Infant and Maternal Morbidity Symptoms as Predictors for the Interruption of Exclusive Breastfeeding in Lima, Peru: A Prospective Study.

INTRODUCTION: The global prevalence of exclusive breastfeeding for 6 months is 48%. This analysis examined the relationship between infant and maternal morbidity symptoms and the interruption of exclusive breastfeeding. METHODS: Data from a cohort study among women living in a peri-urban community in Peru were used. Data were collected during pregnancy, birth, and the first 6 months postpartum among 179 dyads... RESULTS: After the first month, interruption of exclusive breastfeeding was almost twofold (adjusted odds ration [aOR] = 1.99, 95% confidence interval [CI]: 1.14, 3.45) more likely among infants with symptoms (e.g., diarrhea, cough) than those without. Maternal morbidity symptoms (e.g., gastrointestinal, respiratory) and breast problems were positively associated with interruption of exclusive breastfeeding throughout the first 6 months (aOR = 1.77, 95% CI: 1.11, 2.82 and aOR = 3.23, 95% CI: 1.84, 5.69, respectively). DISCUSSION: Mother-infant dyads often experience illness symptoms that are not contraindications to breastfeeding. Health professionals need to reinforce that exclusive breastfeeding should continue during illness.

The Multiple Dimensions of Participation: Key Determinants of Nutrition Intervention Outcomes.

Nutrition research benefits from broad and intensive participation by stakeholders. The articles in this series demonstrate that understanding participation is complex because it incorporates the dimensions of stakeholders, activity, time, and intensity. Early involvement in research can help prioritize the problems to be addressed, refine the specific research question, and determine acceptable community-based approaches to be used in an intervention. The included studies examined the construct of participation and the diverse means by which it can be measured. They demonstrated how knowledge gained from early participation influenced the direction of interventions and increased relevancy for the community. The researchers assessed participation intensity during the intervention phase to help explain project outcomes and provide estimates of the magnitude of the effect that could be achieved if high-level participation of stakeholders was universal. In addition, participation in the analysis process was a key component of some of the articles in this series, demonstrating the richness of understanding that can be obtained through collaborative analyses. The included papers provide insight into how to define and measure participation, how to explore approaches to encourage participation of direct and indirect beneficiaries, and how participation at different time points and by different stakeholders can validate and support interventions and enhance effectiveness. As such, the series serves as a valuable reference to researchers, program and policy designers, implementers, and evaluators to increase the benefits of community-based interventions for nutrition outcomes.

Women's empowerment, children's nutritional status, and the mediating role of household headship structure: Evidence from sub-Saharan Africa.

We aimed to examine the association between women's empowerment and childhood nutritional status while accounting for the mediating role of household headship structure. Cross-country, cross-sectional quantitative data from the most recent Demographic and Health Surveys (2015-2018) were used. Women's empowerment was measured as a composite index of participation in household decision-making, attitude towards domestic violence, and asset ownership. Childhood nutrition status was measure as anaemia (haemoglobin concentration < 110g/L), stunting (height-for-age z-scorescore <-2) and the co-occurrence of anaemia and stunting. Applying the Lewbel two-stage least squares, women's migration status was used as an instrumental variable. We used data on 25,665 woman-child dyads from eight sub-Saharan African countries: Burundi (2016), Ethiopia (2016), Guinea (2018), Malawi (2016), Mali (2018), Zimbabwe (2015), Uganda (2016), and Tanzania (2015). The women were in their reproductive ages (15-49 years) and children were under 5 years old. The findings showed that an increase in women's empowerment index reduces children's likelihood of being anaemic and having a co-occurrence of anaemia and stunting [coeff (SE), -0.114 (0.025) and -0.072 (0.032), respectively]. Specifically, an increase in asset ownership or decision-making dimensions of empowerment significantly reduces the likelihood of anaemia and the co-occurrence of anaemia and stunting among children. Children of empowered women from male-headed households were more likely to be anaemic and be concurrently anaemic and stunted compared to their counterparts whose mothers were from female-headed households. Interventions designed to improve childhood nutrition through women's empowerment approaches need to consider asset ownership and instrumental agency of women while acknowledging the mediating effect of household headship typology.

