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The Knowledge Hub brings together existing knowledge, guidance, tools, and other useful resources related to women’s nutrition, maternal nutrition, and evidence-based interventions targeting women, such as prenatal multiple micronutrient supplementation (MMS).

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  • South Asia
  • Advocacy
  • Implementation
  • Report
Sight and Life Busch-Hallen et al. May 2023

Implementation Research in Pakistan: Paving the way for a successful transition to multiple micronutrient supplementation

Nutrition International, in collaboration with the Government of Pakistan, is undertaking implementation research to support the introduction of multiple micronutrient supplementation (MMS) in antenatal care (ANC) and identify effective program implementation solutions. The Advancing Maternal Health through MMS Implementation Research in Pakistan (AMMI) project will not only inform the introduction of MMS but also provide useful insights to tackle broader questions related to improving adherence to maternal supplementation and ultimately advancing maternal and newborn health outcomes. The AMMI project comprises several steps: (i) establishing and working with the Pakistan Technical Working Group, (ii) determining the priority research questions using a rigorous methodology, (iii) switching over from IFA to MMS in ANC, (iv) conducting the implementation research using mixed methods, and (v) undertaking knowledge translation to support real-time decision-making. Building on the approach in Pakistan, Nutrition International is working in partnership with the Government of Nigeria to conduct a new MMS implementation research project focusing on optimizing adherence to maternal micronutrient supplementation.

  • Global
  • Research
  • Scientific publication
Front. Nutr. Littlejohn et al. July 2023

Multiple micronutrient deficiencies alter energy metabolism in host and gut microbiome in an early-life murine model

Micronutrients perform a wide range of physiological functions essential for growth and development. However, most people still need to meet the estimated average requirement worldwide. Globally, 2 billion people suffer from micronutrient deficiency, most of which are co-occurring deficiencies in children under age five. Despite decades of research, animal models studying multiple micronutrient deficiencies within the early-life period are lacking, which hinders our complete understanding of the long-term health implications and may contribute to the inefficacy of some nutritional interventions. Evidence supporting the Developmental Origins of Health and Disease (DOHaD) theory demonstrates that early-life nutritional deficiencies carry life-long consequences mediated through various mechanisms such as abnormal metabolic programming, stunting, altered body composition, and the gut microbiome. However, this is largely unexplored in the multiple micronutrient deficient host. We developed a preclinical model to examine undernutrition’s metabolic and functional impact on the host and gut microbiome early in life. Three-week-old weanling C57BL/6N male mice were fed a low-micronutrient diet deficient in zinc, folate, iron, vitamin A, and vitamin B12 or a control diet for 4-weeks. Our results showed that early-life multiple micronutrient deficiencies induced stunting, altered body composition, impaired glucose and insulin tolerance, and altered the levels of other micronutrients not depleted in the diet within the host. In addition, functional metagenomics profiling and a carbohydrate fermentation assay showed an increased microbial preference for simple sugars rather than complex ones, suggestive of a less developed microbiome in the low-micronutrient-fed mice. Moreover, we found that a zinc-only deficient diet was not sufficient to induce these phenotypes, further supporting the importance of studying co-occurring deficiencies. Together, these findings highlight a previously unappreciated role of early-life multiple micronutrient deficiencies in shaping the metabolic phenome of the host and gut microbiome through altered glucose energy metabolism, which may have implications for metabolic disease later in life in micronutrient-deficient survivors.

 

  • Global
  • Policy and policy development
  • Implementation tool
WILEY Verney et al. April 2023

Multiple Micronutrient Supplementation cost-benefit tool for informing maternal nutrition policy and investment decisions

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision‐making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost–benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost–benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost‐effectiveness and benefit–cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost–benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost‐effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit–cost ratio ranges from US$ 41–US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user‐friendly design, open access availability, and online data‐driven analytics, the MMS cost–benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence‐based analyses to inform policy‐decision and investments towards the scale‐up of MMS for pregnant women globally.

