Including calcium-fortified water or flour in modeled diets based on local foods could improve calcium intake for women, adolescent girls, and young children in Bangladesh, Uganda, and Guatemala

Adequate calcium intake is essential for health, especially for infants, children, adolescents, and women, yet is difficult to achieve with local foods in many low- and middle-income countries. Previous analysis found it was not always possible to identify food-based recommendations (FBRs) that reached the calcium population recommended intake (PRI) for these groups in Bangladesh, Guatemala, and Uganda. We have modeled the potential contribution of calcium-fortified drinking water or wheat flour to FBR sets, to fill the remaining intake gaps. Optimized diets containing fortified products, with calcium-rich local foods, achieved the calcium PRI for all target groups. Combining fortified water or flour with FBRs met dietary intake targets for adolescent girls in all geographies and allowed a reduction from 3-4 to the more feasible 1-2 FBRs. Water with a calcium concentration of 100 mg/L with FBRs was sufficient to meet calcium targets in Uganda, but higher concentrations (400-500 mg/L) were mostly required in Guatemala and Bangladesh. Combining calcium-fortified wheat flour at 400 mg/100 g of flour and the FBR for small fish resulted in diets meeting the calcium PRI in Bangladesh. Calcium-fortified water or flour could improve calcium intake for vulnerable populations, especially when combined with FBRs based on locally available foods.

Prevalence of neural tube defects, maternal HIV status, and antiretroviral therapy from a hospital-based birth defect surveillance in Kampala, Uganda

BACKGROUND

The estimated prevalence of neural tube defects (NTDs) in Africa is 11.7 per 10,000 live births; however, data on the impact of antiretroviral therapy (ART) during pregnancy and the risk for birth defects in Africa are limited.

METHODS

Data from a hospital-based surveillance program at four hospitals in Kampala, Uganda were used to estimate the baseline prevalence of NTDs and assess potential associations with HIV status and ART use. All live births, stillbirths, and spontaneous abortions delivered at the participating hospitals affected with selected birth defects between August 2015 and December 2018 were included. Trained midwives collected data from hospital records, maternal interviews, photographs, and narrative descriptions of birth defects. We estimated NTD prevalence per 10,000 births (live, stillbirths, spontaneous abortions), prevalence ratios, and 95% confidence intervals (CIs).

RESULTS

A total of 110,752 births from 107,133 women were included in the analysis; 9,394 (8.8%) women were HIV-infected and among those with HIV infection, 95.6% (n = 8,977) were on ART at delivery. Overall, 109 births were affected with NTDs, giving a prevalence of 9.8 (95% CI [8.2, 11.9]). Spina bifida (n = 63) was the most common type of NTD, with a prevalence of 5.7 (95% CI [4.4, 7.3]), followed by anencephaly (n = 31), with a prevalence of 2.8 (95% CI [2.0, 4.0]).

CONCLUSION

The prevalence of NTDs among births in Kampala, Uganda is consistent with current estimates for Africa. With the continued introduction of new medications that may be taken during pregnancy, sustainable birth defect surveillance systems and pharmacovigilance are indicated.

Widespread heterogeneity in staple crop mineral concentration in Uganda partially driven by soil characteristics

Calcium (Ca), iron (Fe), selenium (Se), and zinc (Zn) deficiencies are widespread in sub-Saharan Africa, with severe implications for human health. In Uganda, where the predominant diet depends heavily on plant-based staples, crop mineral concentration is an important component of dietary mineral intake. Studies assessing the risk of nutrient deficiency or the effectiveness of nutrient-focused interventions often estimate dietary mineral intake using food composition tables that are based on crops grown in developed countries. However, little is known about the actual nutritional content of crops grown in Uganda. Here, we document the Ca, Fe, Se, and Zn concentration of staple crops collected from Ugandan household farms. While median mineral concentrations were similar to those reported previously, variation in crop mineral concentration was high, particularly for Fe and Se. An ordinary least squares regression showed that some soil characteristics were correlated with crop mineral concentrations. Of these, soil pH was often positively associated with crop mineral concentration, while sand and organic carbon concentrations were negatively associated with several crop mineral concentrations. However, much of the variation in crop mineral content was not associated with the soil characteristics measured. Overall, our results suggest that extensive heterogeneity in staple crop mineral concentration in Uganda is likely due to a combination of edaphic characteristics and other variables. Because staple foods constitute a large portion of dietary mineral intake in Uganda and other developing countries, these results have implications for estimates of dietary mineral intake and the development of effective intervention strategies in such regions.