Infant and young child feeding practices are associated with childhood anaemia and stunting in sub-Saharan Africa.

BACKGROUND: The co-occurrence of anaemia and stunting (CAS) presents acute development and morbidity challenges to children particularly in sub-Saharan Africa (SSA). Evidence on the effect of child feeding recommendations on CAS is scarce. METHODS: We used data from 22 recent Demographic and Health Surveys in SSA countries to examine the association between caregivers' implementation of recommendations on infant and young child feeding and the CAS in their 6- to 23-mo-old children. RESULTS: Overall, in multiple logistic regression models, child feed index score, high wealth of household, increasing household size, household head with at least secondary school education, improved sanitation of household, an increase in caregiver's age and caregiver's with at least secondary education were associated with lower odds of CAS (i.e. , AOR: 0.86; 95% CI; 0.84 - 0.88: 0.75; 0.69 - 0.82: 0.98, 0.98 - 0.99: 0.76, 0.70 - 0.83: 0.81, 0.74 - 0.87: 0.87, 0.81 - 0.94: 0.69, 0.62 - 0.77 respectively). Having a diarrhoea in the past 2 weeks and having fever in the past month were associated with higher odds of CAS (AOR:1.1, 95% CI; 1.0 - 1.2: 1.1, 1.0 - 1.2, respectively). Results from the decision tree analysis showed that the educational level of women was the most important predictor of CAS, followed by child feeding score, the level of education of the family head and state of drinking water. CONCLUSION: The results buttress the importance of interventions aimed at improving feeding practices and parental educational as a vehicle to improve children's nutritional status.

Participating in a Nutrition-Sensitive Agriculture Intervention Is Not Associated with Less Maternal Time for Care in a Rural Ghanaian District.

Background: Nutrition-sensitive agriculture (NSA) interventions may increase farm-related work for mothers, with consequences for child nutrition. The Nutrition Links (NL) intervention provided mothers with poultry, gardening inputs, technical support, and education to improve livelihoods and child nutrition outcomes in rural Ghana. Objectives: Our objective was to compare time allocated to child care by a cross-section of mothers in the intervention group of the NL intervention with the control group (NCT01985243). Methods: A cross-section of NL mother-child pairs was included in a time allocation substudy [intervention (NL-I) n = 74 and control (NL-C) n = 69]. In-home observations of the mother-child pair were conducted for 1 min, every 5 min, for 6 h. Observations were categorized into 4 nonoverlapping binary variables as follows: 1) maternal direct care, 2) maternal supervisory care, 3) allocare, and 4) no direct supervision. Allocare was defined as care by another person in the presence or absence of the mother. Any care was defined as the observation of maternal direct care, maternal supervisory care, or allocare. Generalized linear mixed models with binomial data distribution were used to compare the child care categories by group, adjusting for known covariates. Results: Maternal direct care (OR = 1.07; 95% CI: 0.89, 1.28) and any care (OR = 1.56; 95% CI: 0.91, 2.67) did not differ by intervention group. However, there was a higher odds of allocare (OR = 1.36; 95% CI: 1.04, 1.79) in NL-I than in NL-C women. Conclusions: Maternal participation in an NSA intervention was not associated with a decrease in time spent directly on child care but was associated with an increase in care from other household and community members.The clinicaltrials.gov number provided is for the main NL intervention and not this current substudy.

The Association of Women's Participation in Farmer-Based Organizations with Female and Male Empowerment and its Implication for Nutrition-Sensitive Agriculture Interventions in Rural Ghana.

