measurements, can assist mothers in enhancing their understanding and assessing their child's nutritional status with greater accuracy. Further qualitative research may be instrumental in getting deeper insights into maternal perception to develop context-specific interventions.

Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh.

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh.

Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.

Maternal and Child Survival in Haor Region in Bangladesh. An Analysis of Fathers' Capabilities to Save the Future.

Maternal and child survival is a major public health problem in haor areas in Bangladesh. Fathers feel responsible as expressed by their capability "to save the future". Using the Capability Framework for Child Growth, we aimed to identify what contextual factors underlie a father's real opportunities to secure a safe delivery, including social norms and beliefs. Parents from households having children less than two years old were asked to participate in two rounds of qualitative research. In total, 25 focus group discussions and eight in-depth interviews were conducted. Late admission to health facilities emerged as the overarching disabling factor for fathers' capability to save the lives of mothers and children. Poor communication about the mother's health condition between spouses and fear for caesarean birth were underlying this late admission. In addition, inadequate advice by local doctors, underdeveloped infrastructure, and seasonal extremities contributed to late admission to health care facilities. The participants indicated that mother's autonomy in haor to seek health care is a constraint. This capability analysis points towards relevant interventions. In addition to the need for an improved health infrastructure, programs to improve maternal and child survival in haor could focus on the gendered household responsibilities and poor communication between spouses.

A single nucleotide polymorphism in OPRM1(rs483481) and risk for heroin use disorder.

Opioid receptor mu1 (OPRM1) is the target of many opioid drugs, and it is known to have affinity toward both endogenous and exogenous opioids, opiate and opioid analgesic drugs. The present study was undertaken to explore association of single nucleotide polymorphisms (SNPs) in the OPRM1 gene with heroin use disorder. Ten OPRM1 polymorphisms were analyzed in 132 cases and 147 healthy controls. The SNP rs483481 showed significant allelic, genotypic and haplotypic association (Allelic: p-value = 0.003, OR = 1.75, CI = 1.21-2.55) (Genotypic: p-value = 0.003, OR = 1.72, CI = 1.08-2.75) with heroin use disorder. Allelic and genotypic association remained significant even after multiple testing corrections with 1000 permutations. A significant positive correlation between 'Number of times drug abstained' and 'rs483481-AA genotype' (p-value = 0.002; Pearson correlation = 0.265) was also observed. One-way ANOVA analysis demonstrated significant association of rs483481 with 'number of times drug abstained' (F = 4.86, p-value =0.009). 'A' allele and 'AA' genotype of marker rs483481 seem to confer protective effect while 'G' allele and 'GG' genotype potentiates risk for heroin use disorder. OPRM1 is found to be associated with heroin use disorder in the studied Manipuri cohort. The study suggests that individuals with G allele and GG genotypes at rs483481 could be more vulnerable to heroin dependence, and it could be taken into consideration in prevention and intervention programs.

"We struggle with the earth everyday": parents' perspectives on the capabilities for healthy child growth in haor region of Bangladesh.

BACKGROUND: Childhood stunting is an important public health problem in the haor region of Bangladesh. Haor areas are located in the north-eastern part of the country and are vulnerable to seasonal flooding. The key objective of this study is to identify the capabilities of the parents and their children that shape multidimensional child growth outcomes in the haor region in the first thousand days of life. METHODS: A qualitative study was conducted in two sub-districts of the haor region, including in Derai in the Sunamganj district and Baniachang in the Habiganj district. We facilitated eight focus group discussions with the parents of children under age two. To allow us to explore individual stories, we conducted in-depth interviews with four fathers and four mothers. A capability framework to child growth was used in shaping the interview guides and analysing the data. RESULTS: The findings were categorised at four levels: a) capabilities for the child, b) capabilities for the mother, c) capabilities for the father, and d) capabilities at the household level. At the child's level, the parents discussed the capability to stay away from disease and to eat well, the capability to stay happy and playful, and the capability to be born with God's blessings and the hereditary traits needed to grow in size. The mothers frequently mentioned the capability to stay healthy and nourished, to stay away from violence, and to practice autonomy in allocating time for child care. The fathers stressed the earning opportunities that are affected by long-term flooding and the loss of agricultural productivity. At the household level, they discussed the capability to live in a safe shelter, to be mobile, to overcome their struggles with the earth, and to have a source of safe drinking water. CONCLUSIONS: The capability framework for child growth helped identify relevant capabilities in the haor region. These findings can guide discussions with communities and policy makers about developing programmes and interventions aimed at enhancing the identified capabilities for child growth in this vulnerable region.

