Community-based supplementary feeding for food insecure, vulnerable and malnourished populations - an overview of systematic reviews

Identifying effective obesity prevention intervention components: An umbrella review mapping systematic review evidence

This overview of reviews synthesizes the effectiveness of obesity prevention interventions in children and adults on BMI/zBMI, following JBI and Cochrane Handbook guidelines. The protocol was prospectively registered in OSF in September 2020. Searches for eligible reviews were run in five databases and gray literature in May 2022. Systematic reviews published in 2010 and assessed BMI/zBMI outcomes of obesity prevention interventions were eligible. Screening, data extraction, and quality assessment were performed independently and in duplicate using standardized tools. For similar interventions, the more recent, higher-quality review was included. Thirty reviews reporting on 60 discrete interventions (i.e., a specific intervention component), mapped to 14 of 21 IOM sub-domains, were included. Nine interventions were classified as effective in improving BMI outcomes, including digital health or counseling interventions for adults in 'healthcare environments', behavioral interventions for children (broadly nutrition education), physical education curriculum modifications, and policies targeting food and beverages in 'School environments'. This review extends on previous reviews by consolidating evidence from high-quality, recent reviews to identify effective intervention components. Thus, this review provides direction for implementation efforts and highlights research gaps, where future research is warranted. However, as primary studies were not directly analyzed, gaps may reflect a lack of systematic reviews rather than primary research.

Perinatal intervention strategies providing food with micronutrients to pregnant and breastfeeding women in low- and middle-income countries: A scoping review

In resource-constrained settings, pregnant and breastfeeding women and girls (PBW/G) are particularly vulnerable to undernutrition. Micronutrient-fortified balanced energy protein (BEP) supplementation may be provided to boost maternal nutritional status and improve birth and infant outcomes. We conducted a scoping review of the published literature to determine the impact of BEP and other related nutrition interventions that provided fortified food or cash along with a minimum of 3 micronutrients on maternal, birth, and infant/child outcomes in low- and middle-income countries. We conducted a PubMed search using pre-defined keywords and controlled vocabulary search terms. All titles and abstracts were reviewed for eligibility by two independent reviewers, and data were extracted according to outcome type. We identified 149 eligible research articles that reported on a total of 21 trials and/or programme evaluations which assessed the health impact of one or more products (fortified lipid-based nutrient supplement [LNS, n = 12], fortified blended flours [n = 5], milk-based beverages [n = 2], and local food/snacks [n = 3]) that provided 118-750 kcal/day and varying levels of protein and micronutrients. Only one of these programme evaluations assessed the impact of the provision of cash and fortified food. Effects on maternal outcomes such as gestational weight gain and duration of gestation were promising but inconsistent. Birth outcomes were reported in 15 studies, and the effects on birthweight and birth length were generally positive. Seven studies demonstrated sustained benefits on infant and child growth out of the 15 studies that reported at least one of these outcomes, although data were sparse. Additional research is needed to investigate issues of dose, cost-effectiveness, and incorporation into multi-component interventions.

Impact of sex, race, and social determinants of health on neonatal outcomes

Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.

Association of prognostic nutritional index with peripheral artery disease in US adults: a cross-sectional study

BACKGROUND

The objective of this study was to investigate the relationship between the prognostic nutritional index (PNI) and peripheral artery disease (PAD).

METHODS

The present study is a cross-sectional study based on the National Health and Nutrition Survey (1999-2004). The laboratory-calculated PNI was divided into four groups based on quartiles(Q1:PNI ≤ 50.00; Q2: 50.01-53.00; Q3:53.01-56.00; Q4: > 56.00). PAD was defined as an ankle brachial pressure index (ABPI) ≤ 0.9 on the left or right. The relationship between PNI and PAD was examined using multifactor weighted logistic regression analysis, as well as subgroup analysis. Subgroup analyses were conducted based on demographic and clinical variables.

RESULTS

A total of 5,447 individuals were included in our final analysis. The age of the participants was 59.56 ± 13.10 years, and males accounted for 52.8% (n = 2820). The prevalence of PAD was 6.7% (n = 363). After adjusting for all factors, participants with Q1 still had an increased risk of PAD, with an OR value of 1.593 and a 95% CI of 1.232-1.991. Subgroup analysis showed no significant interaction among multiple factors.

CONCLUSIONS

In summary, we report that lower PNI are associated with a higher risk of PAD in US adults. It is hoped that this discovery can provide a reference for the prevention of PAD.

Undernutrition in older children and adolescents in peri-urban Zambia

Background

Adolescents make up roughly a quarter of the population in Zambia; however, most nutrition-related programming is targeted at the under-five population. Understanding the scale of undernutrition in older children and adolescents is fundamental to alleviating food insecurity and addressing undernutrition across all age groups.

