Publications by authors named "Rolf D Klemm"

37 Publications

The Risk Factors for Child Anemia Are Consistent across 3 National Surveys in Nepal.

Curr Dev Nutr 2021 Jun 21;5(6):nzab079. Epub 2021 May 21.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Anemia is an etiologically heterogeneous condition affecting over half of preschool-aged children in South Asia. An urgent need exists to elucidate context-specific causes of anemia to effectively address this issue.

Objectives: This study investigated national trends and stability in the prevalence of child anemia and associated risk factors from 2013 to 2016 in Nepal.

Methods: Same-season national surveys were administered in 2013, 2014, and 2016 in 63 sites across 21 districts, selected using multistage random sampling, representing the mountains, hills, and Tarai (plains). Among consenting households with children aged 6-59 mo, a random sample of capillary blood was selected each year for anemia assessment using an Hb 201+ hemoglobinometer, with  = 835, 807, and 881 children assessed, respectively. Prevalence of child anemia, defined as hemoglobin <11.0 g/dL with adjustment for altitude, was estimated each year and disaggregated by region and child age. Prevalence ratios were estimated using log-binomial regression models with robust SE or robust Poisson regression when models failed to converge. Interaction terms between each risk factor and year were created to test for consistencies in associations over time.

Results: The national prevalence of child anemia decreased from 63.3% (95% CI: 59.0%, 67.5%) in 2013 to 51.9% (95% CI: 46.5%, 57.2%) in 2014 and increased to 59.3% (95% CI: 54.7%, 63.8%) in 2016. Across years, prevalence was highest in the Tarai (58.4-70.2%), followed by the mountains (53.0-61.1%) and hills (37.5-51.4%). Nationally and across time, child age and maternal anemia were significantly associated with child anemia. Child diarrhea and stunting, maternal thinness, and poor water and sanitation conditions also showed consistent trends toward higher anemia prevalence.

Conclusions: Anemia affects more than half of Nepalese children aged 6-59 mo. Although prevalence varies year to year, the stability of observed risk factors suggests the need to focus on reducing gastrointestinal infection, promoting adequate household sanitation, and improving maternal and child health.
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http://dx.doi.org/10.1093/cdn/nzab079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178108PMC
June 2021

Between the City and the Farm: Food Environments in Artisanal Mining Communities in Upper Guinea.

Public Health Nutr 2021 May 12:1-34. Epub 2021 May 12.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, USA.

Objective: Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries, however many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and subsistence rural areas examined in much existing food environment literature.

Design: We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves.

Setting: Eighteen study sites in ASM communities in northern Guinea.

Participants: Surveys covered mothers in mining households with young children (n=613); in-depth interviews engaged mothers of young children (n=45), food vendors (n=40), and young single miners (n=15); observations focused on mothers of young children (n=25).

Results: The external food environment in these ASM communities combines widespread availability of commercially-processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation.

Conclusions: We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming.
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http://dx.doi.org/10.1017/S1368980021002020DOI Listing
May 2021

"If you don't find anything, you can't eat" - Mining livelihoods and income, gender roles, and food choices in northern Guinea.

Resour Policy 2021 Mar;70:101939

Department of International Health, Johns Hopkins Bloomberg School of Public Health - 615 N Wolfe St, Baltimore, MD, 21205, USA.

Artisanal and small-scale mining (ASM) continues to grow as a viable economic activity in sub-Saharan Africa. The health and environmental impacts of the industry, notably linked to the use of potentially toxic chemicals, has been well documented. What has not been explored to the same extent is how pressures associated with ASM affect food choices of individuals and families living in mining camps. This paper presents research conducted in 18 mining sites in northern Guinea exploring food choices and the various factors affecting food decision-making practices. Two of the most influential factors to emerge from this study are income variability and gender roles. Results from this study suggest that through artisanal mining, women have the opportunity to earn a larger income that would otherwise be unavailable through agriculture. However, this benefit of potentially earning a larger income is often reduced or constrained by existing gender roles both at the mines and in the home, such as disparity in pay between men and women and increased pressures on women's time. This limits the potential benefit to household food decision-making that could have been gained from higher income. These results do not seek to establish one livelihood as superior; rather, they demonstrate that even when presented with opportunities to earn higher incomes, women still face many of the same barriers and challenges that they would in other economic activities. Additionally, while work and time demands on women change upon arrival in the mining camps, existing gender roles and expectations do not, further restricting women's decision-making capacity.
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http://dx.doi.org/10.1016/j.resourpol.2020.101939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7976851PMC
March 2021

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi.

Am J Clin Nutr 2021 Mar 19. Epub 2021 Mar 19.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity.

Objectives: To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices.

Methods: This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences.

Results: We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up.

Conclusions: The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.
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http://dx.doi.org/10.1093/ajcn/nqab010DOI Listing
March 2021

Food Security in Artisanal Mining Communities: An Exploration of Rural Markets in Northern Guinea.

Foods 2020 Apr 10;9(4). Epub 2020 Apr 10.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

The number of people engaged in artisanal and small-scale mining (ASM) has grown rapidly in the past twenty years, but they continue to be an understudied population experiencing high rates of malnutrition, poverty, and food insecurity. This paper explores how characteristics of markets that serve ASM populations facilitate and pose challenges to acquiring a nutritious and sustainable diet. The study sites included eight markets across four mining districts in the Kankan Region in the Republic of Guinea. Market descriptions to capture the structure of village markets, as well as twenty in-depth structured interviews with food vendors at mining site markets were conducted. We identified three forms of market organization based on location and distance from mining sites. Markets located close to mining sites offered fewer fruit and vegetable options, as well as a higher ratio of prepared food options as compared with markets located close to village centers. Vendors were highly responsive to customer needs. Food accessibility and utilization, rather than availability, are critical for food security in non-agricultural rural areas such as mining sites. Future market-based nutrition interventions need to consider the diverse market settings serving ASM communities and leverage the high vendor responsiveness to customer needs.
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http://dx.doi.org/10.3390/foods9040479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231122PMC
April 2020

Thinness and fecundability: Time to pregnancy after adolescent marriage in rural Bangladesh.

