Hydrothermally-treated soybean-fortified maize-based nsima (stiff porridge) could contribute towards alleviating seasonal body weight loss in farming communities in sub-Saharan Africa.

Objective: This study explored the use of hydrothermally-treated soybean-fortified maize-based stiff porridge (nsima) in managing body weight losses among the farming family community in Malawi during the labour-intensive cropping (growing) season. We hypothesized that soybean-fortified maize-based nsima could prevent seasonal body weight losses in farming communities during labour-intensive seasons better than conventional 100% maize nsima. Research methods & procedures: A single-blind parallel dietary intervention 90-day study. During energy stress months, 42 farming households in Malawi were supplied with 15 kg of blind formulation of soybean-fortified maize flour (soybean: maize, 1:4, wt/wt) per person per month except for under-fives who were allotted half the quantity. Forty households were provided with equivalent quantities of 100% maize flour and served as control. Body weights of participants were taken at baseline and endpoint. Results: After 3 months, the experimental group registered 3.7, 4.2, 2.9, and 5.2% statistically higher body weight compared to the controls for the under-five, the 5-9-year-olds, the 10-19-year-olds, and the >20-year-olds, respectively. Conclusion: Soybean-fortified stiff porridge could feasibly be used to alleviate wasting among the resource-constraint populace in Malawi and many other parts of sub-Saharan Africa that rely on maize as a major staple.

Hydrothermally Treated Soybeans Can Enrich Maize Stiff Porridge (Africa's Main Staple) without Negating Sensory Acceptability.

Maize-based stiff porridge, a starchy protein-deficient staple food, dominates among the populations in sub-Saharan Africa (SSA). Unfortunately, this is often consumed along with leafy vegetables since the majority of the population in this region lack resources for the purchase of high protein animal source foods, a situation that exacerbates protein-energy malnutrition. Considering this, the current study evaluated the effect of enriching maize-based stiff porridge with flour made from hydrothermally treated soybeans on consumer acceptability. A total of nine experimental flours were prepared from maize and maize-soybean mixtures following a 32 factorial design involving two factors, namely maize flour type (whole maize, non-soaked dehulled maize, and soaked dehulled maize) and soybean flour proportion (0%, 20%, and 30%). A total of 125 adult consumers from a rural setting in Malawi evaluated maize-based stiff porridges made thereof using a 7-point hedonic scale. Subsequently, the participants were asked to guess an ingredient that was added to some of the test samples. The 10% and 20% soybean-enriched maize-based stiff porridges scored 5/7 and above, with some being statistically similar to plain maize-based stiff porridges. No participant recognized that soybeans were incorporated into the maize-based stiff porridges. The study has clearly demonstrated the potential of enriching maize-based stiff porridge with hydrothermally treated soybeans without compromising consumer acceptability. This innovation could significantly contribute towards reducing the burden of energy-protein under-nutrition in SSA.

Tackling protein-energy under-nutrition among resource-limited people living with HIV/AIDS in Malawi using soybean-enriched maize-based stiff porridge (nsima): A pilot study.

AIM: The Ministry of Health in Malawi has scaled-up antiretroviral therapy (ART) for HIV infection. However, the majority of Malawians heavily depend on maize-based stiff porridge (nsima), a protein-deficient staple, a practice that exacerbates wasting and ultimately compromises the success of ART programming. This pilot study was conducted to evaluate the efficacy of utilising soybean-enriched nsima as a strategy for managing HIV-related wasting among resource-poor people. METHODS: A before and after designed study involving 25 wasted (<18.5 BMI (body mass index)) to normal (18.5-24.9 BMI) HIV-positive rural women (21-40 years) taking ART and provided with soybean-maize flour (20 kg/month for 3 months) prepared from hydrothermally treated soybeans and maize in the ratio of 1:4 (wt/wt). Anthropometry was performed at baseline and every month for the 3-month study period. Paired sample t-tests were used to test for changes in body mass and BMI between baseline and the subsequent months. RESULTS: Statistically significant (P < 0.001) cumulative mean weight gain for the first, second and third month of the study were 1.6, 2.1 and 2.9 kg, respectively. The number of participants with low BMI reduced from 6/25 at baseline to 2/25 after 3 months, and the mean BMI improved from 19.3 to 21.1 kg/m2 . CONCLUSIONS: Nsima prepared from a blend of maize and hydrothermally treated soybeans could feasibly be used to prevent and manage wasting among resource-poor people living with HIV/AIDS in sub-Saharan Africa who rely on maize as a major staple.

Reduced Morbidity Motivated Adoption of Infant and Young Child Feeding Practices after Nutrition Education Intervention in Rural Malawi.

This study assessed caregivers' knowledge and practices and factors that influence the adoption of improved infant and young child feeding (IYCF) practices after nutrition education in Kasungu and Mzimba districts among 198 caregivers. Mixed-methods convergent-parallel design, including knowledge tests, focus group discussions, and in-depth interviews in the intervention areas, was used to collect quantitative and qualitative data. Data were analyzed using count regression and content analysis, which showed that knowledge increased among caregivers after nutrition education. The knowledge about diet diversification for young children as well as about hygienic practices when preparing food and during feeding improved in addition. Enhanced health among children motivated caregivers to apply improved IYCF practices. The study was based on the caregivers' reports. Long-term effects of exposure to nutrition education are unknown. However, the nutrition education that focused on the child's health benefits motivated mothers to adopt improved IYCF practices.

