bluuebunny/crossref_metadata_2025_split huggingface dataset:
Identifying Zambia's Industrial Fortification Options: Toward Overcoming the Food and Nutrition Information Gap-Induced Impasse
Authors: Fiedler John L. , Lividini Keith , Zulu Rodah , Kabaghe Gladys , Tehinse John , Bermudez Odilia I. 
Published: November 2015

Background Zambia was a pioneer when it started fortifying sugar with vitamin A in 1998. Micronutrient deficiencies—especially among young children—have changed little over the past decade. In 2008 an initiative to introduce fortified flours was halted when last-hour questions about the program could not be answered. Objective To provide information about the need, coverage, and impact of alternative fortification portfolio options to help Zambia overcome its fortification impasse. Methods Using household data from the 2006 Living Conditions Monitoring Survey, apparent micronutrient intake levels and apparent consumption levels of sugar, vegetable oil, wheat flour and maize meal were estimated. The household level data were used to estimate individual intakes by assuming that food was distributed among household members in direct proportion to their share of the household's total adult consumption equivalent. Intake adequacy was measured relative to age- and gender-specific Estimated Average Requirements. Combining information on the industrial structure and estimated fortifiable quantities consumed of each food, and assuming the nutrient content is that specified in official regulations, simulations were conducted of the coverage and impact of 14 fortification portfolios. Results Maize, the most commonly consumed food, is consumed in a fortifiable form by only 23% of the population. Sugar fortification is estimated to have reduced inadequate intake of vitamin A from 87% to 79%. Introducing oil fortification could reduce the prevalence of inadequate vitamin A intake to 61%, and fortifying roller and breakfast maize meal would further reduce it to 57%, and reduce inadequate iron and zinc intakes by 2.2% and 5.5%, respectively. Implementing WHO flour guidelines would triple the potential iron and zinc impacts. Conclusion Analysis of LCMS apparent consumption data have helped address important information gaps and provide better understanding of the coverage and impacts of alternative fortification portfolios.
Key Strategies to Further Reduce Stunting in Southeast Asia: Lessons from the ASEAN Countries Workshop
Authors: Bloem Martin W. , de Pee Saskia , Le Hop Thi , Khan Nguyen Cong , Laillou Arnaud , Minarto  , Moench-Pfanner Regina , Soekarjo Damayanti , Soekirman  , Solon J. Antonio , Theary Chan , Wasantwisut Emorn 
Published: November 2015

Background To further reduce stunting in Southeast Asia, a rapidly changing region, its main causes need to be identified. Objective Assess the relationship between different causes of stunting and stunting prevalence over time in Southeast Asia. Methods Review trends in mortality, stunting, economic development, and access to nutritious foods over time and among different subgroups in Southeast Asian countries. Results Between 1990–2011, mortality among under-five children declined from 69/1,000 to 29/1,000 live births. Although disease reduction, one of two direct causes of stunting, has played an important role which should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to reduce stunting further. This requires dietary diversity, which is affected by rapidly changing factors: economic development; urbanization, giving greater access to larger variety of foods, including processed and fortified foods; parental education; and modernizing food systems, with increased distance between food producers and consumers. Wealthier consumers are increasingly able to access a more nutritious diet, while poorer consumers need support to improve access, and may also still need better hygiene and sanitation. Conclusions In order to accelerate stunting reduction in Southeast Asia, availability and access to nutritious foods should be increased by collaboration between private and public sectors, and the Association of Southeast Asian Nations (ASEAN) can play a facilitating role. The private sector can produce and market nutritious foods, while the public sector sets standards, promotes healthy food choices, and ensures access to nutritious foods for the poorest, e.g, through social safety net programs.
Tailoring Communication Strategies to Improve Infant and Young Child Feeding Practices in Different Country Settings
Authors: Sanghvi Tina , Jimerson Ann , Hajeebhoy Nemat , Zewale Medhanit , Nguyen Giang Huong 
Published: November 2015