Matern Child Nutr 2020 07 24;16(3):e12985. Epub 2020 Mar 24.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001-2002, 5,516 newlywed women aged 12-19 years participated in a home-based, 5-weekly surveillance system for 5-6 years to enrol pregnant women into an antenatal vitamin A or β-carotene supplementation trial. Thinness was defined as a left mid-upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan-Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58-68] vs. 51 [49-54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy.
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http://dx.doi.org/10.1111/mcn.12985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296800PMC
July 2020

Prevalence of damaged and missing teeth among women in the southern plains of Nepal: Findings of a simplified assessment tool.

PLoS One 2019 3;14(12):e0225192. Epub 2019 Dec 3.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Objective: To assess the prevalence of missing and damaged teeth among women in the rural southern plains of Nepal using an interviewer-administered tooth assessment module.

Setting: 21wards in seven Village Development Committees across the Tarai of Nepal in 2015.

Participants: Resident, married women of children less than 5 years of age or those married in the 2 years prior to the survey, 14 to 49 years of age participating in a mid-year nutrition and health survey in the Tarai region of Nepal.

Outcome Measures: Prevalence of missing and damaged teeth, history of dental problems, oral hygiene practices, access to dental treatment and risk factors for missing and damaged teeth.

Results: Of 3007 assessed women, aged 14 to 49 years of age, 22.8% (95% CI: 21.4-24.4) reported ≥ 1 missing or damaged teeth; 81.5% (95% CI 80.1-82.9) reported regularly practicing oral hygiene, typically with standard local dentifrices. Pain or discomfort in the oral cavity in the previous 6 months affected 17.6% of women. Among these, 43.8% had sought treatment from a dental facility, pharmacy or village doctor. Home remedies were commonly applied to relieve pain.

Conclusion: Broken and missing teeth are common, affecting nearly one-quarter of adult women of reproductive age in rural Southern Nepal, as assessed by an interviewer-administered questionnaire.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225192PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890177PMC
March 2020

Antenatal Multiple Micronutrient Supplementation Compared to Iron-Folic Acid Affects Micronutrient Status but Does Not Eliminate Deficiencies in a Randomized Controlled Trial Among Pregnant Women of Rural Bangladesh.

J Nutr 2019 07;149(7):1260-1270

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Background: Antenatal multiple micronutrient (MM) supplementation improves birth outcomes relative to iron-folic acid (IFA) in developing countries, but limited data exist on its impact on pregnancy micronutrient status.

Objective: We assessed the efficacy of a daily MM (15 nutrients) compared with IFA supplement, each providing approximately 1 RDA of nutrients and given beginning at pregnancy ascertainment, on late pregnancy micronutrient status of women in rural Bangladesh. Secondarily, we explored other contributors to pregnancy micronutrient status.

Methods: Within a double-masked trial (JiVitA-3) among 44,500 pregnant women, micronutrient status indicators were assessed in n = 1526 women, allocated by cluster to receive daily MM (n = 749) or IFA (n = 777), at 10 wk (baseline: before supplementation) and 32 wk (during supplementation) gestation. Efficacy of MM supplementation on micronutrient status indicators at 32 wk was assessed, controlling for baseline status and other covariates (e.g., inflammation and season), in regression models.

Results: Baseline status was comparable by intervention. Prevalence of deficiency among all participants was as follows: anemia, 20.6%; iron by ferritin, 4.0%; iron by transferrin receptor, 4.7%; folate, 2.5%; vitamin B-12, 35.4%; vitamin A, 6.7%; vitamin E, 57.7%; vitamin D, 64.0%; zinc, 13.4%; and iodine, 2.6%. At 32 wk gestation, vitamin B-12, A, and D and zinc status indicators were 3.7-13.7% higher, and ferritin, γ-tocopherol, and thyroglobulin indicators were 8.7-16.6% lower, for the MM group compared with the IFA group, with a 15-38% lower prevalence of deficiencies of vitamins B-12, A, and D and zinc (all P < 0.05). However, indicators typically suggested worsening status during pregnancy, even with supplementation, and baseline status or other covariates were more strongly associated with late pregnancy indicators than was MM supplementation.

Conclusions: Rural Bangladeshi women commonly entered pregnancy deficient in micronutrients other than iron and folic acid. Supplementation with MM improved micronutrient status, although deficiencies persisted. Preconception supplementation or higher nutrient doses may be warranted to support nutritional demands of pregnancy in undernourished populations. This trial was registered at clinicaltrials.gov as NCT00860470.
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http://dx.doi.org/10.1093/jn/nxz046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602890PMC
July 2019

Determinants of infant breastfeeding practices in Nepal: a national study.

Int Breastfeed J 2019 3;14:14. Epub 2019 Apr 3.

3Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA.

Background: Optimal breastfeeding practices, reflected by early initiation and feeding of colostrum, avoidance of prelacteal feeds, and continued exclusivity or predominance of breastfeeding, are critical for assuring proper infant nutrition, growth and development.

Methods: We used data from a nationally representative survey in 21 district sites across the Mountains, Hills and Terai (southern plains) of Nepal in 2013. Determinants of early initiation of breastfeeding, feeding of colostrum, prelacteal feeding and predominant breastfeeding were explored in 1015 infants < 12 months of age. Prelacteal feeds were defined as food/drink other than breast milk given to newborns in first 3 days. Predominant breastfeeding was defined as a child < 6 months of age is mainly breastfed, not fed solid/semi-solid foods, infant formula or non-human milk, in the past 7 days. Adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated, using log Poisson regression models with robust variance for clustering.

Results: The prevalence of breastfeeding within an hour of birth, colostrum feeding, prelacteal feeding and predominant breastfeeding was 41.8, 83.5, 32.7 and 57.2% respectively. Compared to infants not fed prelacteal feeds, infants given prelacteal feeds were 51% less likely to be breastfed within the first hour of birth (APR 0.49; 95% CI 0.36, 0.66) and 55% less likely to be predominantly breastfed (APR 0.45; 95% CI 0.32, 0.62). Infants reported to have received colostrum were more likely to have begun breastfeeding within an hour of birth (APR 1.26; 95% CI 1.04, 1.54) compared to those who did not receive colostrum. Infants born to mothers ≥ 20 years of age were less likely than adolescent mothers to initiate breastfeeding within 1 hour of birth. Infants in the Terai were 10% less likely to have received colostrum (APR 0.90; 95% CI 0.83, 0.97) and 2.72 times more likely to have received prelacteal feeds (APR 2.72; 95% CI 1.67, 4.45) than those in the Mountains.