Background: Few studies have examined the influence of women's participation in farmer groups on female and male empowerment, which is considered essential to improving nutrition. Objectives: The study aimed to 1) assess the empowerment of Ghanaian women farmers, 1 adult male family decision-maker per household, and the household gender equality; and 2) investigate the relation of empowerment and household gender equality with women's participation in farmer-based organizations (FBOs), women's and men's nutritional status, and household food security. Methods: A cross-sectional study investigated secondary outcomes using baseline data from a nutrition-sensitive agriculture intervention implemented through FBOs in rural Ghana. Existing FBOs in 8 communities were selected based on 6 criteria (e.g., participation level, readiness to change). Female FBO (n = 166) and non-FBO (n = 164) members together with a male family member (n = 205) provided data on individual and household characteristics; empowerment was measured across 11 indicators with the project-level Women's Empowerment in Agriculture Index. Generalized linear mixed models tested the associations of empowerment and household gender equality with FBO membership, nutritional status, and household food security. Results: Women's FBO membership was associated with an increased likelihood of women's empowerment [adjusted odds ratio (aOR): 3.25; 95% CI: 1.97, 5.33] and household gender parity (aOR: 2.82; 95% CI: 1.39, 5.84) but not men's empowerment. Household food insecurity, but not nutritional status, was positively associated with women's FBO participation and individual empowerment indicators (financial services). Food insecurity was negatively associated with the women's empowerment indicator related to attitudes about domestic violence [adjusted ß coefficient (aß): -0.78; 95% CI: -1.35, -0.21] and men's overall empowerment (aß: -0.79; 95% CI: -1.58, -0.01). Conclusions: Understanding the complexity in which FBO participation, empowerment, nutritional status, and food security are linked is critical in designing interventions that promote gender equality and improved nutrition.This trial was registered at clinicaltrials.gov as NCT03869853.

Growing and Learning Together in Fostering Multisectoral Participation for Sustaining Interventions: Lessons from 3 Successive Integrated Multidisciplinary Interventions in Rural Ghana.

Despite the recognition of nutrition as a multisectoral development issue, institutional silos persist as barriers to addressing community nutrition challenges effectively and sustainably. Over the past 2 decades, 3 integrated agriculture, livelihood, nutrition, and health interventions have been implemented in rural communities across Ghana, aimed at nurturing multisectoral collaborations to enhance institutional capacity, women's empowerment, children's diets and nutritional status, and general household well-being. Using information from published articles on the interventions, workshop reports, informal institutional engagements, and field notes, insights are presented on the efforts to garner multisectoral participation to sustain these interventions. Challenges and opportunities encountered in the process of growing and learning together relative to overcoming institutional cultures, building trust, empathizing with partners' institutional challenges, making collective decisions, and building common ownership and accountability are explored. Fostering effective multisectoral participation is a dynamic process of continuous learning.

Maternal Participation Level in a Nutrition-Sensitive Agriculture Intervention Matters for Child Diet and Growth Outcomes in Rural Ghana.

Background: Little is known about how the level of program participation affects child nutrition in rural interventions. Objectives: This study examined the association between participation level in a nutrition-sensitive agriculture intervention and children's diet and anthropometric outcomes in rural Ghana. Methods: Nutrition Links was a cluster randomized controlled trial (clinicaltrials.gov NCT01985243), which enrolled caregivers with children (aged less than 2 mo in 2014-2015 and less than 18 mo in 2016-2017). Of the 287 caregivers in 19 intervention communities who enrolled, 233 adopted the intervention and received layer poultry, garden inputs, and weekly child feeding education. The egg production and repayment of poultry were monitored, and feed was sold at the weekly meetings. After endline, the nutrition educators rated each woman who adopted the intervention on a scale [very poor (1) to excellent (5)] for: 1) meeting attendance, 2) egg productivity, 3) feed and poultry loan payment, 4) contributions during meetings, and 5) attentiveness towards group members. Participation level was classified as high, medium, and low by dividing the sum of these 5 items into tertiles; 54 women who did not adopt the intervention were classified as "no participation." Generalized mixed linear models tested the difference in changes in children's diet and anthropometric indices between the participation levels and the control category - 213 caregiver-child dyads in 20 communities who received standard-of-care health and agricultural services. Results: Compared with the control category, only high participation was associated with egg consumption [adjusted OR (aOR) = 3.03; 95% CI: 1.15, 7.94]. Both medium and high participation levels were associated with length-for-age z-scores (LAZ)/height-for-age z-scores (HAZ) [adjusted ß-coefficients (aß) = 0.44; 95% CI: 0.16, 0.72 and 0.40; 95% CI: 0.12, 0.67, respectively]. Conclusion: These results highlight the importance of promoting and monitoring the level of beneficiary participation to estimate the full potential of nutrition-sensitive agriculture interventions to improve nutritional outcomes.

