The use and interpretation of serum retinol distributions in evaluating the public health impact of vitamin A programmes.

OBJECTIVE: Developing countries have adopted universal, high-potency vitamin A (VA) supplementation and food fortification as major strategies to control deficiency, prevent nutritional blindness and reduce child mortality. Yet questions persist regarding how best to measure impact and when to phase out supplementation. The present paper provides guidance on the use and interpretation of serum retinol (SROL) distributions as indicators of both programme impact and adequate VA intake in a population. DESIGN: We reviewed extant data on SROL's response to high-potency VA supplementation and VA-fortified foods in children. RESULTS: Supplementation virtually eliminates xerophthalmia and reduces child mortality; however, it shifts the SROL distribution only transiently (<2 months). Regular consumption of VA-fortified foods prevents xerophthalmia, lowers mortality and sustainably improves SROL distributions, from which both compliance and public health impact can be inferred. CONCLUSIONS: Given SROL's limited responsiveness to high-potency VA supplementation, target population coverage remains the preferred performance indicator. However, periodic SROL surveys do reflect underlying dietary risk and can guide programming: low or marginal SROL distributions in areas with high supplementation coverage do not signify programme failure, but rather suggest the need to continue supplementation while working to effectively raise dietary VA intakes. We propose that a sustained rise in the SROL distribution, defined as ≤5 % prevalence of SROL < 0·70 µmol/l among vulnerable population groups in at least two consecutive surveys (≥1 year apart), be used as an indicator of stable and adequate dietary VA intake and status in a population, at which point programmes may re-evaluate the need for continued universal supplementation.

Revisiting the concept of growth monitoring and its possible role in community-based nutrition programs.

BACKGROUND: Community-based growth monitoring (GM) and growth monitoring and promotion (GMP) have been implemented worldwide. The literature provides controversial messages regarding their effectiveness. Numerous countries have GM as their main community-based activity and need guidance for future programming. The notion of GM is usually clear, but the follow-up actions include a range of activities and interventions, all under the heading of "promotion." OBJECTIVE: We suggested definitions, objectives, and outcomes of the GM and GMP. By providing some clarity on these conceptual issues we attempted to provide a basis for consensus building and development of recommendations on when this activity should be promoted or discouraged. METHODS: We reviewed basic concepts and global experience of GM and GMP using publications about GM and GMP, UNICEF country reports and other publications, field observations, and reports of recent expert consultations. RESULTS: Realistic added benefits are suggested as compared with general counseling that could also be delivered outside the GM session. We provide a narrow definition of "promotion" in GMP, in which actions are tailored to the results of monitoring, as well as suggest quality implementation criteria. CONCLUSIONS: GM, even if complemented by a promotional package, can have only a limited impact if it is not part of a comprehensive program. GMP cannot be viewed as a competitor to highly effective interventions, but may serve as a possible platform for their delivery. The decision to build community-based programs on a GMP platform should be based on consideration of benefits, feasibility of quality implementation, and capacity of human resources.

Enhancements to nutrition program in Indian integrated child development services increased growth and energy intake of children.

The Indian Integrated Child Development Services (ICDS) provides supplemental food to children aged 6 mo to 6 y. This study assessed the impact of enhancements to the existing Supplemental Nutrition Program of local production of supplemental food, home fortification with a micronutrient powder, and improved program monitoring. A quasi-experimental longitudinal design was used. Data were collected from 15 Anganwadi centers randomly selected from the enhanced program and 15 from the usual program. Multilevel linear regression was used to examine changes over time between the 2 groups accounting for village-level variation in intent-to-treat analysis. Children in the enhanced program initially aged 12-18 mo gained 0.72 (P = 0.02) greater height-for-age Z-score. Significant differences were observed in gain in weight-for-age Z-score among those initially aged 9-11 (2.48; P = 0.01), 12-18 (0.76; P = 0.01), and 19-24 mo old (0.73; P = 0.01), and gain in weight-for-height Z-score among 9-11 (2.66; P = 0.04) and 19-24 mo old (0.99; P = 0.01). For these age groups, the prevalence of stunting, underweight, or wasting averted ranged from 20.3 to 33.4%. Energy intake in the enhanced program was significantly greater for boys initially aged 12-18 mo (575.1 kJ/d; P = 0.03). Results from a qualitative substudy supported the plausibility of observed outcomes. ICDS would be more effective in improving child nutrition if it included these enhancements. The enhancements studied may be useful in improving program delivery and uptake of other similar programs.