Conclusions: Most infants in Nepal receive colostrum but less than half initiate breastfeeding within an hour of birth and one-third are fed prelacteal feeds, which may negatively affect breastfeeding and health throughout early infancy.
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http://dx.doi.org/10.1186/s13006-019-0208-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448244PMC
April 2020

Unintended pregnancy is a risk factor for depressive symptoms among socio-economically disadvantaged women in rural Bangladesh.

BMC Pregnancy Childbirth 2018 Dec 13;18(1):490. Epub 2018 Dec 13.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St., Room E2519, Baltimore, MD, 21205-2179, USA.

Background: Little is known about the relation between unwanted pregnancy and intention discordance and maternal mental health in low-income countries. The study aim was to evaluate maternal and paternal pregnancy intentions (and intention discordance) in relation to perinatal depressive symptoms among rural Bangladeshi women.

Methods: Data come from a population-based, community trial of married rural Bangladeshi women aged 13-44. We examined pregnancy intentions among couples and pregnancy-intention discordance, as reported by women at enrollment soon after pregnancy ascertainment, in relation to depressive symptoms in the third trimester of pregnancy (N = 14,629) and six months postpartum (N = 31,422). We calculated crude and adjusted risk ratios for prenatal and postnatal depressive symptoms by pregnancy intentions.

Results: In multivariable analyses, women with unwanted pregnancies were at higher risk of prenatal (Adj. RR = 1.60, 95% CI: 1.37-1.87) and postnatal depressive symptoms (Adj. RR = 1.32, 95% CI: 1.21-1.44) than women with wanted pregnancies. Women who perceived their husbands did not want the pregnancy also were at higher risk for prenatal (Adj. RR = 1.42, 95% CI: 1.22-1.65) and postnatal depressive symptoms (Adj. RR = 1.30, 95% CI: 1.19-1.41). Both parents not wanting the pregnancy was associated with prenatal and postnatal depressive symptoms (Adj. RR = 1.34, 95% CI: 1.19-1.52; Adj. RR = 1.13, 95% CI: 1.06-1.21, respectively), compared to when both parents wanted it. Adjusting for socio-demographic and pregnancy intention variables simultaneously, maternal intentions and pregnancy discordance were significantly related to prenatal depressive symptoms, and perception of paternal pregnancy unwantedness and couple pregnancy discordance, with postnatal depressive symptoms.

Conclusions: Maternal, paternal and discordant couple pregnancy intentions, as perceived by rural Bangladeshi women, are important risk factors for perinatal maternal depressive symptoms.
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http://dx.doi.org/10.1186/s12884-018-2097-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292066PMC
December 2018

Nutritional resilience in Nepal following the earthquake of 2015.

PLoS One 2018 7;13(11):e0205438. Epub 2018 Nov 7.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.

Background: The 2015 earthquake in Nepal caused massive damages and triggered relief activities to minimize human suffering. The post-earthquake nutrition and food security situation in the hardest hit areas remains uncertain.

Methods: Two national cross-sectional surveys were conducted in 2014 and 2016 among households (HH) with pre-school aged children or newly married women. Of the 21 village development committees (VDCs) included in this sample, 7 fell within "earthquake-affected" areas. This paper presents data from 982 HH, 1015 women, and 883 children from 2014 and 1056 HH, 1083 women, and 998 children from 2016 living in these areas, with longitudinal overlap of about 55%. Prevalence estimates and 95% confidence intervals were calculated, and logistic regression was used to calculate p-values, both using robust estimates of standard errors to account for clustering.

Results: From 2014 to 2016, child wasting (weight-for-height z score <-2) fell from 4.5% (95% CI 3.3%- 6.1%) to 2.1% (1.4%- 3.1%) and food insecurity (assessed using the household food insecurity access scale) dropped from 17.6% (11.7%- 25.6%) to 12.4% (6.9%- 21.2%). Child stunting prevalence remained similar at both time-points. Improvements were also evident in dietary diversity and breastfeeding indicators.

Conclusions: Nutrition and food security conditions remained comparable or improved one year after the earthquake despite evidence of structural and other damage. Livelihood resilience to shocks and/or effective nutrition, food or health interventions may have helped buffer the impact on nutrition, although this hypothesis requires further exploration.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205438PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221269PMC
April 2019

Identifying maternal and infant factors associated with newborn size in rural Bangladesh by partial least squares (PLS) regression analysis.

PLoS One 2017 20;12(12):e0189677. Epub 2017 Dec 20.

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.

Birth weight, length and circumferences of the head, chest and arm are key measures of newborn size and health in developing countries. We assessed maternal socio-demographic factors associated with multiple measures of newborn size in a large rural population in Bangladesh using partial least squares (PLS) regression method. PLS regression, combining features from principal component analysis and multiple linear regression, is a multivariate technique with an ability to handle multicollinearity while simultaneously handling multiple dependent variables. We analyzed maternal and infant data from singletons (n = 14,506) born during a double-masked, cluster-randomized, placebo-controlled maternal vitamin A or β-carotene supplementation trial in rural northwest Bangladesh. PLS regression results identified numerous maternal factors (parity, age, early pregnancy MUAC, living standard index, years of education, number of antenatal care visits, preterm delivery and infant sex) significantly (p<0.001) associated with newborn size. Among them, preterm delivery had the largest negative influence on newborn size (Standardized β = -0.29 - -0.19; p<0.001). Scatter plots of the scores of first two PLS components also revealed an interaction between newborn sex and preterm delivery on birth size. PLS regression was found to be more parsimonious than both ordinary least squares regression and principal component regression. It also provided more stable estimates than the ordinary least squares regression and provided the effect measure of the covariates with greater accuracy as it accounts for the correlation among the covariates and outcomes. Therefore, PLS regression is recommended when either there are multiple outcome measurements in the same study, or the covariates are correlated, or both situations exist in a dataset.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189677PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738092PMC
January 2018

Improving maternal, infant and young child nutrition in Nepal via peer mobilization.