TSH Mediated the Effect of Iodized Salt on Child Cognition in a Randomized Clinical Trial.

OBJECTIVES: This study examines the hormonal mediators of the effect of iodized salt in pregnancy on child cognition. METHODS: Sixty districts across 6 zones in the Amhara region of Ethiopia were randomly allocated to a control or intervention arm of early market access to iodized salt. Twenty-two villages per arm were randomly selected for this sub-study. A total of 1220 pregnant women who conceived after the intervention began were enrolled and assessed for their iodine and iron status. Data were collected once on the household socio-demographic status and iodized salt use, and maternal urinary iodine during pregnancy. Then, infants' diet, urinary iodine level, cognitive development (Bayley III), serum hormonal levels, iron status, and inflammation markers were measured between 2 and 13 months of age. RESULTS: The median maternal urinary iodine concentration was adequate and significantly higher in the intervention mothers than that of the controls (163 vs 121 µg/L, P < .0001). Intervention children compared to the control children had lower thyroid-stimulating hormone (TSH) (mean: 2.4 ± 1.0 µIU/mL vs 2.7 ± 1.0 µIU/mL, effect size = 0.18, P < .01) and thyroglobulin (Tg) (41.6 ± 1.0 ng/mL vs 45.1 ± 1.0 ng/mL, effect size = 0.14, P < .05). There was an interaction between the intervention and iron stores such that cognition was higher with iron (effect size = 0.28, 100 vs 94 IQ points). TSH was a partial mediator (12%) of the effect of the intervention on child cognition (Sobel z-score = 2.1 ± 0.06, P < .05). CONCLUSION: TSH partially mediated the effect of the iodized salt intervention on child cognition.

Maternal postpartum deworming and infant milk intake: Secondary outcomes from a trial.

The World Health Organization recommends deworming to reduce soil-transmitted helminth (STH)-attributable morbidity in women of reproductive age, including pregnant and lactating women, to reduce blood loss, iron deficiency anaemia and nutrient malabsorption. This study assessed the impact of maternal postpartum deworming with albendazole approximately 1 day after delivery on infant milk intake among a subset of 216 randomly selected mother-infant pairs recruited into a large trial in Peru. Infant milk intake was measured using the deuterium-oxide method at 1- and 6-month postpartum. Maternal STH infection was measured at 6-month postpartum. At 1-month postpartum, mean intake was 756 ± 16 and 774 ± 18 mL day-1 in the albendazole and placebo groups, respectively (mean difference: -18 mL day-1 ; 95% CI: -65, 30). At 6-month postpartum, mean intake was 903 ± 16 and 908 ± 18 mL day-1 in the albendazole and placebo groups, respectively (mean difference: -5 mL day-1 ; 95% CI: -52, 43). There was no statistically significant difference in milk intake between groups at either time point. At 6-month postpartum, mothers infected with Trichuris trichiura had infants with higher milk intakes (adjusted mean difference: 70 mL day-1 ; 95% CI: 20, 120) compared with uninfected mothers. However, there was no statistically significant difference in infant milk intake between mothers who had moderate-and-heavy intensity infection compared with the comparison group (mothers with no and light intensity infection). A lower prevalence and intensity of infection, and inclusion of uninfected mothers in both arms of the trial, resulting in effect dilution, may explain the null findings.

Pre-pregnancy iodized salt improved children's cognitive development in randomized trial in Ethiopia.