FRAGILE ENVIRONMENT, SEASONALITY AND MATERNAL AND CHILDHOOD UNDERNUTRITION IN BANGLADESH.

This study assessed whether agricultural and household incomes were the same across different agro-ecological environments in Bangladesh. An in-depth analysis of the effect of unfavourable ecologies on maternal and child malnutrition was carried out. Data were from a longitudinal data set comprising a nationally representative data sample collected in 2014 and the Food Security Nutrition Surveillance Project (FSNSP) conducted in 2011 and 2012. Anthropometric indices were used to assess the nutritional status of mothers and under-five children. The key variables of interest were food seasonality and geographical location. Data were analysed using the General Linear Model and multinomial and binary logistic regression analysis. Panel data analysis showed that household income was not equal across agro-ecological zones, indicating that the fragility of the environment affects a household's ability to access food, and thus the nutritional status of mothers and children. Coastal areas of Bangladesh were found to be less dependent on agriculture, particularly cultivation, which had diminished during last few decades. Per capita income has been increasing in coastal areas of Bangladesh, led by remittance (money sent home by migrant workers) growing at 8% per year against 6% in other areas. Regression analysis showed that a household in a coastal zone earned 19% less than one in more favourable zones. Although the income from farm practices was found to be lower in unfavourable areas, the deficiency was compensated by increased non-farm incomes. The results from the FSNSP data showed that overall the rates of stunting and wasting among under-five children were 37% and 11.7%, respectively, and nearly 28% of mothers suffered from undernutrition. A highly significant regional heterogeneity in undernutrition was found, with alarmingly high levels in the Haor Basin and coastal belt areas. There were significantly higher rates of underweight and wasting in the monsoon season compared with the two harvest seasons among children under the age of five. The findings stress the importance of bringing geographical location and seasonality thinking into debates on hunger and nutrition in Bangladesh.

Agriculture and Nutrition in Bangladesh: Mapping Evidence to Pathways.

BACKGROUND: Although much work has been done on the theoretical links between agriculture and nutrition, there is limited understanding of the evidence from observational and experimental research studies on the impacts of agriculture programs on nutrition outcomes. OBJECTIVE: To assess the emphasis of the literature on different agriculture-nutrition pathways in Bangladesh. METHODS: Twenty databases and Web sites were searched, yielding more than 2400 resources that were pared down through an iterative, eliminative process to 60 articles. These articles were then rated for quality and mapped to 1 of the 6 agriculture-nutrition pathways. RESULTS: The body of evidence reveals gaps in knowledge in all of the pathways, but especially in the areas of agriculture as a source of livelihoods, and women's role as intermediaries between agriculture and good nutrition and health within their household. CONCLUSION: More research is needed on the links between agriculture and nutrition in country-specific settings, particularly as regards the role of women. Nutrition-related outcomes, such as dietary diversity and women's empowerment, need to be measured more explicitly when evaluating the impact of agricultural production systems and development initiatives.

Is There an Enabling Environment for Nutrition-Sensitive Agriculture in South Asia? Stakeholder Perspectives from India, Bangladesh, and Pakistan.