Public Health Nutr 2018 03 6;21(4):796-806. Epub 2017 Nov 6.

5Helen Keller International,Kathmandu,Nepal.

Objective: To evaluate the impact of a peer facilitator (PF) approach for improving mothers' knowledge and practices relating to maternal and child nutrition.

Design: A quasi-experimental design nested within a large-scale integrated nutrition programme, Suaahara, in Nepal. Suaahara interventions were implemented in all study sites, but peer facilitators were used in only half of the study sites.

Setting: Rural, disadvantaged villages in three districts of Nepal: Bhojpur, Bajhang and Rupandehi.

Subjects: Mothers of children aged 6-23·9 months (n 1890).

Results: Differences over time between comparison (C) and intervention (I) groups show that the PF approach had a significant positive impact on several indicators of mothers' knowledge and practices relating to maternal and child nutrition: (i) knowing that fruits and vegetables are good for children 6-23·9 months (C: -0·7, I: 10·6; P=0·03); (ii) child dietary diversity (C: 0·02, I: 0·04; P=0·02); (iii) child minimum dietary diversity (≥4 of 7 food groups; (C: 6·9, I: 16·0; P=0·02); (iv) maternal dietary diversity (C: 0·1, I: 0·4; P=0·01); and (v) maternal minimum dietary diversity (≥4 food groups; C: 3·6, I: 14·0; P=0·03). Additionally, exposure to a PF three or more times in the past 6 months was positively associated with a small improvement in maternal (β=0·06, P=0·04) and child (β=0·06, P=0·02) dietary diversity scores. Improvements were not observed in maternal health-seeking behaviours such as number of antenatal care visits.

Conclusions: Peer mobilization is a potential approach for improving health- and nutrition-related knowledge and behaviours among women in hard-to-reach communities of Nepal.
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http://dx.doi.org/10.1017/S1368980017002993DOI Listing
March 2018

Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency.

Nutrients 2017 Feb 24;9(3). Epub 2017 Feb 24.

GroundWork, 7306 Fläsch, Switzerland.

Vitamin A supplementation (VAS) programs targeted at children aged 6-59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.
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http://dx.doi.org/10.3390/nu9030190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372853PMC
February 2017

Individual, household, and community level risk factors of stunting in children younger than 5 years: Findings from a national surveillance system in Nepal.

Matern Child Nutr 2018 01 23;14(1). Epub 2017 Feb 23.

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Despite substantial reductions in recent years in Nepal, stunting prevalence in children younger than 5 years remains high and represents a leading public health concern. To identify factors contributing to the stunting burden, we report multilevel risk factors associated with stunting in 4,853 children aged 6-59 months in a nationally and agroecologically representative random sample from the first year of the Policy and Science for Health, Agriculture, and Nutrition Community Studies, a community-based observational, mixed-panel study. Mixed effects logistic regressions controlling for multilevel clustering in the study design were used to examine the association of individual-, household-, and community-level factors associated with stunting. Stunting prevalence was 38% in our sample. After adjustment for potential confounding variables, maternal factors, including maternal height and education, were generally the strongest individual-level risk factors for stunting, adjusted odds ratio (AOR) = 2.52, 95% CI [1.96, 3.25], short (<145 cm) versus not short mothers; AOR = 2.09, 95% CI [1.48, 2.96], uneducated mothers versus secondary school graduates. Among the household- and community-level factors, household expenditure and community infrastructure (presence of paved roads, markets, or hospitals) were strongly, inversely associated with increased stunting risk, AOR = 1.68, 95% CI [1.27, 2.24], lowest versus highest household expenditure quintile; AOR = 2.38, 95% CI [1.36, 4.14], less developed (lacking paved roads, markets, or hospitals) versus more developed communities. Although most factors associated with stunting are not rapidly modifiable, areas for future research and possible interventions emerged.
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http://dx.doi.org/10.1111/mcn.12434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865942PMC
January 2018

Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity.

Matern Child Nutr 2017 10 6;13(4). Epub 2017 Jan 6.

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non-health determinants of undernutrition. In Nepal, one large-scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000-day period, while simultaneously addressing inequities. In this study, we use household-level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non-disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child-, maternal-, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non-Suaahara areas and sometimes even than non-DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non-DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large-scale integrated interventions can influence nutrition-related knowledge and practices, while simultaneously reducing inequities.
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http://dx.doi.org/10.1111/mcn.12415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6866152PMC
October 2017

Early newborn ritual foods correlate with delayed breastfeeding initiation in rural Bangladesh.

Int Breastfeed J 2016 8;11:31. Epub 2016 Dec 8.

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA.

Background: Early and exclusive breastfeeding may improve neonatal survival in low resource settings, but suboptimal breastfeeding still exists in areas with high infant mortality. Prelacteal feeding, the practice of giving a non-breastmilk food as a neonate's first food, has been associated with suboptimal breastfeeding practices. We examined the association of feeding a non-breastmilk food in the first three days of life (early neonatal food, or ENF) with time from birth to initiation of breastfeeding among 25,286 Bangladeshi mother-neonate pairs, in a secondary analysis of a randomized controlled trial in northwestern rural Bangladesh conducted from 2001-2007.

Methods: Trained interviewers assessed the demographic characteristics during pregnancy. At three months postpartum, the interviewers visited participants again and retrospectively assessed demographic and breastfeeding characteristics surrounding the birth. We assessed the relationship between ENF and time to initiation of breastfeeding in hours in both unadjusted and adjusted linear regression analyses. We also calculated reverse cumulative distribution curves for time to initiation of breastfeeding and analyses were stratified by an infant's ability to breastfeed normally at birth.