The overarching Ethiopia project examined the effects of early market introduction of iodized salt on the growth and mental development of young children. Sixty districts were randomly assigned to intervention (early market access to iodized salt) or control (later access through market forces), and one community per district was randomly chosen as the sampling unit. For this project, 22 of the districts were included. The participants were 1,220 pregnant women who conceived after the intervention began. When their children were 2 to 13 months old, field staff collected information on household sociodemographic status and iodized salt intake, child stimulation, maternal depression symptoms, children's diet, anthropometry, urinary iodine concentration (UIC), hemoglobin, and mental development scores (Bayley III scales). Fewer mothers prepartum (28% vs. 41%, p < .05) and their children (13% vs. 20%, p < .05) were iodine deficient (UIC <50 µg/L) in the intervention compared with the control group. The intervention children had higher cognitive scores (33.3 ± 0.3 vs. 32.6 ± 0.3; Δ = 0.6; 95% CI [0.0, 1.3]; d = 0.17; p = .01; 4 IQ points) than their controls. The other Bayley subscale scores did not differ from control children. The intervention group had a higher child stimulation (22.7 ± 0.2 vs. 22.1 ± 0.2; Δ = 0.5; 95% CI [0.02, 0.89]; d = 0.17; p = .01) but not growth indicators (weight-for-age z score, length-for-age z score, and weight-for-length z score: -1.1 ± 0.1 vs. -1.1 ± 0.1, -1.7 ± 0.1 vs. -1.7 ± 0.1; -0.2 ± 0.1 vs. -0.1 ± 0.1, respectively, all p > .05) compared with their controls. Iodized salt intake improved iodine status of both pregnant women and their children and also child cognitive development.

Household food insecurity but not dietary diversity is associated with children's mean micronutrient density adequacy in rural communities across Ghana.

OBJECTIVE: The aim of this study was to examine predictors of household food insecurity, dietary diversity, and children's mean micronutrient density adequacy and the relationship among these dietary measures. METHOD: Baseline analysis of a quasi-experimental 16-mo intervention study conducted in 12 rural communities in the three main agroecological zones in Ghana. The study included 608 caregivers with their 2- to 5-y-old children. Nutrient density adequacy was estimated for a subsample of 120 children. RESULTS: Food insecurity was more severe among farming households than their non-farming counterparts (P = 0.032). Dietary diversity score was significantly higher among non-farming households than farming households (P < 0.001). Food insecurity was negatively correlated with both household dietary diversity (r = -0.385; P < 0.001) and child mean micronutrient adequacy (r = -0.305; P < 0.001). There was no significant correlation between dietary diversity and children's mean micronutrient density adequacy. Belonging to a household that is severely food insecure and household size were significant predictors of children's mean micronutrient density adequacy (ß = -0.124, P = 0.006; ß = 0.011, P = 0.006, respectively). CONCLUSION: Household food insecurity continues to be a good indicator of lower nutrient intake in children.

Spatial Variation of Human Selenium in Ethiopia.

Selenium is an important nutrient for humans and livestock. Soil selenium concentration in the world is highly variable; deficiency and toxicity occur in populations living short distance apart. Knowledge of Se concentrations in humans and the environments, especially because the range for toxicity and deficiency is narrow, is important for effective intervention. Dietary data and serum samples were collected from children (n = 555) 69-78 months old from rural villages of the Amhara Region, Ethiopia. In addition, information on the socio-demography of households was collected. Serum Se was analyzed by inductively coupled plasma mass spectrometer. Almost all (90.3%) of participants reported eating grain, roots, or tubers 24 h preceding the survey followed by legumes, nuts, and seeds (64.6%). Consumption of animal source foods was very low (4.6%). Compared to children from the western part of the region, children from eastern Amhara had higher dietary diversity score (2.1 ± 0.9 vs 1.8 ± 0.7; p < 0.001).The median serum Se concentration was 70.6 µg/l (IQR 48.2, 96.6). Selenium inadequacy (serum Se < 70 µg/l) was detected in 49.1% of children. However, the distribution had an important geographical pattern across administrative zones. Children from the western part of the Amhara Region were highly deficient (up to 91.1% prevalence), while there was little or no Se deficiency in children from the eastern part of the region. Serum Se level exhibited an important spatial variation in the Amhara Region, Ethiopia. Further studies investigating contributing factors for the variation such as soil characteristics and Se concentration in staple crops are needed.