Methods

A cross-sectional survey was performed in four low-income, peri-urban compounds in Chilanga District which included anthropometric measurements of children between ages 6 months-19 years and a household-level diet diversity and food security questionnaire. Wasting was used for children under 5 and thinness for children 5-19 years. Descriptive analysis and multivariate logistic regression were conducted to quantify the prevalence and distribution of malnutrition and understand the impact of food security.

Results

We surveyed 393 households and 1,004 children between the ages of 6 months and 19 years. Children aged 6-9 years had the highest prevalence of severe thinness (5.2%) and adolescents (10-19 years) had the highest rates of moderate thinness (6.5%). Across all age groups, more than 75% of children were in households that worried about running out of food in the previous month. 24.9% of adolescents and 28.4% of older children were in households were more likely to go a whole day without eating compared to 16.9% of children under 5.

Conclusion

Our survey indicated that malnutrition in adolescents and older children living in Chilanga district was comparable to those under 5. Interventions to address undernutrition must be targeted at older children and adolescents in order to ameliorate this burden.

Association of the controlling nutritional status score with all-cause mortality and cancer mortality risk in patients with type 2 diabetes: NHANES 1999-2018

OBJECTIVE

There are studies on the nutritional status of type 2 diabetes (T2D), but there are no large cohort studies on the prognosis of Controlling Nutritional Status (CONUT) score for T2D. The aim of this study was to examine the association between CONUT score and all-cause mortality as well as cancer mortality in adults with T2D.

METHODS

For this study, we analyzed a total of 3763 adult patients with T2D who were part of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. Mortality outcomes were determined by linking to the National Death Index records as of December 31, 2019. Cox proportional risk models were used to estimate risk ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cancer deaths.

RESULTS

During the mean follow-up of 8.17 years, there were 823 deaths from all causes and 155 deaths from cancer. After adjusting for multiple variables, the risk of all-cause mortality was higher in patients with a Mild (CONUT score ≥ 2), compared with patients with a Normal (CONUT score of 0-1). All-cause mortality risk was 39% higher, and cancer mortality risk was 45% higher. Consistent results were observed when stratified by age, sex, race, BMI, smoking status, and glycated hemoglobin levels.

CONCLUSIONS

In a nationally representative sample of American adults with T2D, we found an association between CONUT score and all-cause mortality and cancer mortality.

Knowledge, attitudes, and practices of registered dietitians and nutritionists regarding enteral and parenteral nutrition support in Ghana: a needs assessment study

Background

There is a paucity of data on enteral and parenteral (EN and PN) nutrition support (NS) provided by nutrition and dietetic practitioners in adult acute care settings in Ghana. Furthermore, gray literature suggests that Ghanaian clinical nutrition professionals (CNPs) are seldom involved in advanced nutrition care teams.

Objectives

To assess the knowledge, attitudes, and practices of Ghanaian CNPs regarding EN and PN.

Methods

An online cross-sectional survey was administered to Ghanaian CNPs ahead of a professional development workshop on EN and PN Support. Participants were asked questions about initiation and timing of NS, and knowledge on availability of commercial formula. A 5-point Likert scale was used to assess self-efficacy in using EN and PN. To assess practical knowledge on EN and PN, participants were asked to identify whether EN or PN was indicated for seven short case scenarios. Open-ended questions were used to assess reasons for participant self-ratings.

Results

A total of 76 dietitians, nutritionists, students, and interns completed the survey. For EN, self-efficacy scores were lowest for the calculation of enteral goal rate, and goal volume (mean 3.20 ± 1.27), and writing of EN prescriptions (mean 3.07 ± 1.29). Self-efficacy scores for the formulation of alternative formulas in lieu of commercial formula were the highest (3.63 ± 1.36). For PN, self-efficacy scores for all domains were lower than 3, with the lowest scores observed for writing PN prescriptions (2.19 ± 1.14) and determining micronutrient additives (2.12 ± 1.04). We identified limited training and lack of practical exposure to NS, limited ability to effectively monitor tube feeds, and prohibitive cost and limited availability of EN and PN formula among the barriers impacting self-efficacy scores.

Conclusion

Given the vital role that CNPs play in the delivery of EN and PN, it is important to develop professional training programs especially focused on PN to bridge knowledge and practice gaps.