Results: The mean ± SD time from birth to initiation of breastfeeding was 30.6 ± 27.9 hours. Only 2,535 (10.0%) of women reported initiating breastfeeding in the first hour after birth and 10,207 (40.4%) reported initiating breastfeeding in the first 12 hours after birth. In adjusted linear regression analyses, feeding ENF was associated with a significant increase in time, in hours, to breastfeeding initiation both among children not able to breastfeed at birth (37.4; 95% CI 33.3, 41.5) and among children able to breastfeed at birth (13.3; 95% CI 12.7, 14.0).

Conclusions: Feeding ENF was strongly associated with delayed initiation of breastfeeding, even after adjusting for other related factors and stratifying on the neonate's ability to suckle normally after birth. More research is needed to understand the impact of these findings on optimal breastfeeding in this setting. It is possible that ENF feeding and the ability to breastfeed immediately after birth are interrelated in their respective associations to suboptimal breastfeeding initiation. This study in a large population representative of other populations in rural South Asia, demonstrates significantly longer times to breastfeeding initiation than previously appreciated, with a possible important role of ENF feeding.

Trial Registration: The randomized controlled trial on which this analysis is based, "Impact of Maternal Vitamin A or Beta-Carotene Supplementation on Maternal and Infant Mortality in Bangladesh", was registered with ClinicalTrials.gov as trial number ID GHS-A-00-03-00019-00 and identifier NCT00198822. The identifier was first received September 12, 2005 (retrospectively registered). The first participant was enrolled in August 2001.
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http://dx.doi.org/10.1186/s13006-016-0090-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143457PMC
December 2016

What Does It Cost to Improve Household Diets in Nepal? Using the Cost of the Diet Method to Model Lowest Cost Dietary Changes.

Food Nutr Bull 2016 Sep 7;37(3):247-260. Epub 2016 Jul 7.

1 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: In Nepal, limited availability and affordability of nutritious foods contribute to malnutrition.

Objectives: To identify nutrient deficiencies in commonly consumed diets and model lowest cost changes that could improve diet quality in 3 agroecological zones of Nepal.

Methods: In August to September 2014, we collected market price and women's food frequency data from 3 representative villages in Nepal's mountains (Mahat Gaun, Jumla, n = 181 households), hills (Sitapur, Arghakhanchi, n = 166), and terai (Saigaun, Banke, n = 232) and verified local diets during women's group discussions. Using the Cost of the Diet method, we compared models of the most nutritious version of a commonly consumed diet given locally available foods ("common diet") with the cheapest possible diet meeting nutrient requirements, including foods not currently available ("optimal diet").

Results: The household common diet lacks sufficient vitamin B12, riboflavin, and calcium in the mountains; B6, B12, calcium, and iron in the hills; vitamin A, calcium, and iron in the terai. Adding fish to the mountain and hill diets and increasing dark green leafy vegetable consumption in all zones yielded nutritional adequacy. Optimal diets are more expensive than the common diet in the mountains and hills but less expensive in the terai.

Conclusion: The modeled lowest cost diet commonly eaten in 3 Nepalese communities lacks key nutrients. Policies and interventions that increase market availability and consumption of vitamin B12- and calcium-rich fish and dark green leafy vegetables could improve local diets, particularly in the mountains and hills.
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http://dx.doi.org/10.1177/0379572116657267DOI Listing
September 2016

A Qualitative Analysis of Barriers and Facilitators to Optimal Breastfeeding and Complementary Feeding Practices in South Kivu, Democratic Republic of Congo.

Food Nutr Bull 2016 06 6;37(2):119-31. Epub 2016 Apr 6.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Helen Keller International, Washington, DC, USA

Background: Suboptimal infant and young child feeding (IYCF) practices are determinants of poor child nutritional status. In the Democratic Republic of Congo, few children are fed according to international guidelines; this combined with endemic poverty and food insecurity have contributed to the high prevalence of child undernutrition.

Objective: To characterize IYCF practices and barriers and enablers to optimal child feeding in South Kivu.

Methods: Focus group discussions, structured and in-depth interviews with women of reproductive age, mothers of children <2 years, and health workers were conducted in 2012 as part of formative research for the US Agency for International Development (USAID)-funded Jenga Jamaa II multiyear assistance program.

Results: Although breastfeeding was prevalent, few mothers engaged in optimal feeding practices. Barriers included poverty, high work burden, lack of decision-making power in the household, and perceived milk insufficiency. Health provider guidance and mothers' motivation to breastfeed and feed nutrient-dense foods emerged as facilitators to optimal practices.

Conclusions: Structural factors, especially long hours working in agricultural fields, impeded mothers' ability to feed their children optimally. Interventions to address child nutrition and improve IYCF practices should take into account these factors, in addition to food access, nutrition education, and behavior change.
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http://dx.doi.org/10.1177/0379572116637947DOI Listing
June 2016

A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety.

Food Nutr Bull 2016 06 22;37(2 Suppl):S75-86. Epub 2016 Mar 22.

UNICEF, West and Central Africa Regional Office, Dakar, Senegal, Africa.

Background: Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options.

Objective: This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs.

Methods: We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk.

Results: Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented.

Conclusions: Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.
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http://dx.doi.org/10.1177/0379572116630481DOI Listing
June 2016

Assessing Child Nutrient Intakes Using a Tablet-Based 24-Hour Recall Tool in Rural Zambia.

Food Nutr Bull 2015 Dec 19;36(4):467-80. Epub 2015 Oct 19.

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Background: Detailed dietary intake data in low-income populations are needed for research and program evaluation. However, collection of such data by paper-based 24-hour recall imposes substantial demands for staff time and expertise, training, materials, and data entry.

Objective: To describe our development and use of a tablet-based 24-hour recall tool for conducting dietary intake surveys in remote settings.

Methods: We designed a 24-hour recall tool using Open Data Kit software on an Android tablet platform. The tool contains a list of local foods, questions on portion size, cooking method, ingredients, and food source and prompts to guide interviewers. We used this tool to interview caregivers on dietary intakes of children participating in an efficacy trial of provitamin A-biofortified maize conducted in Mkushi, a rural district in central Zambia. Participants were children aged 4 to 8 years not yet enrolled in school (n = 938). Dietary intake data were converted to nutrient intakes using local food composition and recipe tables.