Caregivers' Nutrition Knowledge and Dietary Intake of Type 1 Diabetic Children Aged 3-14 Years in Uganda

PURPOSE

This study aimed to assess the association between caregiver's level of type 1 diabetes (T1D) nutrition knowledge with children's dietary diversity score (DDS), mean intake of macronutrients, nutrient adequacy ratios (NARs) and mean adequacy ratio (MAR).

RESEARCH DESIGN AND METHODS

A cross-sectional analytical study design was used. The study was conducted at 6 diabetes clinics in Uganda among 59 caregivers and 61 children. T1D nutrition knowledge survey (NKS) was used to assess the caregiver's nutrition knowledge, and the 24-hour dietary recall and dietary diversity score (DDS) questionnaires were used to collect data on the child's dietary intake.

RESULTS

Majority (93.2%) of the caregivers had low T1D nutrition knowledge. Carbohydrate counting was the least performed nutrition knowledge domain. The children's mean DDS, calorie intake and MAR were 5.7 ± 1.6, 666.7 ± 639.8 kcal and 0.7 ± 0.3, respectively. The mean NARs of carbohydrate, protein, and fat were 0.9 ± 0.3, 0.9 ± 0.4, 0.5 ± 0.5, respectively. There was a significant association between DDS with NARs of carbohydrate, protein, fat, vitamins A, B2, B3, B5, B12, folic acid, zinc and MAR. No formal education was significantly associated with a lower mean NKS score among caregivers (p = 0.039). Caregivers' T1D nutrition knowledge, age and family size explained 14% of variation in the child's dietary diversity (p = 0.041).

CONCLUSION

Despite poor nutrition knowledge among caregivers especially on carbohydrate counting, dietary diversity among children with T1D remained favorable. Excess carbohydrate intake was observed with inadequate intake of proteins, fats and micronutrients (vitamin A, B vitamins and calcium). Caregivers with low education were more likely to register poor nutrition knowledge; therefore, there is need to develop and tailor nutrition education programmes to enhance comprehensive learning among caregivers for improved outcomes.

Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries

BACKGROUND

Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified.

OBJECTIVES

We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA).

METHODS

In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI).

RESULTS

Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda.

CONCLUSIONS

Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.

Are dietary intake and nutritional status influenced by gender? The pattern of dietary intake in Lao PDR: a developing country

Background

Recognition of discrepancies between men and women in nutritional intake is important to tackle food and nutrition insecurity and the often-double burden of malnutrition. The purpose of this study was to assess nutritional status and dietary intake of the Lao population, with a focus on possible influences of gender.

Methods

Dietary intake was assessed in a national cross-sectional study of 1771 randomized participants aged from 1.01 to 89 years, using 24-h dietary recall. Dietary reference intakes were used to assess nutrient insufficiency. Chi-square test was used to evaluate gender differences and multiple univariate logistic regression to examine associations between gender, nutritional status, demographics and nutrient insufficiency.

Results

Nutrient insufficiencies were higher among pregnant and lactating women than other adult men and women, especially for protein and micronutrients such as vitamin B3, B1, C and other vitamins. Dietary intake and BMI were similar between men and women; all had insufficient intake of all types of nutrients, except sodium. However, women had lower intake than men for almost all nutrients and age groups. The prevalence of overnutrition was higher among those aged 18 years and over for both sexes. Among adult women (15–49.9 years old) and older adult women (50 years old or above), the proportions were: underweight 8.6% (both groups), overweight 18.4 and 20.5%, and obese 34.2 and 39.1%, respectively. Among pregnant and lactating women, the rates of underweight were 7.5 and 1.4%, of overweight were 17.8 and 27.1%, and obese, 21.9 and 40.0%. Among adult and older men, 3.2 and 8.3% were underweight; 21.0 and 18.6% were overweight and 28.2 and 27.6% were obese. Multiple univariate logistic regressions revealed that the factors rural area, dry season and Northern-Lowland region were associated with inadequate micronutrient intake among children, adolescents and adults of both genders.

Conclusions

Dietary intakes were alarmingly micronutrient-insufficient. Macronutrient imbalance and double burden of malnutrition were confirmed in both sexes. Gender differences were limited; men and women had similarly insufficient intakes, but pregnant and lactating women were disproportionately affected. Nutritional interventions should also take men and older people into account to solve nutrition problems.