Diverse policy maker perspectives on the mental health of pregnant and parenting adolescent girls in Kenya: Considerations for comprehensive, adolescent-centered policies and programs

The pregnancy rate in Kenya among adolescent girls is among the highest in the world. Adolescent girls experience increased risk of anxiety and depression during pregnancy and postpartum which can result in poor health outcomes for both mother and baby, and negatively influence their life course. Mental health is often given low priority in health policy planning, particularly in Sub-Saharan Africa (SSA). There is an urgent need to address the treatment gap and provide timely mental health promotion and preventative services, there is a need to focus on the shifting demographic of SSA-the young people. To understand perspectives on policymakers on the mental health prevention and promotion needs of pregnant and parenting adolescent girls, we carried out a series of interviews as part of UNICEF funded helping pregnant and parenting adolescents thrive project in Kenya. We interviewed 13 diverse health and social policy makers in Kenya to understand their perspectives on the mental health experiences of pregnant and parenting adolescent girls and their ideas for optimizing mental health promotion. Six principal themes emerged including the mental health situation for adolescent girls, risk factors for poor mental health and barriers to accessing services for adolescent girls, health seeking behavior effect on maternal and child health outcomes, mental health promotion, protective factors for good mental health, and policy level issues. Examination of existing policies is required to determine how they can fully and effectively be implemented to support the mental health of pregnant and parenting adolescent girls.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BACKGROUND

Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.

METHODS

We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).

RESULTS

In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.

CONCLUSION

The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Harmonization of maternal balanced energy-protein supplementation studies for individual participant data (IPD) meta-analyses - finding and creating similarities in variables and data collection

BACKGROUND

Public health and clinical recommendations are established from systematic reviews and retrospective meta-analyses combining effect sizes, traditionally, from aggregate data and more recently, using individual participant data (IPD) of published studies. However, trials often have outcomes and other meta-data that are not defined and collected in a standardized way, making meta-analysis problematic. IPD meta-analysis can only partially fix the limitations of traditional, retrospective, aggregate meta-analysis; prospective meta-analysis further reduces the problems.

METHODS

We developed an initiative including seven clinical intervention studies of balanced energy-protein (BEP) supplementation during pregnancy and/or lactation that are being conducted (or recently concluded) in Burkina Faso, Ethiopia, India, Nepal, and Pakistan to test the effect of BEP on infant and maternal outcomes. These studies were commissioned after an expert consultation that designed recommendations for a BEP product for use among pregnant and lactating women in low- and middle-income countries. The initiative goal is to harmonize variables across studies to facilitate IPD meta-analyses on closely aligned data, commonly called prospective meta-analysis. Our objective here is to describe the process of harmonizing variable definitions and prioritizing research questions. A two-day workshop of investigators, content experts, and advisors was held in February 2020 and harmonization activities continued thereafter. Efforts included a range of activities from examining protocols and data collection plans to discussing best practices within field constraints. Prior to harmonization, there were many similar outcomes and variables across studies, such as newborn anthropometry, gestational age, and stillbirth, however, definitions and protocols differed. As well, some measurements were being conducted in several but not all studies, such as food insecurity. Through the harmonization process, we came to consensus on important shared variables, particularly outcomes, added new measurements, and improved protocols across studies.

DISCUSSION

We have fostered extensive communication between investigators from different studies, and importantly, created a large set of harmonized variable definitions within a prospective meta-analysis framework. We expect this initiative will improve reporting within each study in addition to providing opportunities for a series of IPD meta-analyses.

Implementation and maintenance of infant dietary diversity in Zimbabwe: contribution of food and water insecurity

Background

Inadequate food and water resources negatively affect child health and the efficiency of nutrition interventions.

Methods

We used data from the SHINE trial to investigate the associations of food insecurity (FI) and water insecurity (WI) on mothers’ implementation and maintenance of minimum infant dietary diversity (MIDD). We conducted factor analysis to identify and score dimensions of FI (poor access, household shocks, low availability & quality), and WI (poor access, poor quality and low reliability). MIDD implementation (n = 636) was adequate if infants aged 12 months (M12) ate ≥ four food groups. MIDD maintenance (n = 624) was categorized into four mutually exclusive groups: A (unmet MIDD at both M12 and M18), B (unmet MIDD at M12 only), C (unmet MIDD at M18 only), and D (met MIDD at both M12 and M18). We used multivariable-adjusted binary logistic and multinomial regressions to determine likelihood of MIDD implementation, and of belonging to MIDD maintenance groups A-C (poor maintenance groups), compared to group D, respectively.

Results

Low food availability & quality were negatively associated with implementation (OR = 0.81; 0.69, 0.97), and maintenance (ORB = 1.29; 1.07, 1.56). Poor water quality was positively associated with implementation (OR = 1.25; 1.08, 1.44), but inconsistently associated with maintenance, with higher odds of infants being in group C (OR = 1.39; 1.08, 1.79), and lower odds of being in group B (OR = 0.80; 0.66, 0.96).

Conclusion

Food security should be prioritized for adequate implementation and maintenance of infant diets during complementary feeding. The inconsistent findings with water quality indicate the need for further research on WI and infant feeding.