An agriculture-nutrition intervention improved children's diet and growth in a randomized trial in Ghana.

Stunting in Ghana is associated with rural communities, poverty, and low education; integrated agricultural interventions can address the problem. This cluster randomized controlled trial tested the effect of a 12-month intervention (inputs and training for poultry farming and home gardening, and nutrition and health education) on child diet and nutritional status. Sixteen clusters were identified and randomly assigned to intervention or control; communities within clusters were randomly chosen, and all interested, eligible mother-child pairs were enrolled (intervention: 8 clusters, 19 communities, and 287 households; control: 8 clusters, 20 communities, and 213 households). Intention-to-treat analyses were used to estimate the effect of the intervention on endline minimum diet diversity (≥4 food groups), consumption of eggs, and length-for-age (LAZ)/height-for-age (HAZ), weight-for-age (WAZ), and weight-for-length (WLZ)/weight-for-height (WHZ) z-scores; standard errors were corrected for clustering. Children were 10.5 ± 5.2 months (range: 0-32) at baseline and 29.8 ± 5.4 months (range: 13-48) at endline. Compared with children in the control group, children in the intervention group met minimum diet diversity (adjusted odds ratio = 1.65, 95% CI [1.02, 2.69]) and a higher LAZ/HAZ (ß = 0.22, 95% CI [0.09, 0.34]) and WAZ (ß = 0.15, 95% CI [0.00, 0.30]). Sensitivity analyses with random-effects and mixed-effects models and as-treated analysis were consistent with the findings. There was no group difference in WLZ/WHZ. Integrated interventions that increase access to high-quality foods and nutrition education improve child nutrition.

Selenium inadequacy hampers thyroid response of young children after iodine repletion.

Selenium (Se) is an integral component of iodothyronine deiodinase, glutathione peroxidase and thioredoxin reductase enzymes and thus is important for normal thyroid function. This study investigated the influence of Se inadequacy on thyroid response of iodine-replete young children. Serum thyroxine (T4), triiodothyronine (T3), thyroglobulin (Tg), thyroid stimulating hormone (TSH), and Se were analyzed in 54-60 mo old children (n = 628) from the Amhara region of Ethiopia before salt iodization was commenced; analyses were repeated (n = 555) 15 mo after iodized salt became available. Iodized salt coverage increased from 12.2% to 91.6% of households. Median urinary iodine concentration (UIC) among children increased from 9 µg/l to 167 µg/l (p < 0.001). In addition, all thyroid indices except T3 showed significant improvement (p < 0.05). Nearly, half of the study children (49.1%) had Se inadequacy (serum Se < 70 µg/l). Serum Se was significantly correlated with T3 (r = 0.38, p < 0.001), T4 (r = 0.15, p < 0.001), TSH (r=-0.205, p < 0.001) and Tg (r= -0.11, p < 0.01) concentrations 15 mo after iodine repletion; baseline serum Se and T4(r= -0.22, p < 0.01) were inversely correlated. Despite adequate iodine status, children with low serum Se had lower serum T4 (p = 0.003) and T3(p < 0.001) but higher TSH concentration (p = 0.003). In the partial least square regression model, Se was among the latent variables significantly explaining T4 and T3. Results of the present study suggest that Se inadequacy negatively affects the thyroid metabolism of iodine-replete children and may present a substantial public health concern thus emphasize the need to consider correction of Se status for normal thyroid function as well as for benefits from its diverse biological roles.

Association of Whole Blood Fatty Acids and Growth in Southern Ghanaian Children 2⁻6 Years of Age.