Background Alive & Thrive aims to increase exclusive breastfeeding and complementary feeding practices in Bangladesh, Ethiopia, and Vietnam. Objective To develop and execute comprehensive communication strategies adapted to each context. Methods We documented how three countries followed an established iterative planning process, with research steps followed by key decisions, to develop a communication strategy in each country. Secondary analysis and formative research identified the priority practices to focus on, and locally specific constraints to proper infant and young child feeding (IYCF). Communication strategies were then developed based on the social, cultural, economic, epidemiological, media use, and programmatic contexts of each country. Results There were widespread gaps between recommended and actual feeding practices, and these varied by country. Gaps were identified in household, community, and institutional levels of awareness and skills. Strategies were designed that would enable mothers in each specific setting to adopt practices. To improve priority behaviors, messaging and media strategies addressed the most salient behavioral determinants through face-to-face communication, social mobilization, and mass media. Trials of improved practices (TIPs), concept testing, and pretesting of materials proved useful to verify the relevance and likely effectiveness of communication messages and materials tailored for different audiences in each setting. Coordination and collaboration with multiple stakeholders from the start was important to harmonize messages and approaches, expand geographic coverage to national scale, and sustain the interventions. Conclusions Our experience with designing largescale communication strategies for behavior change confirms that systematic analysis and local planning cannot be omitted from the critical process of strategic design tailored to each context. Multiple communication channels matched to media habits in each setting can reach a substantial proportion of mothers and others who influence their IYCF practices. Preliminary data suggest that exposure to mass media plays a critical role in rapidly reaching mothers, household members, community influentials, and health workers on a large scale. Combining face-to-face interventions for mothers with social mobilization and mass media was effective in improving IYCF practices.
Household Food Insecurity and Nutritional Status of Children and Women in Nepal
Authors: Singh Abhishek , Singh Ashish , Ram Faujdar 
Published: November 2015

Background Information on the association between household food insecurity and nutritional status of children and women based on a nationally representative sample is not available from Nepal. Objective To examine the association between food insecurity and nutritional status of children and married women in Nepal using data from the 2011 Nepal Demographic and Health Survey. Methods The Household Food Insecurity Access Scale was used to assess food insecurity in the 2011 Nepal Demographic and Health Survey. We used body mass index (BMI) to assess the nutritional status of married women, and stunting, wasting, and underweight to assess the nutritional status of children under 5 years of age. Binary logistic regression and multinomial logistic regression were performed to examine the associations. Results In severely food-insecure households, 51% of children were stunted and 40% were underweight; 27% of married women had a BMI below 18.5 kg/m2; children were 1.50 (95% CI, 1.15 to 1.97) and 1.40 (95% CI, 1.05 to 1.85) times as likely as children in food-secure households to be stunted and underweight, respectively; and married women were 1.5 (95% CI, 1.17 to 1.92) times as likely as married women in food-secure households to have a BMI below 18.5 kg/m2. No association was found between household food insecurity and wasting among children. Conclusions There is a significant association between food insecurity and malnutrition among children in Nepal. Among women, food insecurity is associated with underweight (BMI < 18.5 kg/m2) but not with overweight (BMI ≥ 25.0 kg/m2).
Macronutrient and Sociodemographic Determinants of Gestational Weight Gain among HIV-Negative Women in Tanzania
Authors: Changamire Freeman T. , Mwiru Ramadhani S. , Msamanga Gernard I. , Spiegelman Donna , Urassa Willy , Hertzmark Ellen , Fawzi Wafaie W. , Peterson Karen E. 
Published: November 2015