Social Determinants of the Non-Utilization of the Supplementary Feeding Program (PACAM) Aimed at Older Adults' Nutritional Support

Chile has implemented the PACAM program to support older people with nutrition and for the prevention of malnutrition and frailty. This work aims to identify the social determinants of older persons not withdrawing PACAM food in order to obtain helpful knowledge for improving the program. First, the CASEN Survey 2017 was used (960,498 observations); the inclusion criterion was PACAM recipients (Yes/No). Next, a probit model was performed with a dichotomous response to determine the marginal effects of each independent variable (e.g., demographic, health, and social). The model shows a good fit (64.4%) with an explained variance between 10.5% to 14.1%. Those variables with more significant marginal effects are people aged 70-75, having tertiary and secondary education, urban living, not participating in social organizations, immigrants, and living in the austral zone. On the other hand, a higher likelihood of consumption was found among people of greater vulnerability (lowest income, lowest education, low health insurance, and aged over 80) and, therefore, in greater fragility. To conclude, the program achieves effective targeting, although improvement actions are required to expand coverage in some groups (indigenous people, immigrants, and people with disabilities). Moreover, authorities should evaluate and reinforce the program with tailored strategies for the older adults who actually withdraw food.

Evaluation of the child growth monitoring programme in two Zimbabwean provinces

Background

The child growth monitoring (CGM) programme is an important element of nutrition programmes, and when combined with other child health programmes, it can assist in successful management and control of malnutrition in children.

Aim

This study aimed to assess the extent to which the CGM programme is able to identify instances of childhood malnutrition and how much this contributes towards malnutrition reduction in Zimbabwe.

Setting

The study was conducted in Manicaland and Matabeleland South provinces of Zimbabwe. The two provinces were purposively selected for having the highest and least proportion of children affected by stunting in the country.

Methods

The CGM programme in Zimbabwe was evaluated using the logic model to assess the ability of the programme to identify growth faltering and link children to appropriate care.

Results

Records from 60 health facilities were reviewed. Interviews were conducted with 60 nurses, 100 village health workers (VHWs) and 850 caregivers (300 health facility exit interviews, 450 community based). Nearly all (92%) health facilities visited had functional measuring scales. Twelve health facilities (20%) had no functional height board, with five using warped height boards for measuring children’s height. Less than a quarter (21%) of the children had complete records for weight for age and height for age. A large proportion of children eligible for admission for the management of moderate (83%) and severe malnutrition (84%) were missed.

Conclusion

The CGM programme in Zimbabwe is not well equipped for assessing child height for age and management of children identified with malnutrition, thus failing to timely identify and manage childhood stunting.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Risk Factors of Pulmonary Tuberculosis and Countermeasures: A Literature Review

BACKGROUND: Tuberculosis is still the primary infectious disease in the world due to HIV/AIDS. In the 2015-2019 strategic plan of the Ministry of Health, infectious diseases are one of the main priorities that must create a Healthy Indonesia. The prevalence rate of pulmonary tuberculosis cases in Indonesia is 539,000 new cases each year, with the number of deaths around 101,000 per year. Acid Fast Bacilli (AFB) (+) incidence rate is around 110/ 100,000 population. AIM: This study aimed to identify the influencing factors and efforts to overcome pulmonary tuberculosis disease. MATERIALS AND METHODS: The research method was carried out by tracing the research reports/articles related to pulmonary tuberculosis incidence as many as 38 selected articles. RESULT: Factors that influence tuberculosis infection incidence include age, income level (socioeconomic), housing conditions, the behavior of opening windows every morning, smoking, and a history of contact with tuberculosis patients. There are various countermeasures undertaken to overcome pulmonary tuberculosis, one of which uses a tissue model. This model involves many stakeholders whose duty is to provide knowledge and record the number of sufferers. The stages of action to control tuberculosis include discovery, treatment, and surveillance. CONCLUSION: Facts in the field show that several factors can affect the success of implementing pulmonary tuberculosis control. Therefore, it is necessary to participate in all society components and involve other agencies beyond the health agency so the reduction in the incidence of pulmonary tuberculosis can be appropriately realized.

A Cross-sectional Study on the Magnitude of undernutrition in Tuberculosis Patients in the Oromia Region of Ethiopia

PURPOSE

To estimate the magnitude of undernutrition in tuberculosis (TB) patients and evaluate its association with selected sociodemographic and clinical characteristics of the patients.

PATIENTS AND METHODS

A health facility-based cross-sectional design was used. Four hundred and fifty pulmonary TB (PTB) patients were recruited between September 2017 and August 2018. Data were collected by structured questionnaire and anthropometric measurements. Data were analyzed using SPSS 20. Descriptive statistics was used for the analysis and expression of the data. Regression model was used to determine the association between undernutrition and selected factors.