  • South Asia
  • Research
  • Scientific publication
Nutrients Khan et al. March 2023

Long-term impact of multiple micronutrient supplementation on micronutrient status, hemoglobin level, and growth in children 24 to 59 months of age: a non-randomized community-based trial from Pakistan

Cost-effective interventions are needed to address undernutrition, particularly micronutrient deficiencies, which are common in children under the age of five in low- and middle-income countries. A community-based, non-randomized clinical trial was undertaken in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019, to evaluate the effect of locally produced micronutrient powder (local name: Vita-Mixe) on plasma micronutrient status, hemoglobin level, and anthropometric outcomes. Children aged 24–48 months old were recruited and allocated to the intervention and control arm of the study. The enrolled children in the intervention arm received one micronutrient powder (MNP) sachet for consumption on alternate days for 12 months. To assess the impact of the intervention on plasma levels of zinc, vitamin D, vitamin A, and hemoglobin level, blood samples were taken at baseline and after one year following the intervention. The analysis was conducted using Enzyme-Linked Immunosorbent Assay (ELISA), atomic absorption spectrometry, and an automated hematology analyzer. For the impact on growth parameters, the anthropometric assessment was performed using WHO standard guidelines. A 24 h dietary recall interview was used to assess the nutrient intake adequacy. Results showed that in the intervention arm, children had on average a 7.52 ng/mL (95% CI 5.11–9.92, p-value < 0.001) increase in the plasma level of vitamin A, 4.80 ng/mL (95% CI 1.63–7.95, p-value < 0.002) increase in vitamin D levels and 33.85 µg/dL (95% CI 24.40–43.30, p-value < 0.001) increase in the plasma zinc level, as well as a 2.0g/dL (95% CI 1.64–2.40, p-value < 0.001) increase in hemoglobin level. Statistically significant improvement was observed in the weight-for-height z-score (WHZ) (from −1.0 ± 0.88 to −0.40 ± 1.01, p < 0.001) and weight-for-age z-score (WAZ) (from −1.40 ± 0.50 to −1.05 ± 0.49, p < 0.001) in the intervention group compared to the control group. No statistically significant change was observed in the height-for-age z-score (HAZ) in the intervention group (p = 0.93). In conclusion, micronutrient powder supplementation is a cost-effective intervention to improve the micronutrient status, hemoglobin level, and growth parameters in under-five children, which can be scaled up in the existing health system to address the alarming rates of undernutrition in Pakistan and other developing countries.

  • West and Central Africa
  • Research
  • Scientific publication
The American Journal of Clinical Nutrition Cliffer et al. September 2023

School-based supplementation with iron-folic acid or multiple micronutrient tablets to address anemia among adolescents in Burkina Faso: a cluster-randomized trial

Iron-deficiency anemia is a leading cause of morbidity among adolescents (aged 10–19 y), especially in low- and middle-income settings. Few policies and programs have targeted adolescent health. This study aimed to evaluate the effectiveness of school-based supplementation with iron-folic acid (IFA) or multiple micronutrient supplements (MMSs) in addressing anemia among adolescents in Burkina Faso. In this cluster-randomized trial, 3123 secondary school students aged 10 to 18 y in Burkina Faso were either supplemented with weekly IFA, daily MMSs, or received standard nutrition education as controls. Supplementation occurred between April 2021 and April 2022 over 2 supplementation periods (10 weeks, then 16 weeks) separated by a gap of 20 weeks without supplementation. Hemoglobin was evaluated 4 times: at baseline prior to each supplementation period and at the end of each period. Anemia was categorized by the World Health Organization hemoglobin level cutoffs as none, mild, moderate, or severe. Associations between treatment arm and anemia or continuous hemoglobin (g/dL) were assessed using multilevel mixed effects generalized linear models with schools as a random effect, controlling for baseline hemoglobin or anemia status. Baseline anemia prevalence was similar across study arms, with 32.7% in IFA, 31.2% in MMS, and 29.5% in the control arm. Over the full study period, adolescents provided IFA had hemoglobin levels higher than those in the control arm (adjusted β: 0.32; 95% CI: 0.02, 0.62). No significant associations were observed for MMS or for anemia outcomes; however, the direction and magnitude of nonsignificant associations indicate potential protective effects of IFA and MMSs on anemia. The results do not provide strong evidence that weekly IFA or daily MMS alone is effective, but supplementation may play a role in addressing adolescent anemia if combined with cointerventions. Additional research is required to determine the best strategy to address anemia.