Results: We developed a tablet-based 24-hour recall tool and used it to collect dietary data among 928 children. The majority of foods consumed were maize, leafy vegetable, or small fish dishes. Median daily energy intake was 6416 kJ (1469 kcal).

Conclusions: Food and nutrient intakes assessed using the tablet-based tool were consistent with those reported in prior research. The tool was easily used by interviewers without prior nutrition training or computing experience. Challenges remain to improve programming, but the tool is an innovation that enables efficient collection of 24-hour recall data in remote settings.
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http://dx.doi.org/10.1177/0379572115612631DOI Listing
December 2015

First-trimester plasma tocopherols are associated with risk of miscarriage in rural Bangladesh.

Am J Clin Nutr 2015 Feb 26;101(2):294-301. Epub 2014 Nov 26.

From the Center for Human Nutrition, Department of International Health, Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD (AAS, KS, RDM, PC, SS, LW, HA, ABL, SM, RDWK, and KPW); The JiVitA Project of Johns Hopkins University, Bangladesh, Gaibandha, Bangladesh (AAS, AK, SS, HA, and MR); and the Institute of Nutrition, Mahidol University, Bangkok, Thailand (PS and EU).

Background: Tocopherols were discovered for their role in animal reproduction, but little is known about the contribution of deficiencies of vitamin E to human pregnancy loss.

Objective: We sought to determine whether higher first-trimester concentrations of α-tocopherol and γ-tocopherol were associated with reduced odds of miscarriage (pregnancy losses <24 wk of gestation) in women in rural Bangladesh.

Design: A case-cohort study in 1605 pregnant Bangladeshi women [median (IQR) gestational age: 10 wk (8-13 wk)] who participated in a placebo-controlled vitamin A- or β-carotene-supplementation trial was done to assess ORs of miscarriage in women with low α-tocopherol (<12.0 μmol/L) and γ-tocopherol (<0.81 μmol/L; upper tertile cutoff of the γ-tocopherol distribution in women who did not miscarry).

Results: In all women, plasma α- and γ-tocopherol concentrations were low [median (IQR): 10.04 μmol/L (8.07-12.35 μmol/L) and 0.66 μmol/L (0.50-0.95 μmol/L), respectively]. In a logistic regression analysis that was adjusted for cholesterol and the other tocopherol, low α-tocopherol was associated with an OR of 1.83 (95% CI: 1.04, 3.20), whereas a low γ-tocopherol concentration was associated with an OR of 0.62 (95% CI: 0.41, 0.93) for miscarriage. Subgroup analyses revealed that opposing ORs were evident only in women with BMI (in kg/m(2)) ≥18.5 and serum ferritin concentration ≤150 μg/L, although low BMI and elevated ferritin conferred stronger risk of miscarriage.

Conclusions: In pregnant women in rural Bangladesh, low plasma α-tocopherol was associated with increased risk of miscarriage, and low γ-tocopherol was associated with decreased risk of miscarriage. Maternal vitamin E status in the first trimester may influence risk of early pregnancy loss. The JiVitA-1 study, from which data for this report were derived, was registered at clinicaltrials.gov as NCT00198822.
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http://dx.doi.org/10.3945/ajcn.114.094920DOI Listing
February 2015

Availability of emergency obstetric care (EmOC) among public and private health facilities in rural northwest Bangladesh.

BMC Public Health 2015 Jan 31;15:36. Epub 2015 Jan 31.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Although safe motherhood strategies recommend that women seek timely care from health facilities for obstetric complications, few studies have described facility availability of emergency obstetric care (EmOC). We sought to describe and compare availability and readiness to provide EmOC among public and private health facilities commonly visited for pregnancy-related complications in two districts of northwest Bangladesh. We also described aspects of financial and geographic access to healthcare and key constraints to EmOC provision.

Methods: Using data from a large population-based community trial, we identified and surveyed the 14 health facilities (7 public, 7 private) most frequently visited for obstetric complications and near misses as reported by women. Availability of EmOC was based on provision of medical services, assessed through clinician interviews and record review. Levels of EmOC availability were defined as basic or comprehensive. Readiness for EmOC provision was based on scores in four categories: staffing, equipment, laboratory capacity, and medicines. Readiness scores were calculated using unweighted averages. Costs of C-section procedures and geographic locations of facilities were described. Textual analysis was used to identify key constraints.

Results: The seven surveyed private facilities offered comprehensive EmOC compared to four of the seven public facilities. With 100% representing full readiness, mean EmOC readiness was 81% (range: 63%-91%) among surveyed private facilities compared to 67% (range: 48%-91%) in public facilities (p = 0.040). Surveyed public clinics had low scores on staffing and laboratory capacity (69%; 50%). The mean cost of the C-section procedure in private clinics was $77 (standard deviation: $16) and free in public facilities. The public sub-district facilities were the only facilities located in rural areas, with none providing comprehensive EmOC. Shortages in specialized staff were listed as the main barrier to EmOC provision in public facilities.

Conclusions: Although EmOC availability and readiness was higher among the surveyed seven most commonly visited private clinics, public facilities appeared to be more affordable for C-section and more geographically accessible. Strategies to retain anesthesiologists and surgeons, such as non-financial incentives, are needed to improve EmOC provision in the public sector. Centralized blood banks are recommended to streamline safe blood acquisition for obstetric surgeries.
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http://dx.doi.org/10.1186/s12889-015-1405-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316389PMC
January 2015

Effect of maternal multiple micronutrient vs iron-folic acid supplementation on infant mortality and adverse birth outcomes in rural Bangladesh: the JiVitA-3 randomized trial.

JAMA 2014 Dec 24-31;312(24):2649-58

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Importance: Maternal micronutrient deficiencies may adversely affect fetal and infant health, yet there is insufficient evidence of effects on these outcomes to guide antenatal micronutrient supplementation in South Asia.

Objective: To assess effects of antenatal multiple micronutrient vs iron-folic acid supplementation on 6-month infant mortality and adverse birth outcomes.