RESULTS

The magnitude of underweight was 51.6%, (95%CI: 47.15-56.2). Binary logistic regression indicated that previous treatment with anti-TB (crude odds ratio, COR=1.68, 95%CI: 1.08-2.63; p<0.023), duration of illness greater than two months (COR=2.11, 95%CI: 1.26-3.55, p<0.005), positive HIV serum status (COR=3.83, 95%CI: 1.63-9.02, p<0.002) and history of resistance to any anti TB drug (COR=2.76, 95%CI: 1.29-5.91, p<0.009) were associated with underweight. Multiple logistic regression analysis of the association of the aforementioned variables with undernutrition indicated that HIV positivity (adjusted odds ratio, AOR=0.26, 95%CI: 0.104-0.65, p<0.004) and resistance to any anti-TB drug (AOR=0.39, 95%CI: 0.173-0.90, p<0.026) were the associated factors.

CONCLUSION

A significant proportion of TB patients in the Oromia Region were malnourished. Therefore, nutritional counseling and nutritional supplementation are required for the effective treatment of TB patients in the Region.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews

BACKGROUND

Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.

METHODS

We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.

RESULTS

We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.

CONCLUSION

Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

Risk prediction models based on hematological/body parameters for chemotherapy-induced adverse effects in Chinese colorectal cancer patients

PURPOSE

To determine risk factors and develop novel prediction models for chemotherapy-induced adverse effects (CIAEs) in Chinese colorectal cancer (CRC) patients receiving capecitabine.

METHODS

A total of 233 Chinese CRC patients receiving post-operative chemotherapy with capecitabine were randomly divided into a training set (70%) and a validation set (30%). CIAE-related hematological/body parameters were screened by univariate logistic regression. Based on a set of factors selected from LASSO (least absolute shrinkage and selection operator) logistic regression, stepwise multivariate logistic regression was applied to develop prediction models. Area under the receiver operating characteristic (ROC) curve and Hosmer-Lemeshow (HL) test were used to evaluate the discriminatory ability and the goodness of fit of each model.

RESULTS

In total, 35 variables were identified to be associated with CIAEs in univariate analysis. Developed multivariable models had AUCs (area under curve) ranging from 0.625 to 0.888 and 0.428 to 0.760 in the training and validation set, respectively. The grade ≥ 1 anemia multivariable model achieved the best discriminatory ability with AUC of 0.760 (95%CI: 0.609-0.912) and good calibration with HL P value of 0.450. Then, a nomogram was constructed to predict grade ≥ 1 anemia, which included variables of age, pre-operative hemoglobin count, and pre-operative albumin count, with C-indexes of 0.775 and 0.806 in the training and validation set, respectively.

CONCLUSIONS

This study identified valuable hematological/body parameters related to CIAEs. A nomogram based on the multivariable model including three hematological/body predictors can accurately predict grade ≥ 1 anemia, facilitating clinicians to implement personalized medicine early for Chinese CRC patients receiving post-operative chemotherapy for better safety treatment. Trial registration This study was registered as a clinical trial at www.clinicaltrials.gov (NCT03030508).

Undernutrition and HIV Infection in Sub-Saharan Africa: Health Outcomes and Therapeutic Interventions

PURPOSE OF REVIEW

Sub-Saharan Africa (SSA) is disproportionately burdened by the twin epidemics of food insecurity and HIV infection, and protein-calorie undernutrition is common among persons with HIV (PWH) initiating antiretroviral therapy (ART) in the region. In this review, we discuss the intersection of HIV infection and undernutrition, health outcomes among undernourished PWH starting ART, and the demonstrated and potential benefits of therapeutic interventions such as micro/macronutrient supplementation and pharmacological agents.

RECENT FINDINGS

A low body mass index (BMI), used as a general indicator of poor nutrition in most studies, is associated with impaired immune recovery and increased mortality in the early ART period. The increased risk of mortality is multifactorial, and contributors include undernutrition-related immune system dysfunction, increased susceptibility to opportunistic infections, and metabolic and cardiovascular dysregulation. Clinical trials of micro/macronutrient supplementary feeding, appetite stimulants (hormones and anabolic agents), and recombinant adipokines have shown a benefit for weight gain and metabolic health, but there are few data on mortality or immune recovery. A substantial proportion of PWH in SSA are undernourished, and undernutrition contributes to an increased risk of mortality and other adverse health outcomes. To date, there have been few prospective trials of nutritional supplementation and/or pharmacologic therapy among undernourished PWH in SSA, though findings from other settings suggest a potential benefit in this population.

INTERGROWTH-21 Identifies High Prevalence of Low Symphysis-Fundal Height in Indigenous Pregnant Women Experiencing Multiple Infections, Nutrient Deficiencies, and Inflammation: The Maternal Infections, Nutrient Deficiencies, and Inflammation (MINDI) Cohort

BACKGROUND

In the absence of ultrasound, symphysis-fundal height (SFH) can assess maternal-fetal well-being as it is associated with gestational age, fetal weight, and amniotic fluid volume. However, other modifiers of SFH, including maternal infections, nutrient deficiencies, and inflammation (MINDI), have not been widely explored.