Dietary Micronutrients and Gender, Body Mass Index and Viral Suppression Among HIV-Infected Patients in Kampala, Uganda

BACKGROUND

HIV/AIDS is a hallmark of immune suppression. Micronutrient deficiencies in diet and recurrent opportunistic infections play major roles in the lives of people living with HIV. Although benefits of providing adequate diet to HIV positive persons are well documented, the demand for key elements still remain unclear in particular settings, especially in low and middle-income countries.

METHODS

This was a cross sectional analysis of baseline data collected from HIV-infected adults initiating antiretroviral therapy, and who were enrolled in a multivitamin supplementation trial. A food frequency questionnaire was used and intake were obtained as a product of quantities consumed. Adequacy was calculated as the proportion of Recommended Dietary Allowances (RDA). A chi square test and logistic regression analysis were used at p-value 0.05 to show significant associations.

RESULTS

Mean intakes were above minimum requirements for analyzed micronutrients with the exception of Calcium and Iron. Participants who met RDA intakes were as follows: highest (≥ 80%) for Magnesium, Selenium, Zinc and Vitamins B2, B6, B9, C and E; moderate (50% to <80%) for Vitamins B3, and A; and lowest (≤50%) for Iron (30%), Calcium (14.9%), Vitamins B12 and B1. Gender differences in met RDA were observed for Iron, Selenium, Zinc, Vitamins A, B1, B3 and E. In multivariable analyses, nutritional status and CD4 count had no influence on meeting RDA for majority of micronutrients such as magnesium, Selenium, B class vitamins (B1, B2, B3, B6, B9, B12), vitamin (A, C, and E), Zinc and Calcium, but not including iron.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Diets consumed by the study participants were low in most protective nutrients (Iron, Calcium, Zinc, Vitamin A, B1, B3, and B12). This deficiency was more common among females than males, and irrespective of BMI or CD 4 count. Findings warrant further investigation on the impact and cost implications for suplementation interventions that target the elements lacking in the diets of people living with HIV in similar low-resourced settings.

Weighing the risks of high intakes of selected micronutrients compared with the risks of deficiencies

Several intervention strategies are available to reduce micronutrient deficiencies, but uncoordinated implementation of multiple interventions may result in excessive intakes. We reviewed relevant data collection instruments and available information on excessive intakes for selected micronutrients and considered possible approaches for weighing competing risks of intake above tolerable upper intake levels (ULs) versus insufficient intakes at the population level. In general, population‐based surveys in low‐ and middle‐income countries suggest that dietary intakes greater than the UL are uncommon, but simulations indicate that fortification and supplementation programs could lead to high intakes under certain scenarios. The risk of excessive intakes can be reduced by considering baseline information on dietary intakes and voluntary supplement use and continuously monitoring program coverage. We describe a framework for comparing risks of micronutrient deficiency and excess, recognizing that critical information for judging these risks is often unavailable. We recommend (1) assessing total dietary intakes and nutritional status; (2) incorporating rapid screening tools for routine monitoring and surveillance; (3) addressing critical research needs, including evaluations of the current ULs, improving biomarkers of excess, and developing methods for predicting and comparing risks and benefits; and (4) ensuring that relevant information is used in decision‐making processes.

What Can Dietary Patterns Tell Us about the Nutrition Transition and Environmental Sustainability of Diets in Uganda?

Uganda is undergoing dietary transition, with possible environmental sustainability and health implications, particularly for women. To explore evidence for dietary transitions and identify how environmentally sustainable women's dietary patterns are, principal component analysis was performed on dietary data collected using a 24 h recall during the Uganda Food Consumption Survey (n = 957). Four dietary patterns explained 23.6% of the variance. The "traditional, high-fat, medium environmental impact" pattern was characterized by high intakes of nuts/seeds, fats, oils and spreads, fish and boiled vegetables. High intakes of bread and buns, rice and pasta, tea and sugar characterized the "transitioning, processed, low environmental impact' pattern. The 'plant-based, low environmental impact" pattern was associated with high intakes of legumes, boiled roots/tubers, boiled traditional vegetables, fresh fruit and fried traditional cereals. High intakes of red/organ meats, chicken, and soups characterized the "animal-based high environmental impact" pattern. Urban residence was positively associated with "transitioning, processed, low environmental impact" (β = 1.19; 1.06, 1.32) and "animal-based high environmental impact" (β = 0.45; 0.28, 0.61) patterns; but negatively associated with the "plant-based low environmental impact" pattern (β= -0.49; -0.62, -0.37). A traditional, high-fat dietary pattern with medium environmental impact persists in both contexts. These findings provide some evidence that urban women's diets are transitioning.