The challenges of iodine supplementation: a public health programme perspective.

An adequate iodine intake during pregnancy, lactation and early childhood is particularly critical for optimal brain development of the foetus and of children 7-24 months of age. While the primary strategy for sustainable elimination of iodine deficiency remains universal salt iodisation, the World Health Organization and the United Nations Children's Fund recommend a complementary strategy of iodine supplements as a temporary measure when salt iodisation could not be implemented. This article aims to review current evidence on efficacy and implications of implementing iodine supplementation as a public health measure to address iodine deficiency. Iodine supplementation seems unlikely to reach high coverage in a rapid, equitable and sustained way. Implementing the programme requires political commitment, effective and efficient supply, distribution and targeting, continuous education and communication and a robust monitoring system. Thus, universal salt iodisation should remain the primary strategy to eliminate iodine deficiency.

Effective nutrition programming for children and the role of UNICEF: consensus points from an expert consultation.

Countries of the world have agreed on eradicating extreme poverty and hunger and reducing the mortality rate of children under five by two-thirds by 2015 as part of the Millennium Development Goals, and without mainstreaming maternal, infant, and young child nutrition in the development agenda, these goals cannot be achieved. Although the recent Lancet Series on Maternal and Child Undernutrition brought attention to the importance of early nutrition interventions to improve child health, nutrition, and future economic productivity, there needs to be a more concerted effort at clarifying the path forward, focusing on moving beyond projects and evidence from randomized, controlled trials towards developing large-scale programs with sound plausibility design to achieve results for children. In an effort to cast a fresh eye on nutrition programming in light of the new evidence, UNICEF Headquarters hosted an Expert Consultation on effective nutrition programming with participants from various academic organizations and United Nations agencies to discuss effective program strategies in nutrition. The consultation resulted in recommendations for UNICEF on eight focus areas for programming and recognition of six overarching themes. It is clear that more action is needed to accelerate progress: more effective global coalitions, better coordination, more coherence, and better targeting of efforts.

An assessment of progress toward universal salt iodization in Rajasthan, India, using iodine nutrition indicators in school-aged children and pregnant women from the same households.

BACKGROUND: In Rajasthan, an Indian State with significant salt production, the sale of non-iodized salt for human consumption was banned in 1992. This study explored the relationships between the use of iodized salt in Rajasthan and the iodine status of children and pregnant women living in the area. METHODS: In a State-wide survey, 30 clusters were selected proportionate-to-population-size and 40 school children, 6-12 years old, were enrolled by random house-to-house visits in each cluster. Twelve pregnant women from the same households were also sampled. Salt used for cooking and a casual urine sample from each child and pregnant woman were collected. The salt iodine content was measured by titration and the urinary iodine concentration (UIC) by a quality-assured colorimetric method. RESULTS: Salt iodine content was >or=15 mg/kg in 41.9% of the households, and 23.0% used non-iodized salt. Median UIC was 139 microg/L in children and 127 microg/L in pregnant women. In households using non-iodized salt, the median UIC's were 96 microg/L and 100 microg/L in children and women, respectively. Dis-aggregating the UIC distributions by salt iodine levels revealed a consistent, step-wise pattern of UIC in children with increasing salt iodine content. A similar but less steep pattern was observed in pregnant women. The iodine status of both children and pregnant women attained the optimal range only when the salt iodine content was close to 30 mg/kg. CONCLUSION: For optimum iodine status in the population of Rajasthan, the iodization of household salt should be mandated at a higher level than what is practiced at present.

Utilization of positive deviance analysis in evaluating community-based nutrition programs: an application to the Dular program in Bihar, India.