Nutrition education improves dietary diversity of children 6-23 months at community-level: Results from a cluster randomized controlled trial in Malawi.

BACKGROUND: Low dietary quality and quantity and inappropriate feeding practices can cause undernutrition. Poor nutritional status in early childhood is associated with growth faltering. The objective of the study was to assess the potential of community-based nutrition education to improve height-for-age z-scores in children 6-23 months of age. METHODS AND FINDINGS: We carried out a cluster-randomized-controlled trial to assess the effectiveness of nutrition education. A total of 24 Extension Planning Area Sections served as clusters. The selection criteria were: the position of the extension officer was staffed and the sections had been selected by the project for activities in its first project year. The sections were randomized into intervention and control restricted on mean height for age Z-score using baseline information. In the intervention area, food security activities and community-based nutrition education was implemented. The control area received food security activities only. At baseline (2011) and endline (2014), caregivers with a child below two years of age were enrolled. Data assessment included anthropometric measurements, interviews on socio-economic status, dietary intake and feeding practices. A difference-in-differences estimator was used to calculate intervention effects. A positive impact on child dietary diversity was observed (B (SE) = 0.39 (0.15), p = 0.01; 95%CI 0.09-0.68). There was a non-significant positive intervention effect on mean height-for-age z-scores (B (SE) = 0.17 (0.12), p = 0.15; 95%CI -0.06-0.41). LIMITATIONS: The 24h dietary recalls used to measure dietary diversity did not consider quantities of consumed foods. Unrecorded poor quality of consumed foods might have masked a potential benefit of increased child dietary diversity on growth. CONCLUSIONS: Participatory community-based nutrition education for caregivers improved child dietary diversity even in a food insecure area. Nutrition education should be part of programs in food insecure settings aiming at ameliorating food insecurity among communities.

Involving communities in the design of clinical trial protocols: the BAN Study in Lilongwe, Malawi.

OBJECTIVE: To learn the attitudes and concerns of the local community on participating in research, infant feeding practices, and maternal nutrition in order to inform the design of a clinical trial in Lilongwe, Malawi on the safety and efficacy of antiretroviral and nutrition interventions to reduce postnatal transmission of HIV. DESIGN: Formative research methods were used, including semi-structured interviews, focus group discussions, home observations, and taste trials. Data were collected, analyzed, and incorporated into the protocol within 3 months. RESULTS: Participants were supportive of the clinical trial, although their overall understanding of research was limited. Mothers agreed that infants' blood could be drawn by venipuncture, yet concern was raised about the amount of blood proposed to be collected from both infants and mothers. Data demonstrated that rapid breastfeeding cessation would be difficult and malnutrition could be a risk if infants were weaned early. Mothers selected a maternal supplement suitable for use in the clinical trial. CONCLUSIONS: The protocol was rapidly modified to achieve cultural acceptability while maintaining study objectives. Without the formative research, several significant areas would have been undetected and may have jeopardized the implementation of the trial. Additional research was carried out to develop a meaningful informed consent process, the amount of blood collected was reduced to acceptable levels, and the protocol was modified to reduce the risk of malnutrition. Researchers who conduct clinical trials are encouraged to incorporate formative research into their protocol design to ensure participant understanding of the research, to safeguard participants, and to increase feasibility and acceptance of the clinical research in the community.

Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi.

BACKGROUND: To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers. METHODS: As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi. RESULTS: Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workers had concerns about early cessation of breastfeeding. CONCLUSION: Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions.

Efficacy of a community-based dietary intervention to enhance micronutrient adequacy of high-phytate maize-based diets of rural Malawian children.

OBJECTIVE: To evaluate the efficacy of a community-based dietary intervention to reduce risk of micronutrient inadequacies in high-phytate maize-based Malawian diets. DESIGN: Quasi-experimental post-test design with a non-equivalent control group. SETTING: Four villages in Mangochi District, Southern Malawi. PARTICIPANTS: Households with children aged 3-7 years in two intervention (n = 200) and two control (n = 81) villages participated in a 6-month intervention employing dietary diversification, changes in food selection patterns, and modifications to food processing to reduce the phytate content of maize-based diets. Baseline comparability between the groups was confirmed via assessment of sociodemographic characteristics, anthropometry, knowledge and practices, morbidity, haemoglobin and hair zinc. After 12 months, knowledge and practices and dietary intakes were assessed by interactive 24-hour recalls, one during the food plenty and a second during the food shortage season. Nutrient adequacy for the two groups was compared via dietary quality indicators and predicted prevalence of inadequate intakes using the probability approach. RESULTS: Intervention children had diets that were significantly more diverse and of a higher quality than those of controls. Median daily intakes of protein, calcium, zinc (total and available), haem iron, vitamin B12 and animal foods (grams; % of total energy) were higher (P < 0.05) whereas phytate intakes, phytate/zinc and phytate/iron molar ratios were lower (P < 0.01) in the intervention group; some spread of knowledge and practices to controls occurred. CONCLUSIONS: Our community-based dietary strategies reduced the predicted prevalence of inadequate intakes of protein, calcium, zinc and vitamin B12, but not iron, in children from Malawian households with very limited resources.