  • Global
  • Research
  • Report
Emergency Nutrition Network Hemler et al. November 2021

Current evidence on anaemia and micronutrient supplementation strategies in school-age children and adolescents

Globally, one in four adolescents is affected by anaemia (Azzopardi et al, 2019). Asia contributes the highest number of cases, with approximately 194 million anaemic adolescents living in India and China (Wang et al, 2020). While the etiology of anaemia in low-and middle-income countries (LMICs) is multi-faceted, including infection and chronic illness, the predominant causes during adolescence are iron and other micronutrient deficiencies. Iron deficiency and iron deficiency anaemia (IDA) contribute the majority of disability[1]adjusted life years (DALYs) associated with micronutrient deficiencies globally, with IDA being the leading cause of years lived with disability among children and adolescents (Das et al, 2018). Age-disaggregated data for school-aged children 5-9 years of age, younger adolescents (10- 14 years of age) and older adolescents (15-19 years of age) is scarce. However, combined data for children and adolescents (0-19 years of age) shows that the prevalence of IDA is highest in Afghanistan (41%), followed by Yemen (39.8%) and Senegal (38.5%) (Global Burden of Disease Pediatrics Collaboration, 2016)

  • East and Southern Africa
  • Research
  • Scientific publication
The Journal of Nutrition Olney et al. December 2019

A Multisectoral Food-Assisted Integrated Health and Nutrition Program Targeted to Women and Children in the First 1000 Days Increases Attainment of Language and Motor Milestones among Young Burundian Children

Child development is affected by multiple factors throughout pregnancy and childhood. Multisectoral programs addressing these factors may improve children’s development. We evaluated the impact of a food-assisted multisectoral nutrition program (Tubaramure) on children’s (4– 41.9 mo) motor and language development. Tubaramure was targeted to Burundian women and children in the first 1000 d and provided micronutrient-fortified food rations; nutrition, health, and hygiene behavior change communication; and health system–strengthening activities. Program impact was assessed using a cluster-randomized controlled trial with repeated cross-sections: 2010 (baseline, children 4–41.9 mo), 2012 (follow-up during implementation, children 4–23.9 mo), and 2014 (follow-up postimplementation, children 24–41.9 mo). Sixty villages were randomly assigned to 4 groups with varying timing and duration of food rations: pregnancy–24 mo; pregnancy–18 mo; 0–24 mo; and control, no direct Tubaramure benefits. Treatment groups were pooled and compared with control using difference-in-difference estimates. We examined impact pathways by assessing program impacts on intermediary variables and their associations with development outcomes. At first follow-up, Tubaramure positively affected language (0.4 milestones, P < 0.05) but not motor development among children aged 4–23.9 mo. Among the 12–23.9 mo age subgroup, the program positively affected language (0.7 milestones, P < 0.01) and motor (0.6 milestones, P = 0.08) development. At second follow-up, among children aged 24–41.9 mo, Tubaramure marginally affected motor development (0.4 milestones, P = 0.09). In age subgroup analyses, program impacts were limited to children aged 24–29.9 mo [0.4 motor (P = 0.09) and 1.0 language (P < 0.01) milestones]. Pathway analyses revealed significant positive impacts on diet, health, and nutritional indicators of children aged 12–23.9 mo and health and nutritional indicators of children aged 24–29.9 mo, supporting the plausibility of program impacts on child development. Tubaramure had small positive impacts on children’s motor and language development through multiple pathways, demonstrating the role multisectoral nutrition programs can play in improving children’s development.

  • East and Southern Africa
  • Research
  • Scientific publication
Elsevier Ltd. Galasso et al. September 2019

Effects of nutritional supplementation and home visiting on growth and development in young children in Madagascar: a cluster-randomised controlled trial