BACKGROUND: Almost half of all children in South Asia are stunted. Although agriculture has the potential to be a strong driver of undernutrition reduction and serves as the main source of livelihood for over half of South Asia's population, its potential to reduce undernutrition is currently not being realized. OBJECTIVE: The Leveraging Agriculture for Nutrition in South Asia (LANSA) research consortium seeks to understand how agriculture and agrifood systems can be better designed to improve nutrition in South Asia. In 2013 and 2014, LANSA carried out interviews with stakeholders influential in, and/or knowledgeable of, agriculture-nutrition policy in India, Pakistan, and Bangladesh, to gain a better understanding of the institutional and political factors surrounding the nutrition sensitivity of agriculture in the region. METHODS: Semistructured interviews were carried out in India, Bangladesh, and Pakistan with a total of 56 stakeholders representing international organizations, research, government, civil society, donors, and the private sector. RESULTS: The findings point to mixed perspectives on countries' policy sensitivity toward nutrition. There was consensus among stakeholders on the importance of political commitment to nutrition, improving nutrition literacy, strengthening capacities, and improving the use of financial resources. CONCLUSIONS: Although there are different ways in which South Asian agriculture can improve its impact on nutrition, sensitizing key influencers to the importance of nutrition for the health of a country's population appears as a critical issue. This should in turn serve as the premise for political commitment, intersectoral coordination to implement nutrition-relevant policies, adequately resourced nutrition-specific and nutrition-sensitive programs, and sufficient capacities at all levels.

Impact of pilot project of Rural Maintenance Programme (RMP) on destitute women: CARE, Bangladesh.

BACKGROUND: The rate of malnutrition among women in Bangladesh is high, but historically there has not been a specific program focusing on the improvement of the nutritional status of Bangladeshi women. OBJECTIVE: To observe changes in the nutritional status of destitute women of the Rural Maintenance Programme (RMP) by incorporating a health and nutrition intervention package with RMP ongoing activities. METHODS: An intervention study involving 1,275 poor destitute women was conducted from July 2004 to June 2005 in 17 districts in Bangladesh under two field offices, Mymensingh and Jessore, covering 8 and 9 districts, respectively. The respondents were divided into intervention, comparison, and control groups. All participants in the intervention and comparison groups were paid as part of the RMP and received weekly 30-minute nutrition interventions for 7 weeks in addition to routine training. The comparison group also received RMP training. The control group consisted of women with similar demographic characteristics to the intervention and comparison groups who did not receive pay or any intervention. The intervention was a unique combination of the three components of the UNICEF triangle model (food security, caring practices, and disease control). Data on socioeconomic and anthropometric characteristics, immunization, and vitamin A capsule intake were also collected with the use of a structured questionnaire. RESULTS: After the intervention, the mean body weight had significantly increased by 1,333 g in the intervention group and had decreased by 277 g in the control group and 147 g in the comparison group. The body mass index of women in the intervention group had also significantly increased at the end of the study (p < .001). There was a significant increase in the intake of iodized salt in the intervention group as well as increased immunization coverage in all groups. Intake of the first vitamin A capsule by children increased (from 60% to 97%) in the intervention group only. CONCLUSIONS: The nutrition pilot intervention was highly effective in improving the nutritional status of women in the RMP.

Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial.

OBJECTIVE: To investigate the impact of zinc supplementation in children with cholera. DESIGN: Double blind, randomised, placebo controlled trial. SETTING: Dhaka Hospital, Bangladesh. PARTICIPANTS: 179 children aged 3-14 years with watery diarrhoea and stool dark field examination positive for Vibrio cholerae and confirmed by stool culture. INTERVENTION: Children were randomised to receive 30 mg elemental zinc per day (n=90) or placebo (n=89) until recovery. All children received erythromycin suspension orally in a dose of 12.5 mg/kg every six hours for three days. MAIN OUTCOME MEASURES: Duration of diarrhoea and stool output. Results 82 children in each group completed the study. More patients in the zinc group than in the control group recovered by two days (49% v 32%, P=0.032) and by three days (81% v 68%, P=0.03). Zinc supplemented patients had 12% shorter duration of diarrhoea than control patients (64.1 v 72.8 h, P=0.028) and 11% less stool output (1.6 v 1.8 kg/day, P=0.039). CONCLUSION: Zinc supplementation significantly reduced the duration of diarrhoea and stool output in children with cholera. Children with cholera should be supplemented with zinc to reduce its duration and severity. TRIAL REGISTRATION: Clinical trials NCT00226616.