BACKGROUND: Positive deviance is increasingly employed in international development activities to permit the utilization of proven local solutions. Including positive deviance methods in evaluation analysis, particularly in places like Bihar, India, where the rates of child underweight hover at 55%, can help identify project activities and household characteristics that affect key outcomes. These can, in turn, inform decision-making regarding the intensification of particularly promising activities. OBJECTIVES: To apply positive deviance analysis to the Dular program in Bihar, a community-based nutrition program that seeks to improve the impact of India's Integrated Child Development Services on young children. METHODS: In order to assure that desired program outcomes were not dependent on higher economic status, the analysis isolated a subset of program beneficiaries--the poorest children with the best nutritional outcomes--and examined the behavioral and project factors that may have brought about positive results in this subgroup. The data for this analysis were drawn from a 2005 program evaluation with a sample of 1,560 children. RESULTS: The analysis found that positive deviant children with normal nutritional status in the poorest 50% of Dular households were introduced to complementary food almost 2 months earlier (7.18 vs. 9.02 months of age) than severely malnourished children, were more than twice as likely to use soap for handwashing after defecation (25.0% vs. 11.8%), and were more than seven times as likely to have literate mothers (25.0% vs. 3.5%). CONCLUSIONS: The analysis suggests that programmatic efforts relating to these activities have been particularly effective and may well deserve increased investment.

Intensifying efforts to reduce child malnutrition in India: an evaluation of the Dular program in Jharkhand, India.

BACKGROUND: The Dular strategy is a unique nutrition initiative initiated by UNICEF India in collaboration with the states of Bihar and Jharkhand. Designed to complement the government's Integrated Child Development Services (ICDS) and build upon its infrastructure, one of the major goals of the Dular program is to capitalize and develop community resources at the grassroots level. The emphasis of the Dular program is on establishing a community-based tracking system of the health status of women and of children 0 to 36 months of age by neighborhood-based local resource persons (LRPs). The main objectives of the Dular program include increased prenatal attendance, improvement in breastfeeding and colostrum delivery, improved nutritional practices, and decreased malnutrition. OBJECTIVES AND METHOD: An impact evaluation of 744 women and children in Jharkhand examined antenatal and birthing practices, colostrum delivery, delivery of breastmilk as first food, reported use of iodized salt, measured iodized salt status, immunization and weight-for-age z-scores (WAZ) of children 0 to 36 months of age, controlling for various measures of socioeconomic status. RESULTS: Differences were found between Dular and non-Dular villages in all major outcomes. Particularly noteworthy is that young children in Dular areas had a 45% lower prevalence of severe malnutrition and were four times more likely to receive colostrum than those in non-Dular villages. CONCLUSIONS: Our evaluation results indicate that programmatic overlays to the ICDS program, which focus primary attention on children 0 to 36 months of age and on women, have the potential to transform into a cost-effective instrument for reducing child malnutrition in India, with implications for women and children in India.

Zinc-iron, but not zinc-alone supplementation, increased linear growth of stunted infants with low haemoglobin.

Zinc supplementation has been shown to benefit linear growth. However the effect may depend on whether zinc is the most limiting nutrient. This study aims to investigate the effect of supplementation with zinc-given alone or with iron and vitamin-A in improving infantsf micronutrient status and linear growth. The study was a double-blind-community-intervention study involving 800 infants aged 3-6 months in rural East Lombok, West Nusa Tenggara. Syrup consisting of zinc-alone, Zn (10 mg/d), zinc+iron, Zn+Fe (10 mg/d of each), zinc+iron+vitamin-A, Zn+Fe+vit.A (10 mg/d of each zinc and iron plus 1,000 IU vitamin-A), or placebo were given daily for six months. Outcomes measured were length, weight, and micronutrient status (haemoglobin, se-rum zinc, ferritin and retinol). Zn+Fe and Zn+Fe+vit.A supplementations benefit zinc and iron status of the sub-jects, while Zn-alone supplementation disadvantaged haemoglobin and iron status. The highest increment in vi-tamin A and haemoglobin status was shown in Zn+Fe+vit.A group. An effect on linear growth was observed among initially-stunted subjects in Zn+Fe and Zn+Fe+vit.A groups who grew 1.1-1.5 cm longer than placebo. On the other hand, in the Zn-alone group, mean height-for-age Z-score decreased to a greater extent than placebo. The between-group difference in HAZ among initially-stunted subjects was significant after four months sup-plementation. While the difference was not significant in follow-up after 6 months, the pattern remained the same where means height-for-age Z-score in Zn+Fe+vit.A and Zn+Fe groups were higher than placebo and Zn-alone groups. Given the low haemoglobin/iron status of the subjects, zinc supplementation would have positive effect on growth if the low haemoglobin/iron status is also addressed and corrected.

Efficacy of oral iodized peanut oil is greater than that of iodized poppy seed oil among Indonesian schoolchildren.