OBJECTIVES

Our objectives were 2-fold: 1) to assess prevalence of low SFH in indigenous Panamanian women using both Pan-American Health Organization (PAHO) and INTERGROWTH-21 standards and 2) to explore associations of SFH with maternal health indicators: infections (oral, skin, urogenital, nematode infections), nutrient deficiencies [protein and iron indicators (ferritin, serum iron, serum transferrin receptor, hepcidin), folate, and vitamins A, D, and B-12], and inflammation [leukocytes, C-reactive protein (CRP), cytokines].

METHODS

For this cross-sectional study, low-SFH-for-gestational-age was assessed using PAHO and INTERGROWTH <10th centile in 174 women at ≥16 weeks of gestation. Bootstrapping selected MINDI variables for inclusion in multivariable fractional polynomial (MFP) logistic regressions for low SFH. Associations of MINDI variables with hepcidin were also investigated.

RESULTS

Prevalence of low SFH was 8% using PAHO, but using INTERGROWTH, 50.6% had SFH <10th centile, including 37.9% <3rd centile. Both PAHO-SFH <10th centile and INTERGROWTH-SFH <3rd centile were associated with higher hepcidin (OR = 1.12, P = 0.008, and OR = 3.04, P = 0.001, respectively) and with lower TNF-α (OR = 0.73, P = 0.012, and OR = 0.93, P = 0.015, respectively). Wood-smoke exposure increased the odds of PAHO-SFH <10th centile (OR = 1.19, P = 0.009), whereas higher BMI decreased the odds of INTERGROWTH-SFH <3rd centile (OR = 0.87, P = 0.012). Lower pulse pressure (OR = 0.90, P = 0.009) and lower inflammatory responses [lower lymphocytes (OR = 0.21, P = 0.026), IL-17 (OR = 0.89, P = 0.011)] distinguished SFH <3rd centile from SFH ≥3rd to <10th centiles using INTERGROWTH-21 standards. The MFP regression for hepcidin controlling for SFH (adjusted R 2 = 0.40, P = 0.001) revealed associations with indicators of inflammation (CRP, P < 0.0001; IL-17, P = 0.012), acidic urinary pH (P = 0.008), and higher intake of supplements (P = 0.035).

CONCLUSIONS

Associations of low SFH with MINDI variables, including hepcidin, highlight its potential for early detection of multicausal in utero growth faltering.

Effectiveness of Oral Nutritional Supplements on Older People with Anorexia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Nutrition plays an important role in maintaining the overall health of older people. Inadequate intake may lead to impaired body function, higher morbidity, and mortality. Oral nutritional supplements (ONS) showed positive effect on the nutritional status of the elderly; however, systematic evidence is currently lacking on the effect of ONS on the elderly with anorexia.

AIMS

The current systematic review and meta-analysis included randomized controlled trial (RCT) articles to investigate the effectiveness of ONS on the main aspects of anorexia of aging (AA).

METHODS

By using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, researchers independently searched PubMed/MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, China National Knowledge Infrastructure (CNKI) and other gray literature resources for publications that met the inclusion criteria by October 2020. The Cochrane Risk of Bias Tools were used for quality assessment. The inverse-variance method was used for the fixed model (FM) while the DerSimonian-Laird method was used for the random model (RM). Respective 95% confidence intervals (95% CIs), mean difference (MD) or standardized mean difference (SMD) was used for indices in terms of effect size (ES).

RESULTS

2497 records were found through the systematic search, while 17 RCTs (n = 1204) were included, with a mean age of 81.9 years (range: 74-87 years). Supplementation occurred in the morning, mid-day, and evening, while the times varied from one to three times a day. The results of meta-analysis showed that, generally, ONS had a positive effect on the overall appetite, MD = 0.18, 95% CI (0.03, 0.33), p = 0.02, and consumption, MD = 1.43, 95% CI (0.01, 2.86), p = 0.05; but not significant in terms of other aspects of appetite: hunger, p = 0.73; fullness, p = 0.60; desire to eat, p = 0.80; preoccupation, p = 0.15. Additionally, it showed an increase in the overall energy intake, SMD = 0.46, 95% CI (0.29, 0.63), p < 0.001, in protein intake, SMD = 0.59, 95% CI (0.16, 1.02), p = 0.007, and in fat intake, MD = 3.47, 95% CI (1.98, 4.97), p < 0.001, while no positive effect was found on carbohydrates intake, p = 0.06. Significance differences were also found in the body weight, SMD = 0.53, 95% CI (0.41, 0.65), p < 0.001, and body mass index (BMI), MD = 0.53, 95% CI (0.12, 0.95), p = 0.01. Moreover, subgroup analyses were conducted according to the nutrient density with no positive results showed except for the low-density ONS on overall energy intake.