Prevention of malnutrition among young children in rural Bangladesh by a food-health-care educational intervention: a randomized, controlled trial.

BACKGROUND: As a result of inappropriate feeding, poor health and hygiene, and poor caring practices, the nutritional status of many young infants deteriorates with advancing age. OBJECTIVE: To explore the effectiveness of a nutrition education package to prevent malnutrition among young children. METHODS: A community-based, randomized, controlled trial was conducted among 605 normal and mildly malnourished children aged 6 to 9 months in 121 Community Nutrition Centers (CNCs) of the Bangladesh Integrated Nutrition Project (BINP) in four regions of Bangladesh from 2000 to 2002. The intervention group received weekly nutrition education based on the nutrition triangle concept of UNICEF for 6 months, whereas the control group received regular BINP services. Both groups were observed for a further 6 months to assess the sustainability of the effects. Information on socioeconomic status, feeding patterns, morbidity, and anthropometric features was collected. RESULTS: A significant increase in the frequency of complementary feeding was observed in the intervention group as compared with the control group, and the increase was sustained throughout the observation period. The intervention group had a higher weight gain than the control group after the end of the intervention (0.86 vs. 0.77 kg, p = 0.053) and after the end of the observation period (1.81 vs. 1.39 kg, p < .001). The proportion of normal and mildly malnourished children was greater in the intervention group than in the control group after the end of the observations (88.9% vs. 61.5%, p < .001). Nutrition education successfully prevented malnutrition in all the areas. Variation in the outcome of nutrition education among the regions was observed. CONCLUSIONS: This culturally appropriate nutrition education package based on the nutrition triangle model effectively prevented growth faltering and malnutrition among young children.

Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh.

This prospective randomized trial was carried out to test the efficacy of a specific intervention for reducing the extent of their malnutrition and to change behaviour of mothers relating to child-feeding practices, care-giving, and health-seeking practices under the Bangladesh Integrated Nutrition Project (BINP). The study was conducted in rural Bangladesh among 282 moderately-malnourished (weight-for-age between 61% and 75% of median of the National Center for Health Statistics standard) children aged 6-24 months. Mothers of the first intervention group received intensive nutrition education (INE group) twice a week for three months. The second intervention group received the same nutrition education, and their children received additional supplementary feeding (INE+SF group). The comparison group received nutrition education from the community nutrition promoters twice a month according to the standard routine service of BINP. The children were observed for a further six months. After three months of interventions, a significantly higher proportion of children in the INE and INE+SF groups improved (37% and 47% respectively) from moderate to mild or normal nutrition compared to the comparison group (18%) (p < 0.001). At the end of six months of observation, the nutritional status of children in the intervention groups improved further from moderate to mild or normal nutrition compared to the comparison group (59% and 86% vs 30%, p < 0.0001). As the intensive nutrition education and supplementation given were highly effective, more children improved from moderate malnutrition to mild or normal nutritional status despite a higher incidence of morbidity. The frequency of child feeding and home-based complementary feeding improved significantly (p < 0.001) in both the intervention groups after three months of interventions and six months of observation. Body-weight gain was positively associated with age, length-for-age, weight-for-length, frequency of feeding of khichuri, egg, and potato (p < 0.05). Ability of mothers to identify malnutrition improved from 15% to 99% in the INE group and from 15% to 100% in the INE+SF group, but reduced from 24% to 21% in the comparison group. Use of separate feed pots, frequency of feeding, and cooking of additional complementary feeds improved significantly in the INE and INE+SF groups compared to the comparison group after three months of interventions and six months of observation. It can be concluded from the findings of the study that intensive nutrition education significantly improves the status of moderately-malnourished children with or without supplementary feeding.