Evidence from efficacy trials suggests that lipid-based nutrient supplementation (LNS) and home visits can be effective approaches to preventing chronic malnutrition and promoting child development in low-income settings. We tested the integration of these approaches within an existing, large-scale, community-based nutrition programme in Madagascar. We randomly allocated 125 programme sites to five intervention groups: standard-of-care programme with monthly growth monitoring and nutrition education (T0); T0 plus home visits for intensive nutrition counselling through an added community worker (T1); T1 plus LNS for children aged 6–18 months (T2); T2 plus LNS for pregnant or lactating women (T3); or T1 plus fortnightly home visits to promote and encourage early stimulation (T4). Pregnant women (second or third trimester) and infants younger than 12 months were enrolled in the trial. Primary outcomes were child growth (length-for-age and weight-for-length Z scores) and development at age 18–30 months. Analyses were by intention to treat. The trial was registered with the ISRCTN registry, number ISRCTN14393738. The study enrolled 3738 mothers: 1248 pregnant women (250 women in each of the T0, T1, T2, and T4 intervention groups and 248 in the T3 intervention group) and 2490 children aged 0–11 months (497 children in T0, 500 in T1, 494 in T2, 499 in T3, and 500 in T4) at baseline who were assessed at 1-year and 2-year intervals. There were no main effects of any of the intervention groups on any measure of anthropometry or any of the child development outcomes in the full sample. However, compared with children in the T0 intervention group, the youngest children (<6 months at baseline) in the T2 and T3 intervention groups who were fully exposed to the child LNS dose had higher length-for-age Z scores (a significant effect of 0·210 SD [95% CI −0·004 to 0·424] for T2 and a borderline effect of 0·216 SD [0·043 to 0·389] for T3) and lower stunting prevalence (−9·0% [95% CI −16·7 to −1·2] for T2 and −8·2% [−15·6 to −0·7] for T3); supplementing mothers conferred no additional benefit. Interpretation LNS for children for a duration of 12 months only benefited growth when it began at an early age, suggesting the need to supplement infants at age 6 months in a very low-income context. The lack of effect of the early stimulation messages and home visits might be due to little take-up of behaviour-change messages and delivery challenges facing community health workers><6 months at baseline) in the T2 and T3 intervention groups who were fully exposed to the child LNS dose had higher length-for-age Z scores (a significant effect of 0·210 SD [95% CI −0·004 to 0·424] for T2 and a borderline effect of 0·216 SD [0·043 to 0·389] for T3) and lower stunting prevalence (−9·0% [95% CI −16·7 to −1·2] for T2 and −8·2% [−15·6 to −0·7] for T3); supplementing mothers conferred no additional benefit. LNS for children for a duration of 12 months only benefited growth when it began at an early age, suggesting the need to supplement infants at age 6 months in a very low-income context. The lack of effect of the early stimulation messages and home visits might be due to little take-up of behaviour-change messages and delivery challenges facing community health workers.

  • South Asia
  • Research
  • Scientific publication
BMJ Open Nagpal et al. May 2020

Efficacy of maternal B12 supplementation in vegetarian women for improving infant neurodevelopment: protocol for the MATCOBIND multicentre, double-blind, randomised controlled trial

Vitamin B12 deficiency is widely prevalent across many low- and middle-income countries, especially where the diet is low in animal sources. While many observational studies show associations between B12 deficiency in pregnancy and infant cognitive function (including memory, language and motor skills), evidence from clinical trials is sparse and inconclusive. This double-blind, multicentre, randomised controlled trial will enrol 720 vegetarian pregnant women in their first trimester from antenatal clinics at two hospitals (one in India and one in Nepal). Eligible mothers who give written consent will be randomised to receive either 250 mcg methylcobalamin or 50 mcg (quasi control), from enrolment to 6 months post-partum, given as an oral daily capsule. All mothers and their infants will continue to receive standard clinical care. The primary trial outcome is the offspring’s neurodevelopment status at 9 months of age, assessed using the Development Assessment Scale of Indian Infants. Secondary outcomes include the infant’s biochemical B12 status at age 9 months and maternal biochemical B12 status in the first and third trimesters. Maternal biochemical B12 status will also be assessed in the first trimester. Modification of association by a priori identified factors will also be explored.

  • Global
  • Implementation
  • Guidance document
Emergency Nutrition Network Wrottesley et al. January 2023

Improving Nutrition During Middle Childhood and Adolescence by 2023: A Research Roadmap

Despite the importance of nutrition during middle childhood (5–9 years) and adolescence (10–19 years) for the health and well-being of current and future generations, the 5–19-year period remains relatively neglected in research, policy and programming agendas. In 2021, Emergency Nutrition Network (ENN) conducted a research prioritisation exercise using the Child Health and Nutrition Research Initiative (CHNRI) methodology. This research roadmap provides a scoping review of available literature for the six priority research areas identified by the CHNRI exercise (Table 1). It collates current knowledge, evidence gaps and lessons learnt from research conducted in other health-related fields to set out a detailed, global research agenda to support nutrition for children and adolescents 5–19 years of age in low- and middle-income countries (LMICs) over the next 10 years.