Measurement Errors in Dietary Assessment Using Self-Reported 24-Hour Recalls in Low-Income Countries and Strategies for Their Prevention

Securing accurate measurements of dietary intake across populations is challenging. Of the methods, self-reported 24-h recalls are often used in low-income countries (LICs) because they are quick, culturally sensitive, do not require high cognitive ability, and provide quantitative data on both foods and nutrients. Measuring intakes via 24-h recalls involves 1) collecting data on food intakes, 2) the appropriate use of relevant food-composition data for calculating nutrient intakes, and 3) statistically converting observed intakes to "usual intakes" for evaluating nutrient adequacy or relations between foods and nutrients and health outcomes. Like all dietary methods, 24-h recalls are subject to random errors that lower the precision and systematic errors that can reduce accuracy at each stage of the measurement protocol. Research has identified the potential sources of measurement errors in 24-h recall protocols and emphasized that sources of random error can be reduced by incorporating standardized quality-control procedures and collecting more than one 24-h recall per person, with the number depending on the study objective. Careful design of the initial 24-h recall protocol can take into account potential sources of systematic error, such as day of the week, season, age, etc. Other sources of systematic error (e.g., energy underreporting) can best be detected by including a reference measure (e.g., doubly labeled water to measure energy expenditure). Alternatively, 24-h recall intakes of energy can be compared with same-day weighed intakes. Nevertheless, very few studies in LICs have assessed the validity of 24-h recalls in their study settings or adopted recommended standardized protocols to mitigate random errors. Hence, efforts should be made to improve the assessment, analysis, and interpretation of self-reported 24-h recall data for population studies in LICs. Accurate and precise dietary intake data at the national level can play an essential role in informing food, nutrition, and agricultural policies; food fortification planning; and compliance to food-based dietary guidelines.

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

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.

Assessing the Safety of Vitamin A Delivered Through Large-Scale Intervention Programs: Workshop Report on Setting the Research Agenda

BACKGROUND

Vitamin A (VA) deficiency (VAD) is still a concern in many parts of the world, and multiple intervention strategies are being implemented to reduce the prevalence of VAD and associated morbidity and mortality. Because some individuals within a population may be exposed to multiple VA interventions, concerns have been raised about the possible risk of hypervitaminosis A.

OBJECTIVES

A consultative meeting was held in Vienna, Austria, in March 2014 to (1) review current knowledge concerning the safety and effectiveness of large-scale programs to control VAD, (2) develop a related research agenda, and (3) review current available methods to assess VA status and risk of hypervitaminosis A.

METHODS

Multiple countries were represented and shared their experiences using a variety of assessment methods, including retinol isotope dilution (RID) techniques. Discussion included next steps to refine assessment methodology, investigate RID limitations under different conditions, and review programmatic approaches to ensure VA adequacy and avoid excessive intakes.

RESULTS

Fortification programs have resulted in adequate VA status in Guatemala, Zambia, and parts of Cameroon. Dietary patterns in several countries revealed that some people may consume excessive preformed VA from fortified foods.

CONCLUSION

Additional studies are needed to compare biomarkers of tissue damage to RID methods during hypervitaminosis A and to determine what other biomarkers can be used to assess excessive preformed VA intake.

Addressing the risk of inadequate and excessive micronutrient intakes: traditional versus new approaches to setting adequate and safe micronutrient levels in foods

Fortification of foods consumed by the general population or specific food products or supplements designed to be consumed by vulnerable target groups is amongst the strategies in developing countries to address micronutrient deficiencies. Any strategy aimed at dietary change needs careful consideration, ensuring the needs of at-risk subgroups are met whilst ensuring safety within the general population. This paper reviews the key principles of two main assessment approaches that may assist developing countries in deciding on effective and safe micronutrient levels in foods or special products designed to address micronutrient deficiencies, that is, the cut-point method and the stepwise approach to risk-benefit assessment. In the first approach, the goal is to shift population intake distributions such that intake prevalences below the Estimated Average Requirement (EAR) and above the Tolerable Upper Intake Level (UL) are both minimized. However, for some micronutrients like vitamin A and zinc, a narrow margin between the EAR and UL exists. Increasing their intakes through mass fortification may pose a dilemma; not permitting the UL to be exceeded provides assurance about the safety within the population but can potentially leave a proportion of the target population with unmet needs, or vice versa. Risk-benefit approaches assist in decision making at different micronutrient intake scenarios by balancing the magnitude of potential health benefits of reducing inadequate intakes against health risks of excessive intakes. Risk-benefit approaches consider different aspects of health risk including severity and number of people affected. This approach reduces the uncertainty for policy makers as compared to classic cut-point methods.