Background The effect of dietary macronutrient composition on the rate of gestational weight gain among women in sub-Saharan Africa is unclear. Objective To examine the effect of macronutrient intake on the rate of gestational weight gain among HIV-negative women in Tanzania. Methods The weights of 8,428 women were measured monthly from 12 weeks of gestation to term. Prenatal dietary intake was estimated as the cumulative average of multiple 24-hour dietary recalls. The association between energy intake and percentage of energy from carbohydrate, protein, and total fat and rate of weight gain (grams per month) was estimated from generalized estimating equation models. Macronutrient effects were adjusted for total energy using the nutrient density model and maternal age, maternal height, maternal mid-upper-arm circumference, parity, marital status, maternal occupation, maternal education, household wealth, season, and treatment regimen assignment. Body mass index (BMI) was considered as a confounder and a potential modifier of the effect of macronutrient intake on gestational weight gain. Results A 6 g/month increase in rate of weight gain was associated with every 100-kcal increment in daily total energy intake (95% CI, 1 to 12; p = .03). Analyses substituting 5% of energy from fat by protein showed that weight gain would decrease by 72 g/month (95% CI, 6 to 140; p = .03); substituting 5% of energy from carbohydrate by protein decreased gain by 70 g/month (95% CI, 15 to 124; p = .01). Baseline BMI did not modify these associations. Conclusions Further research on the effects of macronutrient composition on gestational weight gain is needed to inform the design of supplementation programs for women in developing countries.
Managing the Vitamin A Program Portfolio: A Case Study of Zambia, 2013–2042
Authors: Fiedler John L. , Lividini Keith 
Published: November 2015

Background Micronutrient deficiencies continue to constitute a major burden of disease, particularly in Africa and South Asia. Programs to address micronutrient deficiencies have been increasing in number, type, and scale in recent years, creating an ever-growing need to understand their combined coverage levels, costs, and impacts so as to more effectively combat deficiencies, avoid putting individuals at risk for excess intakes, and ensure the efficient use of public health resources. Objective To analyze combinations of the two current programs—sugar fortification and Child Health Week (CHW)—together with four prospective programs—vegetable oil fortification, wheat flour fortification, maize meal fortification, and biofortified vitamin A maize—to identify Zambia's optimal vitamin A portfolio. Methods Combining program cost estimates and 30-year Zambian food demand projections, together with the Zambian 2005 Living Conditions Monitoring Survey, the annual costs, coverage, impact, and cost-effectiveness of 62 Zambian portfolios were modeled for the period from 2013 to 2042. Results Optimal portfolios are identified for each of five alternative criteria: average cost-effectiveness, incremental cost-effectiveness, coverage maximization, health impact maximization, and affordability. The most likely scenario is identified to be one that starts with the current portfolio and takes into account all five criteria. Starting with CHW and sugar fortification, it phases in vitamin A maize, oil, wheat flour, and maize meal (in that order) to eventually include all six individual interventions. Conclusions Combining cost and Household Consumption and Expenditure Survey (HCES) data provides a powerful evidence-generating tool with which to understand how individual micronutrient programs interact and to quantify the tradeoffs involved in selecting alternative program portfolios.
Integrating Food Poverty and Minimum Cost Diet Methods into a Single Framework: A Case Study Using a Nepalese Household Expenditure Survey
Authors: Geniez Perrine , Mathiassen Astrid , de Pee Saskia , Grede Nils , Rose Donald 
Published: November 2015

Background Current tools assessing affordability of nutritious diets are incomplete. “Food poverty” uses expenditure data to identify households unable to acquire a diet adequate in energy but does not consider other nutrients. The “minimum cost of a nutritious diet” method provides a threshold for purchasing a nutritious diet but must rely on other data to identify “nutrient-poor” households. Objective Integrating both methods into a single framework using a common data source, we sought to jointly estimate the proportions of a population that are food and nutrient poor. Methods Household expenditure data from the 2010/11 Nepal Living Standards Survey were used, focusing on representative samples of households from the mountain region ( n = 401) and Kathmandu ( n = 857). Food poverty thresholds were set at the cost for a lowincome household to purchase a basket of foods providing adequate energy following the Cost of Basic Need method. Linear optimization was used to calculate a “nutrient poverty” threshold. Household expenditures were used to determine food and nutrient poverty rates. Results The food and nutrient poverty thresholds were 13,294 and 18,628 rupees/person/year, respectively, in the mountain region and 14,610 and 22,945 rupees/ person/year, respectively, in Kathmandu. In the mountain region, 34% of households were both food and nutrient poor and 24% were just nutrient poor. In Kathmandu the percentages were 7% and 14%, respectively. Conclusions This approach, integrating two commonly used tools, provides a more nuanced interpretation of economic access to a nutritious diet and an opportunity to improve the design and targeting of nutrition and food security interventions.
Determinants of Stunting and Overweight among Young Children and Adolescents in Sub-Saharan Africa
Authors: Keino Susan , Plasqui Guy , Ettyang Grace , van den Borne Bart 
Published: November 2015