BACKGROUND: Oral iodized poppy seed oil is an appropriate measure for controlling iodine deficiency in areas where iodized salt is not yet available. However, a more effective and cheaper iodized oil preparation is needed. OBJECTIVE: The aim of this study was to compare the efficacy of iodized peanut oil with that of iodized poppy seed oil. DESIGN: Schoolchildren aged 8-10 y were supplemented with a single oral dose of iodized peanut oil (P200, P400, or P800 mg I), iodized poppy seed oil (PS400 mg I), or peanut oil (placebo). The concentration of urinary iodine (UI) was measured at 0, 4, 12, 25, and 50 wk, whereas thyroid volume and serum thyrotropin and free thyroxine concentrations were measured at 0, 25, and 50 wk. RESULTS: UI was higher in all treatment groups than in the placebo group, except at baseline. UI in the P200 group was not significantly different from that in the PS400 group at all times of measurement. In a comparison of preparations supplying 400 mg I conducted by using a mathematical model, iodine retention from the peanut oil preparation was 3 times that from the poppy seed oil, and the protection period for peanut oil was twice as long as that for the poppy seed oil (P < 0.001 for both). The reduction in thyroid volume was greater in the treatment groups than in the placebo group (P < 0.001). No significant differences in serum hormone concentrations were observed between groups before or after treatment. CONCLUSION: Iodized peanut oil is more efficacious in controlling iodine deficiency than is iodized poppy seed oil containing the same amount of iodine.

Child survival in India.

About 2.1 million Indian children under 5 years of age die each year. In spite of reductions in child mortality rate over the past two decades, the rate remains high at 87 per 1000 live births. The main causes are diarrhoea, pneumonia, and for deaths among the neonates asphyxia, pre-term delivery, sepsis and tetanus. The major underlying cause of death is undernutrition. Child survival interventions of proven impact, feasible for use at high coverage in India were identified, and their effect on child mortality was calculated if high coverage were to be achieved. Exclusive breastfeeding, oral rehydration therapy, and adequate complementary feeding were among the most effective interventions. If these interventions would be applied universally 57% of mortality among pre-schoolers could be prevented. No cause specific mortality data were available from individual Indian states. Nevertheless, the range of child mortality, as well as the proportion of neo-natal deaths, occurring across the states, suggests that at state level 50-70% of deaths can be prevented. The results show that the targets set in the millennium development goals as well as in the Tenth Five Year plan can be reached.

Mental and psychomotor development in Indonesian infants of mothers supplemented with vitamin A in addition to iron during pregnancy.

Maternal nutrition is important for fetal development, but its impact on the functional outcome of infants is still unclear. The present study investigated the effects of vitamin A and Fe supplementation during gestation on infant mental and psychomotor development. Mothers of infants from five villages in Indonesia were randomly assigned to supervised, double-blind supplementation once per week from approximately 18 weeks of pregnancy until delivery. Supplementation comprised 120 mg Fe+500 microg folic acid with (n 94) or without (n 94) 4800 microg retinol in the form of retinyl acetate. Mothers of infants who participated in the national Fe+folic acid supplementation programme, but whose intake of supplements was not supervised, were recruited from four other villages (n 88). The mental and psychomotor development of infants was assessed, either at 6 or 12 months of age, using the Bayley Scales of Infant Development (BSID). We found no impact of vitamin A supplementation on mental or psychomotor development of infants. In addition, infants whose mothers had received weekly Fe supplementation had similar mental and psychomotor indices as those whose mothers had participated in the governmental Fe supplementation programme. The study population was moderately Fe and vitamin A deficient. The size of the treatment groups was large enough to detect a mean difference of 10 points on the BSID, which is less than 1 sd (15 points) of the average performance of an infant on the BSID. In conclusion, the present study did not find an impact of weekly supplementation of 4800 RE vitamin A in addition to Fe during gestation on functional development of Indonesian infants. However, smaller improvements in development may be seen if studied in a larger and/or more deficient population.

Combating hidden hunger: the role of international agencies.