Simulations based on representative 24-h recall data predict region-specific differences in adequacy of vitamin A intake among Cameroonian women and young children following large-scale fortification of vegetable oil and other potential food vehicles

BACKGROUND

The WHO recommends assessing food and nutrient intakes to design food-fortification programs, but nationally representative dietary data are seldom available in low-income countries.

OBJECTIVE

Prior to initiation of food fortification in Cameroon, we measured intake of vitamin A (VA) and fortifiable foods (vegetable oil, sugar, wheat flour, and bouillon cube) to simulate the effects of fortification with different foods and VA amounts on prevalence of inadequate and excessive VA intake.

METHODS

Twenty-four-hour recalls were conducted among 912 women and 883 children (with duplicates in a subset) in a nationally representative cluster survey stratified by region (North, South, Yaoundé/Douala). Usual intake distributions were estimated by the National Cancer Institute method.

RESULTS

Nationally, 53% of women had a usual intake of <500 μg retinol activity equivalents/d, and 59% of nonbreastfeeding children had an intake of <210 μg retinol activity equivalents/d, although VA intake varied by region. The current fortification program (12 mg/kg VA in oil) would decrease the prevalence of inadequate intakes to 35% among both women and children, without increasing the proportion with retinol intakes >3000 μg/d among women or >600 μg/d among children. However, inadequate VA intake would remain >50% in the North, where VA deficiency was most common. Increasing VA in oil or fortifying a second food (sugar, wheat flour, or bouillon cube) would further decrease the prevalence of inadequate intakes, but, depending on the food vehicle and region, would also increase the prevalence of retinol intakes above the tolerable upper intake level, mainly among children.

CONCLUSIONS

The current food-fortification program can be expected to improve dietary VA adequacy without increasing the risk of excessive intake among women and children in Cameroon. Modifications to the program must balance the potential to further increase VA intake with the risk of excessive intake among children.

Micronutrient research, programs, and policy: From meta-analyses to metabolomics

Micronutrient deficiencies are widespread among women and children in undernourished populations. Research has identified effective approaches to their prevention, including supplementation, fortification, and dietary and other public health interventions. These interventions have made tremendous improvements in the quality of life, health, and survival of populations around the world, yet the impact varies by nutrient, population, and the outcomes chosen that reflect nutritionally driven change. The WHO guides governments and agencies toward effective strategies to prevent micronutrient deficiencies in women and children, but these are often informed by imperfect studies with limited measures of impact and the inadequate program evaluations and survey databases produced by the nutrition community. The resulting knowledge gaps limit our ability to discern what interventions are effective, under what conditions, among whom, and perhaps most important, why. However, we are moving into an era of opportunity to apply the tools of modern nutrition science, including improved methods of assessing nutritional status, "omics," bioarchival access, systems biology thinking, and interdisciplinary collaborations, that can deepen and broaden our understanding of how micronutrients affect health, how their deficiencies diminish human capacity, and how interventions can improve the well-being of those in need. Relevant training and greater cross-disciplinary efforts will be required to ensure a cell-to-society approach that can systematically address where, to whom, and how to provide micronutrients in the future.

Model for estimating nutrient addition contents to staple foods fortified simultaneously: Mexico and Kampala data

The objective of this work was to present a generic model for estimating fortification contents when several food vehicles are being considered simultaneously. It is based on approximating the magnitude of the nutritional inadequacy of the population (nutrient gap), the optimal use of the combination of food vehicles (fortifiable food energy, FFE), and the upper intake level to decrease the possibility that individuals with the highest combined intake of all food vehicles will exceed it. The model is intended to be used when only per capita food and micronutrient intake information, not detailed food intake data, are available. Food consumption survey data from Mexico and Kampala (Uganda) were analyzed for adult women, assuming that their intake may be similar to general per capita values. General adjustment factors for estimating the lowest and highest FFE and micronutrient intake for satisfying the requirements of other family members were calculated. These factors were used to estimate the additional effective content and the maximum allowable content, and then the recommended nutrient contents at the consumers' level were chosen on the basis of technological compatibility and cost. The method should be used in other contexts to test its validity as well as its application to nonstaple foods.