Background Stunting and overweight are nutritional problems affecting most of sub-Saharan Africa. The region now has the world's highest rate of stunting among children (43%), while overweight and obesity are becoming a global epidemic, and Africa is not spared. The past two decades have seen a dramatic increase in obesity in sub-Saharan Africa. Objective The purpose of this systematic review is to explore the determinants of stunting and overweight in sub-Saharan Africa. Methods A literature search was conducted in PubMed using the key words stunting, overweight, obesity, Africa, sub-Saharan Africa, determinants, and prevalence. Limits were set to include articles published between 1990 and 2012. The systematic review resulted in 38 studies, and after selection based on title, content, and country of the study, 18 studies were eligible for this review. Data were analyzed by the chi-square test. Results The prevalence rates of stunting and over-weight were dependent on socioeconomic, demographic, and environmental factors. Many studies indicate that male children and those living in a rural setting are more likely to be stunted, whereas overweight among children depends more on age, household composition, occupation of the mother, and the mother's body mass index. Stunting occurred together with overweight among both boys and girls from 1 to 5 years of age. Stunting was more prevalent among boys than among girls. Indicators of socioeconomic status, such as mother's education, mother's occupation, and household income, were some of the determinants directly linked to stunting, whereas environmental factors, such as rural or urban setting and sanitation, influenced both stunting and overweight. Concurrent stunting and overweight is influenced by maternal and household factors, such as maternal height, age, and education, large household size, and lower socioeconomic status. Conclusions Although socioeconomic, demographic, and environmental factors were significant in determining stunting and overweight, other factors, such as nutrition and lifestyle, were important risk factors. Stunting in childhood is a risk factor that may result in overweight and obesity later in adolescence and adulthood, indicating the need to screen children below 1 year of age to identify stunting early in life. Promoting exclusive breastfeeding is reported to be important in preventing both stunting and overweight among children. More research is needed to explore the relationship between stunting and overweight and to explore policy guidelines to address the phenomenon.
Breastfeeding Knowledge, Attitude, Perceived Behavior, and Intention among Female Undergraduate University Students in the Middle East: The Case of Lebanon and Syria
Authors: Hamade Haya , Naja Farah , Keyrouz Sarah , Hwalla Nahla , Karam Jeanette , Al-Rustom Lea , Nasreddine Lara 
Published: November 2015

Background The Middle East has one of the lowest rates of exclusive breastfeeding in the world, highlighting the need to promote breastfeeding in this region. Young adults represent a key population of interest, since decisions about infant-feeding appear to be made before children are even conceived. Objective To examine breastfeeding knowledge, attitude, and perceived behavior among female undergraduate students in Lebanon and Syria and determine factors associated with intention to breastfeed in this population. Methods This cross-sectional study was conducted in 2010/11 in Damascus and Beirut. Four universities were selected in each city. A multicomponent questionnaire was administered to a convenience sample of participants ( n = 194 from Beirut and n = 199 from Damascus). The questionnaire included breastfeeding knowledge (measured by the Infant Feeding Knowledge Test Form), attitude (Iowa Infant Feeding Attitude Scale), perceived behavior (Breastfeeding Behavior Questionnaire), and intention (Infant Feeding Intention Scale). Factors associated with intention to breastfeed were examined by multivariate linear regression analysis. Results The participants had an average breastfeeding knowledge level (mean score, 10.39 ± 2.09) and neutral perceived behavior (mean score, 22.00 ± 3.68), while having relatively positive attitudes (mean score, 58.12 ± 6.49). Knowledge gaps and negative perceptions were identified, particularly linked to breastfeeding in public and among working mothers. Breastfeeding intention was found to be significantly associated with knowledge and attitude in Lebanon (β = 0.103 and β = 0.230, respectively), and with perceived behavior in Syria (β = −0.135). Conclusions By revealing specific knowledge gaps and misconceptions and identifying country-specific disparities in the predictors of the intention to breastfeed, the findings of this study may provide a basis for devising culture-specific interventions aimed at promoting breastfeeding.
Evaluation of a Residential Nutrition Rehabilitation Center in Rural Bolivia: Short-Term Effectiveness and Follow-Up Results
Authors: Forney Kristen M. , Polansky Lauren S. , Rebolledo Paulina A. , Huamani Katherine Foy , Mues Katherine E. , Ramakrishnan Usha , Leon Juan S. 
Published: November 2015