The importance of micronutrient deficiencies or "hidden hunger" was clearly emphasized by the inclusion of specific goals on iron, vitamin A, and iodine deficiency at the 1990 World Summit for Children and other major international nutrition conferences. Significant progress has since been made toward eliminating vitamin A and iodine deficiencies, with less progress made toward reducing the burden of iron-deficiency anemia. The role of international agencies, such as the World Health Organization, United Nations Children's Fund, Food and Agricultural Organization, and World Bank in assisting countries to make progress toward the World Summit for Children goals has been very important. International agencies have played a critical role in advocating for and raising awareness of these issues at the international, regional, and national levels among policymakers and the general population. Using a rights-based approach, UNICEF and other agencies have been instrumental in elevating to the highest political level the discussion of every child's right to adequate nutrition. International agencies have also been very supportive at the national level in providing technical guidance for programs, including monitoring and evaluation. These agencies have played a critical role in engaging the cooperation of other partners, including bilateral donors, non-governmental organizations, and the private sector for micronutrient programs. Furthermore, international agencies provide financial and material support for micronutrient programs. In the future, such agencies must continue to be heavily involved in programs to achieve the newly confirmed goals for 2010. The present paper focuses on the role of international agencies in combating micronutrient deficiencies, drawing on the lessons learned over the last decade. The first section of the paper summarizes the progress achieved since 1990, and the second section describes the specific role of international agencies in contributing to that progress.

Use of under-five mortality rate as an indicator for vitamin A deficiency in a population.

Vitamin A deficiency (VAD) is an important problem in many developing countries. If population data are unavailable or outdated for common indicators of VAD, a surrogate indicator may suggest whether a problem is likely and full-scale assessment is necessary. The Global Vitamin A Initiative report suggests that the under-five mortality rate (U5MR) might serve that purpose; a U5MR >70 indicates that VAD of public health importance is likely. Should the U5MR be used as a surrogate indicator? If so, is 70 the appropriate cutoff? U5MR data were collected for countries where the United Nations Children's Fund supports programs, along with unpublished vitamin A survey data from the World Health Organization. U5MR distribution was compared in countries with and without VAD. Sensitivity and specificity using U5MR cutoffs of 70 and 50 were calculated and compared with the presence of VAD as proven by a survey. Countries with a U5MR >40 have a VAD problem, about 70% of countries with a U5MR between 20 and 50 have VAD, and about 25% of countries with a rate <20 still have VAD. With a cutoff of 50, the U5MR relates well to the existence of a VAD problem in regions where malnutrition problems are most prominent. Decreasing the cutoff from 70 to 50 increased the sensitivity of the criterion and included nine additional deficient countries. A cutoff of 40 would increase sensitivity but would include countries with localized rather than nationwide problems. It is proposed that a country with a U5MR >50 likely has a VAD problem that requires immediate or continuing action. These actions include proper, formal assessment of the vitamin A status of the population, vitamin A capsule distribution and other program actions. Countries with a U5MR between 20 and 50 should assume they have a VAD public health problem until surveys prove otherwise.

Nutritional status and linear growth of Indonesian infants in west java are determined more by prenatal environment than by postnatal factors.

One of the health problems in Indonesia is the high prevalence of stunting in infants. Determinants and specifically the relative contribution of prenatal and postnatal factors to growth and nutritional status of Indonesian infants were investigated. Newborn infants, from women recruited at approximately 18 wk of pregnancy from 9 rural villages in West Java, Indonesia, were followed until 12-15 mo of age. Weight, length, morbidity, breast-feeding and food intake were assessed monthly. Determinants of length and weight increase and nutritional status reflected by Z-scores were evaluated using multiple linear regression. Neonatal weight (3.2 +/- 0.5 kg) and length (49.7 +/- 2.2 cm) were reasonable. However, growth started to falter at 6-7 mo of age, resulting in prevalences of 24% stunting and 32% underweight at 12 mo of age. The multiple regression models explained 19-41% of the variation in growth and nutritional status of infants. Neonatal weight (beta = 0.285) and length (beta = 0.492) were the strongest positive predictors of weight-for-age and height-for-age Z-scores, respectively. Fever was negatively associated with weight increase (beta = -0.144) and weight-for-age (beta = -0.142) and weight-for-height Z-scores (beta = -0.255) but not with length increase or height-for-age Z-scores. Intake of complementary foods was positively associated with increases in weight (beta = 0.190) and length (beta = 0.179) and nutritional status of infants (beta = 0.136-0.194). In conclusion, in this rural population in West Java, neonatal weight and especially length, reflecting the prenatal environment, are the most important predictors of infant nutritional status.