Design, Setting, And Participants: Cluster randomized, double-masked trial in Bangladesh, with pregnancy surveillance starting December 4, 2007, and recruitment on January 11, 2008. Six-month infant follow-up ended August 30, 2012. Surveillance included 127,282 women; 44,567 became pregnant and were included in the analysis and delivered 28,516 live-born infants. Median gestation at enrollment was 9 weeks (interquartile range, 7-12).

Interventions: Women were provided supplements containing 15 micronutrients or iron-folic acid alone, taken daily from early pregnancy to 12 weeks postpartum.

Main Outcomes And Measures: The primary outcome was all-cause infant mortality through 6 months (180 days). Prespecified secondary outcomes in this analysis included stillbirth, preterm birth (<37 weeks), and low birth weight (<2500 g). To maintain overall significance of α = .05, a Bonferroni-corrected α = .01 was calculated to evaluate statistical significance of primary and 4 secondary risk outcomes (.05/5).

Results: Among the 22,405 pregnancies in the multiple micronutrient group and the 22,162 pregnancies in the iron-folic acid group, there were 14,374 and 14,142 live-born infants, respectively, included in the analysis. At 6 months, multiple micronutrients did not significantly reduce infant mortality; there were 764 deaths (54.0 per 1000 live births) in the iron-folic acid group and 741 deaths (51.6 per 1000 live births) in the multiple micronutrient group (relative risk [RR], 0.95; 95% CI, 0.86-1.06). Multiple micronutrient supplementation resulted in a non-statistically significant reduction in stillbirths (43.1 vs 48.2 per 1000 births; RR, 0.89; 95% CI, 0.81-0.99; P = .02) and significant reductions in preterm births (18.6 vs 21.8 per 100 live births; RR, 0.85; 95% CI, 0.80-0.91; P < .001) and low birth weight (40.2 vs 45.7 per 100 live births; RR, 0.88; 95% CI, 0.85-0.91; P < .001).

Conclusions And Relevance: In Bangladesh, antenatal multiple micronutrient compared with iron-folic acid supplementation did not reduce all-cause infant mortality to age 6 months but resulted in a non-statistically significant reduction in stillbirths and significant reductions in preterm births and low birth weight.

Trial Registration: clinicaltrials.gov Identifier: NCT00860470.
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http://dx.doi.org/10.1001/jama.2014.16819DOI Listing
January 2015

Preferred delivery method and acceptability of Wheat-Soy Blend (WSB++) as a daily complementary food supplement in northwest Bangladesh.

Ecol Food Nutr 2015 26;54(1):74-92. Epub 2014 Nov 26.

a The JiVitA Project , Gaibandha , Bangladesh.

Fortified blended foods (FBFs) are widely used to prevent undernutrition in early childhood in food-insecure settings. We field tested enhanced Wheat Soy Blend (WSB++)-a FBF fortified with micronutrients, milk powder, sugar, and oil-in preparation for a complementary food supplement (CFS) trial in rural northwestern Bangladesh. Formative work was conducted to determine the optimal delivery method (cooked vs. not) for this CFS, to examine mothers' child feeding practices with and acceptance of the WSB++, and to identify potential barriers to adherence. Our results suggest WSB++ is an acceptable CFS in rural Bangladesh and the requirement for mothers to cook WSB++ at home is unlikely to be a barrier to its daily use as a CFS in this population.
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http://dx.doi.org/10.1080/03670244.2014.930030DOI Listing
December 2015

Early neonatal feeding is common and associated with subsequent breastfeeding behavior in rural Bangladesh.

J Nutr 2013 Jul 15;143(7):1161-7. Epub 2013 May 15.

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

Exclusive breastfeeding of newborns, a practice recommended by WHO, is hindered in many countries by practices such as prelacteal feeding (feeding other foods before breast milk is fed to infants). This paper describes maternal and infant characteristics and trends over time associated with early neonatal feeding (ENF) in Bangladesh. The analysis used data from 24,992 participants in a randomized controlled trial supplementing vitamin A and β-carotene to women in northwestern rural Bangladesh. A majority of newborns (89.2%) were fed substances other than breast milk in the first 3 d of life. Early neonatal feeding practices were found to be significantly associated with lower maternal education, higher gravidity, lower socioeconomic status, and younger maternal age. A perceived inability to suckle normally after birth was closely related to the risk of an infant being fed a food other than breast milk in the first 3 d of life [OR = 0.09 (95% CI: 0.08, 0.11)]. Only 18.8% of newborns fed an early neonatal food were exclusively breastfed between 3 d and 3 mo postpartum compared with 70.6% of those not fed an early neonatal food during this period (P < 0.05). Early neonatal feeding practices should be addressed when scaling-up exclusive breastfeeding in South Asia. Maternal education, antenatal care, and support during labor and delivery may help reduce ENF and promote exclusive breastfeeding.
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http://dx.doi.org/10.3945/jn.112.170803DOI Listing
July 2013

Low-birthweight rates higher among Bangladeshi neonates measured during active birth surveillance compared to national survey data.

Matern Child Nutr 2015 Oct 6;11(4):583-94. Epub 2013 May 6.

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Birth size is an important gauge of fetal and neonatal health. Birth size measurements were collected within 72 h of life for 16 290 live born, singleton infants in rural Bangladesh from 2004 to 2007. Gestational age was calculated based on the date of last menstrual period. Newborns were classified as small-for-gestational age (SGA) based on a birthweight below the 10th percentile for gestational age, using three sets of US reference data. Birth size distributions were explored based on raw values as well as after z-score standardisation in reference to World Health Organization (WHO) 2006 growth standards. Mean (SD) birthweight (g), length (cm) and head circumference (cm) measurements, completed within [median (25th, 75th percentile)] 15 (8, 23) h of life, were 2433 (425), 46.4 (2.4) and 32.4 (1.6), respectively. Twenty-two per cent were born preterm. Over one-half (55.3%) of infants were born low birthweight; 46.6%, 37.0% and 33.6% had a weight, length and head circumference below -2 z-scores of the WHO growth standard at birth; and 70.9%, 72.2% and 59.8% were SGA for weight based on Alexander et al., Oken et al. and Olsen et al. references, respectively. Infants in this typical rural Bangladesh setting were commonly born small, reflecting a high burden of fetal growth restriction and preterm birth. Our findings, produced by active birth surveillance, suggest that low birthweight is far more common than suggested by cross-sectional survey estimates. Interventions that improve fetal growth during pregnancy may have the largest impact on reducing SGA rates.
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http://dx.doi.org/10.1111/mcn.12041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860210PMC
October 2015

Effects of vitamin A or beta carotene supplementation on pregnancy-related mortality and infant mortality in rural Bangladesh: a cluster randomized trial.