Background Nutrition rehabilitation centers (NRCs) have shown mixed results in reducing morbidity and mortality among undernourished children in the developing world. Follow-up on children after leaving these programs remains undocumented. Objective To assess the nutritional improvement of children attending the Centro de Rehabilitación Infantil Nutricional (CRIN), a residential NRC in rural Bolivia, from entrance to exit and to a household follow-up visit 1 month to 6 years later, and to identify factors associated with nutritional improvement. Methods A retrospective analysis was conducted of clinical records collected by CRIN staff from 135 children under 3 years of age attending CRIN in rural Cochabamba, Bolivia, from 2003 to 2009, and of clinical records of household follow-up measurements on a subset of 26 children that were taken between 1 month and 6 years postexit. Nutritional status was evaluated by calculating z-scores for weight-for-height (WHZ), weight-for-age (WAZ), and height-for-age (HAZ). Children with z-scores < −2 were considered to be wasted, underweight, or stunted, respectively. Results The prevalence of wasting decreased significantly, while the prevalence of stunting did not change significantly between entrance and exit from the program. From entrance to exit, the mean changes in WHZ (0.79) and WAZ (1.08) were statistically significant, while the mean change in HAZ (–0.02) was not significant. Linear regression analysis suggested that nutritional status and diarrhea at entrance had the greatest effect on WHZ and HAZ changes between entrance and exit. Children maintained their nutritional gains from the program between exit and follow-up and showed statistically significant improvement in WAZ (but not HAZ). Conclusions CRIN is effective at rehabilitating nutritional deficits associated with wasting, but not those associated with stunting.
Design and Development of a Combined Calcium—Iron—Folic Acid Prenatal Supplement to Support Implementation of the New World Health Organization Recommendations for Calcium Supplementation during Pregnancy
Authors: Phillips Ashley Aimone M. , Zlotkin Stanley H. , Baxter Jo-Anna B. , Martinuzzi Frank , Kadria Tanush , Roth Daniel E. 
Published: November 2015

Background Hypertensive diseases of pregnancy are important causes of maternal and perinatal mortality. Based on meta-analyses of efficacy trials of prenatal cal- cium supplementation to reduce the risk of hypertensive diseases of pregnancy, the World Health Organization recommends 1.5 to 2.0 g of elemental calcium per day for pregnant women with low dietary calcium intakes (as well as 60 mg of iron and 400 μg of folic acid). However, implementation of this recommendation is challenged by the size and number of calcium tablets required and the need to avoid concurrent ingestion of calcium and iron due to intraintestinal interactions. Objective We developed a novel micronutrient powder containing microencapsulated pH-sensitive calcium in addition to iron and folic acid, designed to facilitate early intestinal iron release and delayed calcium release. Methods Two pharmaceutical companies were con- tracted to develop a prototype, one of which was chosen for clinical testing. Calcium carbonate granules were coated with a trilayer pH-sensitive enteric coating using a fluid-bed spray coater. Iron and folic acid granules were encapsulated with a time-release coating. Iron and cal- cium dissolution profiles were assessed during exposure to acidic (pH 1.2) and/or basic (pH 5.8) media using a modified USP apparatus 1 (basket) method. Results At pH 1.2, calcium and iron release was ≤ 10% and > 90% after 120 minutes, respectively. At pH 5.8, > 80% of total calcium was released after 90 minutes. Conclusions Based on in vitro criteria, the sup- plement may be a promising approach for delivering calcium, iron, and folic acid as a single daily dose to preg- nant women in settings of low dietary intake of calcium.