In Ghana, stunting rates in children below 5 years of age vary regionally. Dietary fatty acids (FAs) are crucial for linear growth. The objective of this study was to determine the association between blood FAs and growth parameters in southern Ghanaian children 2⁻6 years of age. A drop of blood was collected on an antioxidant treated card and analyzed for FA composition. Weight and height were measured and z-scores calculated. Relationships between FAs and growth were analyzed by linear regressions and factor analysis. Of the 209 subjects, 22% were stunted and 10.6% were essential FA deficient (triene/tetraene ratio > 0.02). Essential FA did not differ between stunted and non-stunted children and was not associated with height-for-age z-score or weight-for-age z-score. Similarly, no relationships between other blood fatty acids and growth parameters were observed in this population. However, when blood fatty acid levels in these children were compared to previously reported values from northern Ghana, the analysis showed that blood omega-3 FA levels were significantly higher and omega-6 FA levels lower in the southern Ghanaian children (p < 0.001). Fish and seafood consumption in this southern cohort was high and could account for the lower stunting rates observed in these children compared to other regions.

Lipid profile and dyslipidemia among school-age children in urban Ghana.

BACKGROUND: Dyslipidemia during childhood has been associated with higher risk of atherosclerosis later in life. Information on the lipid profile of Ghanaian children is scarce. The aim of this study was to assess the lipid profiles of school children between the ages of 9-15 years, living in urban Ghana. METHODS: A total of 802 randomly selected school-age children participated in the Ghana School Survey implemented in Kumasi and Accra, Ghana. A structured questionnaire was used to collect information on child and maternal socio-demographic characteristics (including age, education, and occupation), 7-day food frequency, home and school activity, as well as measurement of weight and standing height. Weight, height, and age data were converted into BMI-for-age indices to determine weight status. Finger-prick fasting blood samples were taken from the school-age children. Total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) cholesterol levels were determined using the CardioChek® PA Test System. Reference lipid levels based on the US National Cholesterol Education Program 2001 guidelines were used to determine the proportion of children with dyslipidemia. RESULTS: The mean TC, LDL-C, HDL-C, and TG levels were 149.0 ± 57.0 mg/dl, 80.1 ± 38.6 mg/dl, 53.5 ± 19.4 mg/dl, and 71.4 ± 54.7 mg/dl, respectively. Mean TC/HDL-C ratio was 3.0 ± 1.0. The proportion of children with abnormal values were 12.1% for TC, 4.5% for TG, 28.4% for HDL-C, 9.2% for LDL-C, and 6.6% for TC/HDL-C ratio. The levels of dyslipidemia (HDL, LDL, and TC/HDL-C ratio) were higher among overweight/obese compared to normal-weight children. More frequent fruit consumption was also linked with lower LDL-C (p = 0.020) while watching television (TV) in the mornings was linked with both higher TC (p = 0.011) and TG (p = 0.006). CONCLUSIONS: Majority of urban-dwelling Ghanaian school children had normal lipid profiles. However, the higher levels of dyslipidemia observed among overweight and obese children suggest the need for population level physical activity and dietary interventions among children to reduce risk of cardiovascular diseases in adult life.

Introduction of iodised salt benefits infants' mental development in a community-based cluster-randomised effectiveness trial in Ethiopia.

The effectiveness of salt iodisation in improving the mental development of young children has not been assessed. We implemented a community-based cluster-randomised effectiveness trial in sixty randomly selected districts in the Amhara region of Ethiopia. We randomly allocated each district to treatment and randomly selected one of its villages. In parallel to national salt iodisation efforts, iodised salt was brought early into the markets of the thirty intervention villages before it became widely available in the thirty control villages 4-6 months later. The primary outcome was children's mental development scores on the Bayley Scales. This was an intention-to-treat analysis using mixed linear models adjusted for covariates and clusters. The trial was registered at ClinicalTrials.gov, NCT013496. We assessed 1835 infants aged 5-11 months at baseline. The same children (85 % of the sample) were re-assessed at 20-29 months when all villages had iodised salt. At endline, urinary iodine concentration was higher in children in the intervention group compared with those in the control group (median 228·0 v. 155·1 µg/l, P=0·001). The intervention group had higher scores compared with the control group on the Bayley composite score (raw scores:130·60 v. 128·51; standardised scores: 27·8 v. 26·9; d=0·13; 95 % CI 0·02, 0·23) and three of the four subscales: cognitive (53·27 v. 52·54, d=0·13; 95 % CI 0·03, 0·23), receptive language (20·71 v. 20·18, d=0·13; 95 % CI 0·03, 0·24) and fine motor (35·45 v. 34·94, d=0·15; 95 % CI 0·04, 0·25). The introduction of iodised salt contributes to children's higher urinary iodine concentration and mental development.