CONCLUSIONS

The results of the present study indicated that ONS had beneficial effects on overall appetite, energy intake, body weight and BMI.

Old Question Revisited: Are High-Protein Diets Safe in Pregnancy?

Background: A previous randomized dietary intervention in pregnant women from the 1970s, the Harlem Trial, reported retarded fetal growth and excesses of very early preterm births and neonatal deaths among those receiving high-protein supplementation. Due to ethical challenges, these findings have not been addressed in intervention settings. Exploring these findings in an observational setting requires large statistical power due to the low prevalence of these outcomes. The aim of this study was to investigate if the findings on high protein intake could be replicated in an observational setting by combining data from two large birth cohorts. Methods: Individual participant data on singleton pregnancies from the Danish National Birth Cohort (DNBC) (n = 60,141) and the Norwegian Mother, Father and Child Cohort Study (MoBa) (n = 66,302) were merged after a thorough harmonization process. Diet was recorded in mid-pregnancy and information on birth outcomes was extracted from national birth registries. Results: The prevalence of preterm delivery, low birth weight and fetal and neonatal deaths was 4.77%, 2.93%, 0.28% and 0.17%, respectively. Mean protein intake (standard deviation) was 89 g/day (23). Overall high protein intake (>100 g/day) was neither associated with low birth weight nor fetal or neonatal death. Mean birth weight was essentially unchanged at high protein intakes. A modest increased risk of preterm delivery [odds ratio (OR): 1.10 (95% confidence interval (CI): 1.01, 1.19)] was observed for high (>100 g/day) compared to moderate protein intake (80–90 g/day). This estimate was driven by late preterm deliveries (weeks 34 to <37) and greater risk was not observed at more extreme intakes. Very low (<60 g/day) compared to moderate protein intake was associated with higher risk of having low-birth weight infants [OR: 1.59 (95%CI: 1.25, 2.03)]. Conclusions: High protein intake was weakly associated with preterm delivery. Contrary to the results from the Harlem Trial, no indications of deleterious effects on fetal growth or perinatal mortality were observed.

Beyond the Obvious: Smoking and Respiratory Infection Implications on Alzheimer's Disease

Tobacco smoke is not only a leading cause for chronic obstructive pulmonary disease, cardiovascular disorders, and lung and oral cancers, but also causes neurological disorders such as Alzheimer 's disease. Tobacco smoke consists of more than 4500 toxic chemicals, which form free radicals and can cross blood-brain barrier resulting in oxidative stress, an extracellular amyloid plaque from the aggregation of amyloid β (Aβ) peptide deposition in the brain. Further, respiratory infections such as Chlamydia pneumoniae, respiratory syncytial virus have also been involved in the induction and development of the disease. The necessary information collated on this review has been gathered from various literature published from 1995 to 2019. The review article sheds light on the role of smoking and respiratory infections in causing oxidative stress and neuroinflammation, resulting in Alzheimer's disease (AD). This review will be of interest to scientists and researchers from biological and medical science disciplines, including microbiology, pharmaceutical sciences and the translational researchers, etc. The increasing understanding of the relationship between chronic lung disease and neurological disease is two-fold. First, this would help to identify the risk factors and possible therapeutic interventions to reduce the development and progression of both diseases. Second, this would help to reduce the probable risk of development of AD in the population prone to chronic lung diseases.

Challenges of COVID-19 in children in low- and middle-income countries

As the coronavirus pandemic extends to low and middle income countries (LMICs), there are growing concerns about the risk of coronavirus disease (COVID-19) in populations with high prevalence of comorbidities, the impact on health and economies more broadly and the capacity of existing health systems to manage the additional burden of COVID-19. The direct effects of COVID are less of a concern in children, who seem to be largely asymptomatic or to develop mild illness as occurs in high income countries; however children in LMICs constitute a high proportion of the population and may have a high prevalence of risk factors for severe lower respiratory infection such as HIV or malnutrition. Further diversion of resources from child health to address the pandemic among adults may further impact on care for children. Poor living conditions in LMICs including lack of sanitation, running water and overcrowding may facilitate transmission of SARS-CoV-2. The indirect effects of the pandemic on child health are of considerable concern, including increasing poverty levels, disrupted schooling, lack of access to school feeding schemes, reduced access to health facilities and interruptions in vaccination and other child health programs. Further challenges in LMICs include the inability to implement effective public health measures such as social distancing, hand hygiene, timely identification of infected people with self-isolation and universal use of masks. Lack of adequate personal protective equipment, especially N95 masks is a key concern for health care worker protection. While continued schooling is crucial for children in LMICs, provision of safe environments is especially challenging in overcrowded resource constrained schools. The current crisis is a harsh reminder of the global inequity in health in LMICs. The pandemic highlights key challenges to the provision of health in LMICs, but also provides opportunities to strengthen child health broadly in such settings.