JAMA 2011 May;305(19):1986-95

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA.

Context: Maternal vitamin A deficiency is a public health concern in the developing world. Its prevention may improve maternal and infant survival.

Objective: To assess efficacy of maternal vitamin A or beta carotene supplementation in reducing pregnancy-related and infant mortality.

Design, Setting, And Participants: Cluster randomized, double-masked, placebo-controlled trial among pregnant women 13 to 45 years of age and their live-born infants to 12 weeks (84 days) postpartum in rural northern Bangladesh between 2001 and 2007. Interventions Five hundred ninety-six community clusters (study sectors) were randomized for pregnant women to receive weekly, from the first trimester through 12 weeks postpartum, 7000 μg of retinol equivalents as retinyl palmitate, 42 mg of all-trans beta carotene, or placebo. Married women (n = 125,257) underwent 5-week surveillance for pregnancy, ascertained by a history of amenorrhea and confirmed by urine test. Blood samples were obtained from participants in 32 sectors (5%) for biochemical studies.

Main Outcome Measures: All-cause mortality of women related to pregnancy, stillbirth, and infant mortality to 12 weeks (84 days) following pregnancy outcome.

Results: Groups were comparable across risk factors. For the mortality outcomes, neither of the supplement group outcomes was significantly different from the placebo group outcomes. The numbers of deaths and all-cause, pregnancy-related mortality rates (per 100,000 pregnancies) were 41 and 206 (95% confidence interval [CI], 140-273) in the placebo group, 47 and 237 (95% CI, 166-309) in the vitamin A group, and 50 and 250 (95% CI, 177-323) in the beta carotene group. Relative risks for mortality in the vitamin A and beta carotene groups were 1.15 (95% CI, 0.75-1.76) and 1.21 (95% CI, 0.81-1.81), respectively. In the placebo, vitamin A, and beta carotene groups the rates of stillbirth and infant mortality were 47.9 (95% CI, 44.3-51.5), 45.6 (95% CI, 42.1-49.2), and 51.8 (95% CI, 48.0-55.6) per 1000 births and 68.1 (95% CI, 63.7-72.5), 65.0 (95% CI, 60.7-69.4), and 69.8 (95% CI, 65.4-72.3) per 1000 live births, respectively. Vitamin A compared with either placebo or beta carotene supplementation increased plasma retinol concentrations by end of study (1.46 [95% CI, 1.42-1.50] μmol/L vs 1.13 [95% CI, 1.09-1.17] μmol/L and 1.18 [95% CI, 1.14-1.22] μmol/L, respectively; P < .001) and reduced, but did not eliminate, gestational night blindness (7.1% for vitamin A vs 9.2% for placebo and 8.9% for beta carotene [P < .001 for both]).

Conclusion: Use of weekly vitamin A or beta carotene in pregnant women in Bangladesh, compared with placebo, did not reduce all-cause maternal, fetal, or infant mortality.

Trial Registration: clinicaltrials.gov Identifier: NCT00198822.
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http://dx.doi.org/10.1001/jama.2011.656DOI Listing
May 2011

A cluster-randomized, placebo-controlled, maternal vitamin A or beta-carotene supplementation trial in Bangladesh: design and methods.

Trials 2011 Apr 21;12:102. Epub 2011 Apr 21.

Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Background: We present the design, methods and population characteristics of a large community trial that assessed the efficacy of a weekly supplement containing vitamin A or beta-carotene, at recommended dietary levels, in reducing maternal mortality from early gestation through 12 weeks postpartum. We identify challenges faced and report solutions in implementing an intervention trial under low-resource, rural conditions, including the importance of population choice in promoting generalizability, maintaining rigorous data quality control to reduce inter- and intra- worker variation, and optimizing efficiencies in information and resources flow from and to the field.

Methods: This trial was a double-masked, cluster-randomized, dual intervention, placebo-controlled trial in a contiguous rural area of ~435 sq km with a population of ~650,000 in Gaibandha and Rangpur Districts of Northwestern Bangladesh. Approximately 120,000 married women of reproductive age underwent 5-weekly home surveillance, of whom ~60,000 were detected as pregnant, enrolled into the trial and gave birth to ~44,000 live-born infants. Upon enrollment, at ~ 9 weeks' gestation, pregnant women received a weekly oral supplement containing vitamin A (7000 ug retinol equivalents (RE)), beta-carotene (42 mg, or ~7000 ug RE) or a placebo through 12 weeks postpartum, according to prior randomized allocation of their cluster of residence. Systems described include enlistment and 5-weekly home surveillance for pregnancy based on menstrual history and urine testing, weekly supervised supplementation, periodic risk factor interviews, maternal and infant vital outcome monitoring, birth defect surveillance and clinical/biochemical substudies.

Results: The primary outcome was pregnancy-related mortality assessed for 3 months following parturition. Secondary outcomes included fetal loss due to miscarriage or stillbirth, infant mortality under three months of age, maternal obstetric and infectious morbidity, infant infectious morbidity, maternal and infant micronutrient status, fetal and infant growth and prematurity, external birth defects and postnatal infant growth to 3 months of age.

Conclusion: Aspects of study site selection and its "resonance" with national and rural qualities of Bangladesh, the trial's design, methods and allocation group comparability achieved by randomization, field procedures and innovative approaches to solving challenges in trial conduct are described and discussed. This trial is registered with http://Clinicaltrials.gov as protocol NCT00198822.
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http://dx.doi.org/10.1186/1745-6215-12-102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110135PMC
April 2011