Reliability of length measurements collected by community nurses and health volunteers in rural growth monitoring and promotion services.

BACKGROUND: Length measurements are important in growth, monitoring and promotion (GMP) for the surveillance of a child's weight-for-length and length-for-age. These two indices provide an indication of a child's risk of becoming wasted or stunted, and are more informative about a child's growth than the widely used weight-for-age index (underweight). Although the introduction of length measurements in GMP is recommended by the World Health Organization, concerns about the reliability of length measurements collected in rural outreach settings have been expressed by stakeholders. Our aim was to describe the reliability and challenges associated with community health personnel measuring length for rural outreach GMP activities. METHODS: Two reliability studies (A and B), using 10 children less than 24 months each, were conducted in the GMP services of a rural district in Ghana. Fifteen nurses and 15 health volunteers (HV) with no prior experience in length measurements were trained. Intra- and inter-observer technical error of measurement (TEM), average bias from expert anthropometrist, and coefficient of reliability (R) of length measurements were assessed and compared across sessions. Observations and interviews were used to understand the ability and experiences of health personnel with measuring length at outreach GMP. RESULTS: Inter-observer TEM was larger than intra-observer TEM for both nurses and HV at both sessions and was unacceptably (compared to error standards) high in both groups at both time points. Average biases from expert's measurements were within acceptable limits, however, both groups tended to underestimate length measurements. The R for lengths collected by nurses (92.3%) was higher at session B compared to that of HV (87.5%). Length measurements taken by nurses and HV, and those taken by an experienced anthropometrist at GMP sessions were of moderate agreement (kappa = 0.53, p < 0.0001). CONCLUSIONS: The reliability of length measurements improved after two refresher trainings for nurses but not for HV. In addition, length measurements taken during GMP sessions may be susceptible to errors due to overburdened health personnel and crowded GMP clinics. There is need for both pre- and in-service training of nurses and HV on length measurements and procedures to improve reliability of length measurements.

Child development in rural Ghana: Associations between cognitive/language milestones and indicators of nutrition and stimulation of children under two years of age.

OBJECTIVES: Two studies aimed to assess the provision of nutrition and psychosocial stimulation in the home and to examine associations between mental development and nutrition and stimulation using a validated measure of development milestones. METHODS: The first study consisted of secondary analyses on health and nutrition data from 1081 mother-child pairs (the children aged 0-12 months) and their households in Ghana's Eastern Region. For the second study, the Ghana Milestones Measure, consisting of items assessing cognitive and language development, was used to assess child development in a subsample (N = 330) of Study 1 participants one year later (children 10-24 months of age). This measure was mother-reported and had been validated in a separate community in Ghana. Correlation and linear regression analyses were used to analyze the data. RESULTS: Family assets and maternal education were identified as key factors of the family context. Both variables were positively associated with preventive health practices (r = 0.08 to 0.13, p < 0.0001 to 0.01), and dietary diversity (r = 0.15, p = 0.0001 to 0.0006), and negatively associated with maternal depressive symptoms (r = -0.19 to -0.12, p < 0.0001). Taller children had higher receptive (standardized beta = 0.16; p = 0.04) and expressive (0.21; 0.003) language, but not cognitive (0.15; 0.07) milestone scores, and psychosocial stimulation was positively associated with all three milestones (receptive = 0.13, p = 0.01; expressive = 0.21, p < 0.0001; and cognitive = 0.24, p < 0.0001). CONCLUSION: Our study provides the first validated measure of children's language and cognitive development in Ghana, finding associations with nutrition and stimulation. The Ghana Milestones Measure can be used to assess and help promote children's mental development.