Effect of lipid-based nutrient supplement-Medium quantity on reduction of stunting in children 6-23 months of age in Sindh, Pakistan: A cluster randomized controlled trial

BACKGROUND

Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan.

OBJECTIVE

The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement-medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group.

DESIGN

A cluster randomized controlled trial was conducted in Thatta and Sujawal districts of Sindh province, Pakistan. A total of 870 (419 in intervention; 451 in control) children between 6-18 months old were enrolled in the study. The unit of randomization was union council and considered as a cluster. A total of 12 clusters, 6 in each study group were randomly assigned to intervention and control group. All children received standard government health services, while children in the intervention group also received 50 grams/day of Wawamum.

RESULTS

Children who received Wawamum were found to have a significantly reduced risk of stunting (RR = 0.91, 95% CI; 0.88-0.94, p<0.001) and wasting (RR = 0.78, 95% CI; 0.67-0.92, p = 0.004) as compared to children who received the standard government health services. There was no evidence of a reduction in the risk of underweight (RR = 0.94, 95% CI; 0.85-1.04, p = 0.235) in the intervention group compared to the control group. Statistically significant reduction in anaemia in the intervention group was also found as compared to the control group (RR = 0.97, 95% CI; 0.94-0.99, p = 0.042). The subgroup analysis by age, showed intervention effect is significant in reduction of risk of stunting in younger children of aged 6-12 month (RR = 0.83, 95% CI; 0.81-0.86, p = <0.001) and their older peers aged 13-18 month- (RR = 0.90, 95% CI; 0.83-0.97, p = 0.008). The mean compliance of Wawamum was 60% among children.

CONCLUSIONS

The study confirmed that the provision of Wawamum to children 6-23 months of age is effective in reducing the risk of stunting, wasting and anaemia. This approach should be scaled up among the most food insecure areas/households with a high prevalence of stunting to achieve positive outcomes for nutrition and health. This study was registered at clinicaltrials.gov as NCT02422953. Clinical Trial Registration Number: NCT02422953.

Household food insecurity associated with gestacional and neonatal outcomes: a systematic review

BACKGROUND

Food insecurity (FI) occurs when people lack secure access to sufficient amounts of safe and nutritious food. FI has been associated with negative effects on human health, including during the prenatal and neonatal periods. The objective of this study is to evaluate the consequences of FI for pregnant women's and newborns' health.

METHODS

A literature search was performed with three independent researchers based on the PRISMA guidelines; the search covered the period of November 2008 to July 2019 and was conducted in the following databases: the US National Library of Medicine at the National Institutes of Health (PubMed), Latin American and Caribbean Health Sciences (LILACS), Cochrane Library, Web of Science, Embase, Scopus and OpenGrey. The terms and descriptors were defined by consulting the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS) platforms and mainly included "food security", "food insecurity", "pregnancy" and "newborn". The studies were selected through a title and abstract review and then a reading of the full text. The quality of the studies and the risk of bias were analysed based on the criteria defined in the "Joanna Briggs Institute Reviewers' Manual" and by Guyatt and colleagues for interventional studies. The population, study design, FI measurement instruments, FI proportions, outcomes, confounders and results were extracted from the 37 studies that were selected according to the eligibility and quality criteria.

RESULTS

FI ​​proportions ranged from 5.2 to 87%. Most studies were conducted with African populations (42.2%) and applied globally used scales to assess FI (56.7%); 27% of the studies adapted scales. There were wide variations in the instruments used to estimate FI. The main outcomes related to FI included stress, anxiety and depression during pregnancy, followed by dietary quality and dietary diversity. Associations of FI with birth defects, neonatal mortality and the early introduction of animal milk to the infant's diet were also observed.

CONCLUSIONS

It is necessary to pay attention to the diversity of FI measurement instruments before FI results are compared. FI can be a risk factor for depression and stress during pregnancy, as well as for neonatal mortality, newborn health problems and breastfeeding interruption.

TRIAL REGISTRATION

This systematic review was registered on PROSPERO (CRD42018109478).

Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis

Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.

Community-based supplementary feeding for food insecure, vulnerable and malnourished populations - an overview of systematic reviews

BACKGROUND

Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low- and middle-income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated.

OBJECTIVES

1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school-aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations.2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups.

METHODS

In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community-based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically.

MAIN RESULTS

This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non-Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC.The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow-up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease-related outcomes, neurocognitive development and psychosocial outcomes, and adverse events.Mortality data were limited and underpowered in meta-analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long-term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer-term outcomes. In one study (505 participants), high-protein supplementation was associated with increased risk of small-for-gestational age babies.Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well-nourished. In children with MAM, the provision of specially formulated food improved their weight, weight-for-height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower-income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance.Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long-term benefit.In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis.The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group.There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.

AUTHORS' CONCLUSIONS

Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short-term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised.