The role of expanded coverage of the national vitamin A program in preventing morbidity and mortality among preschool children in India

Coverage and associated factors of vitamin-A supplementation among children aged 6-59 months in Gondar City, Northwest Ethiopia, 2022: a community-based cross-sectional study

Introduction

vitamin A is a nutrient required for normal visual system function, growth, and development. Periodic vitamin A supplementation is a cost-effective strategy for preventing vitamin A deficiency in children. This study aimed to assess the coverage and associated factors of vitamin A supplementation among children aged 6-59 months in Gondar City, Northwest Ethiopia 2022.

Methods

a community-based cross-sectional study with a multistage random sampling technique was done on 587 mothers with 6-59-month-old children from October 20 to November 10, 2022, in Gondar City. The descriptive statistics are summarized by frequency, percent, and summary statistics. Binary logistic regression was performed, and variables with a P-value <0.05 were considered significantly associated.

Results

the vitamin A supplementation coverage was 34.4% (95% CI (30.3% - 38.3%)). Children aged 6-13 months [AOR=9.50, 95% CI; (4.59-9.66)], 14-27 months [95% CI; (3.07-12.03)], mothers who had an education level of certificate or above [AOR=3.79, 95% CI; (1.45-9.90)], mothers who learned in secondary schools [AOR=3.29, 95% CI; (1.28-8.45)], mothers who had four or more antenatal care visits [AOR=4.32 (95% CI: (1.54-11.97) and mothers' good knowledge towards vitamin A [AOR: 2.20 (95% CI: 1.60-4.10)] showed a statistically significant association.

Conclusion

the coverage of vitamin A supplementation exceeded the 70% UNISAFE threshold. A younger child's age, maternal education level, more than 4 antenatal visits, and good knowledge of vitamin A were significant factors. Extended and more integrated immunization programs with robust health education regarding vitamin A supplementation would play a prodigious role in getting higher coverage.

Acute Diarrhoeal Disease in Children Aged 6 Months to 24 Months: An In-Hospital Cross-Sectional Study

Introduction:

Diarrheal disease comes second among the causes of death in children under 5 years of old. We are well aware that this common disease is preventable and treatable. But the practice of preventive strategies is not as efficient as it should be.

Aims and Objectives:

1. To determine the frequency of acute diarrheal disease in children aged 6 months to 24 months attending the immunization clinic of Lourdes Hospital, Kochi, Kerala. 2. To assess the associated factors and practices involved with acute diarrheal disease in the study group.

Material and Methods:

A cross-sectional study was done in children above 6 months attending immunization clinic in Lourdes hospital during the period from 1^st October 2017 to 31^st March 2019. After receiving their informed consent, a pretested, semistructured, and validated questionnaire was given to the mothers/caregivers to gather data on socio-demographic characteristics and practices. In order to assess the prevalence of diarrhea, details of the diarrheal episode after the 6 months of age were included in the questionnaire. To eliminate repeats, caution was taken not to include previously recorded data on the diarrheal episode.

Discussion and Conclusion:

The proportion of children with diarrhea in the study population was 38.7% which was high compared with other studies in the same age group. Many of the practices associated were found faulty and needing rectification which is a Family Physician's area of expertise. The study concludes that there is a need for identifying novel risk factors for diarrhea and educating the caregivers regarding the prevention of diarrhea. Primary Care Physicians/Family Physicians can play an effective role in educating the caregivers.

Association of vitamin A deficiency with early childhood stunting in Uganda: A population-based cross-sectional study

BACKGROUND

Despite the high prevalence of childhood protein-energy malnutrition and vitamin A deficiency in sub-Saharan Africa, their association has not been explored in this region. A better understanding of the epidemiologic link could help define effective preventive strategies. We aimed to explore the association of vitamin A deficiency (VAD) with stunting, wasting, and underweight among preschool children in Uganda.

METHOD

We analyzed a population-based, cross-sectional data of 4,765 children aged 6-59 months who participated in 2016 Demographic and Health Surveys conducted in Uganda. We utilized generalized linear mixed-effects models with logit link function, adjusting for potential confounders to estimate associations between VAD and stunting, wasting, and underweight.

RESULTS

The prevalence of VAD was 8.9% (95% CI: 8.1% to 9.6%, n = 424). Twenty-seven percent were stunted (95% CI: 26.1% to 28.6, n = 1302), 4% wasted (95% CI: 3.6% to 4.7%, n = 196), and 17% underweight (95% CI: 16.0% to 18.2%, n = 813). After adjusting for household factors (e.g., wealth index, education and working status of parents, owning land for agriculture, livestock, herds, or farm animals), vitamin A supplementation, and community factors (e.g., population density, crop growing season lengths, place of residence), children with VAD had 43% higher odds of stunted growth than those without VAD (adjusted odds ratio, 1.43 (95% CI: 1.08 to 1.89, p = 0.01). No association was observed between VAD and wasting or underweight.

CONCLUSION

Vitamin A deficiency was associated with higher odds of stunting, and the association was independent of the individual, household, and community-level variables.

Tribal Odisha Eye Disease Study Report # 6. Opportunistic screening of vitamin A deficiency through School Sight Program in tribal Odisha (India)

Purpose

To explore the possibility of vitamin A deficiency (VAD) detection through School Sight Program (SSP) in a tribal district of Odisha, India.

Methods

In a cross-sectional observational study, we tracked school children with ocular signs/symptoms of VAD to their villages. The ophthalmologist examined their under-5 siblings and other under-5 children in the village. Information pertaining to family belief and practices of food, water, sanitation, and the socioeconomic status of the family were collected.

Results

The ocular features of VAD were detected in 207 of 4801 (4.3%) examined children. This included 70 children (mean age 11 ± 2.6 years) detected in the school, 22 siblings (mean age 3.2 ± 1.2 years) of these children detected at their home, and 115 children (mean age 3 ± 1.5 years) detected in their habitat. The average family size was 5.8 ± 2.02 and the birth order of the child with VAD was 2.3 ± 1.25. Most parents were farmer, living in asbestos-roofed house, depended on public underground water, and practiced open-air defecation. The distribution of VAD in 207 children was conjunctival xerosis (X1A = 207; 100% of VAD and 4.3% of all children), Bitot's spot (X1B = 169; 81.6% of VAD and 3.5% of all children), corneal scar (XS = 3; 1.4% of VAD and 0.06% of all children), and night blindness (XN = 35; 16.9% of VAD and 0.72% of all children).

Conclusion

An opportunistic screening for detection of VAD through a SSP could be cost-effective and complement the existing strategy.

Coverage and factors associated with vitamin A supplementation among children aged 6-59 months in twenty-three sub-Saharan African countries

OBJECTIVE

The present study aimed to give an overall view of the pattern of high-dose vitamin A supplementation (VAS) coverage in twenty-three sub-Saharan African countries and factors associated with receipt of VAS among children aged 6-59 months.

DESIGN

Cross-sectional data from the twenty-three Demographic and Health Surveys conducted from 2011 to 2015 in twenty-three sub-Saharan African countries were pooled. A multilevel logistic regression model was used to explore factors associated with VAS.

SETTING

Twenty-three sub-Saharan African countries.ParticipantsChildren (n 215 511) aged 6-59 months.

RESULTS

The overall coverage of VAS among children aged 6-59 months for the surveys included was 59·4 %. In the multivariable analysis, children whose mothers had primary (adjusted OR (aOR)=1·43; 95 % CI 1·39, 1·47) or secondary or above (aOR=1·72; 95 % CI 1·67, 1·77) educational status were more likely to receive VAS than children whose mothers had no formal education. Other factors associated with significantly increased likelihood of VAS were: living in urban areas; children of working mothers; children whose mothers had higher media exposure; children of older mothers v. children of mothers aged 15-19 years; and older children v. children aged 6-11 months. At the country level, lower media exposure was significant and negatively associated with VAS.

CONCLUSIONS

Broader VAS coverage is needed according to our data. More efforts are needed to scale up coverage, focusing mostly on groups at risk of non-receipt of vitamin A.

Nutrition (Micronutrients) in Child Growth and Development: A Systematic Review on Current Evidence, Recommendations and Opportunities for Further Research

OBJECTIVE

An important aspect of malnutrition is deficiency of different micronutrients during pregnancy or early childhood. We systematically reviewed the role of nutrition in child growth (weight or height gain) and development.

METHODS

A comprehensive literature search was done on PubMed/Cochrane Library browsing through 38,795 abstracts until December 31, 2016 to select systematic reviews/meta-analyses and individual randomized controlled trials (RCTs) of micronutrient supplementation.

RESULTS

Micronutrients studied included iron, iodine, folate, zinc, calcium, magnesium, selenium, vitamin D, vitamin A, vitamin B complex, and multiple micronutrients. We summarize evidence with details and results of RCTs, highlight strengths/weaknesses, and critically interpret findings. Effects of breastfeeding-promotion, food-supplementation (complementary and school feeding), conditional-cash-transfers, and integrated nutrition/psychosocial interventions are discussed.

CONCLUSION

Based on this evidence we make policy and programmatic recommendations for supplementation to mothers and children at high-risk of deficiency.

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.

Differentials in vitamin A supplementation among preschool-aged children in Ethiopia: evidence from the 2011 Ethiopian Demographic and Health Survey

BACKGROUND

Vitamin A supplementation is one of the best proven, safest and most cost-effective interventions in public health. However, childhood vitamin A supplementation has not reached adequate levels of coverage in developing countries. This study aimed to identify factors associated with childhood vitamin A supplementation in Ethiopia.

STUDY DESIGN

Cross-sectional study with stratified, two-stage cluster design.

METHODS

Analysis of data from the 2011 Ethiopian Demographic and Health Survey (EDHS) was used to identify factors associated with childhood vitamin A supplementation. Data for 9276 children aged 6-59 months were included in the analysis. Binary and multivariable logistic regression models were used.

RESULTS

Over half [54.5%, 95% confidence interval (CI) 53.48-55.51%] of children aged 6-59 months had received vitamin A supplementation in the last six months. Regional differences were found, ranging from 28.1% in Somali to 83.2% in Tigray (P < 0.001). Children in the poorest wealth index category [adjusted odds ratio (AOR) 0.60, 95% CI 0.47-0.77], children with mothers who did not attend any antenatal care (ANC) appointments (AOR 0.56, 95% CI 0.48-0.67), infants aged 6-11 months (AOR 0.52, 95% CI 0.42-0.65), children with mothers who did not have a postnatal medical check-up (AOR 0.69, 95% CI 0.56-0.86) and children with mothers who had not worked in the last year (AOR 0.86, 95% CI 0.76-0.97) were less likely to have received vitamin A supplementation in the last six months.

CONCLUSION

Coverage of childhood vitamin A supplementation was not optimum in Ethiopia and regional differences were found. Lack of a maternal postnatal medical check-up, lack of ANC attendance, poorest wealth index, mother who had not worked in the last year and infant in youngest age group were associated with lower odds of receiving vitamin A supplementation over the last six months. Provision and promotion of ANC and postnatal care, and strengthening routine immunization activity, especially among infants in the youngest age group, are recommended to increase coverage of childhood vitamin A supplementation.

A review of the vitamin A supplementation program in India: reasons for success in the states of Bihar and Odisha

BACKGROUND

Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation.

OBJECTIVE

To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors.

METHODS

A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners.

RESULTS

Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff.

CONCLUSIONS

The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable.

India's vitamin A supplementation programme is reaching the most vulnerable districts but not all vulnerable children. New evidence from the seven states with the highest burden of mortality among under-5s

OBJECTIVE

To characterize the coverage of India's national vitamin A supplementation (VAS) programme and document its performance in reaching children in the districts with higher concentration of poor households (2006-2011).

DESIGN

Analysis of VAS programme coverage data collated and collected using standardized bottom-up procedures, data from India's Office of the Registrar General and Census Commissioner, and data from India's District Level Household Survey to compute exposure (poverty) and outcome (full VAS coverage) variables.

SETTING

Seven Indian states with the highest burden of mortality in children (74 % of all deaths among under-5s in the country in 2006).

SUBJECTS

Children 6-59 months old.

RESULTS

Between 2006 and 2011, the mean full VAS coverage (two VAS doses per child per year) in these seven states increased from 44·7 % to 67·3 % while the number of districts with high (≥80 %) full VAS coverage increased from twenty-four (9·4 %) to 131 (51·4 %). The highest increases in full VAS coverage figures were recorded in the districts with the highest concentration of poor households. The estimated number of poor children (i.e. children living in households classified as poor) who did not receive two VAS doses annually decreased from 8·5 million in 2006 to 5·1 million in 2011 (40·3 % decrease); 2·5 million (49·1 %) of these children lived in the districts with the lowest proportion of poor households.

CONCLUSIONS

Despite significant improvements in VAS, a large number of Indian children are not benefitting yet from this life-protecting intervention, particularly among those who are potentially the most vulnerable. Future programme action needs to give priority to sub-district level units - blocks and villages - with higher concentrations of poor households.

Understanding child stunting in India: a comprehensive analysis of socio-economic, nutritional and environmental determinants using additive quantile regression

Background

Most attempts to address undernutrition, responsible for one third of global child deaths, have fallen behind expectations. This suggests that the assumptions underlying current modelling and intervention practices should be revisited.

Objective

We undertook a comprehensive analysis of the determinants of child stunting in India, and explored whether the established focus on linear effects of single risks is appropriate.

Design

Using cross-sectional data for children aged 0–24 months from the Indian National Family Health Survey for 2005/2006, we populated an evidence-based diagram of immediate, intermediate and underlying determinants of stunting. We modelled linear, non-linear, spatial and age-varying effects of these determinants using additive quantile regression for four quantiles of the Z-score of standardized height-for-age and logistic regression for stunting and severe stunting.

Results

At least one variable within each of eleven groups of determinants was significantly associated with height-for-age in the 35% Z-score quantile regression. The non-modifiable risk factors child age and sex, and the protective factors household wealth, maternal education and BMI showed the largest effects. Being a twin or multiple birth was associated with dramatically decreased height-for-age. Maternal age, maternal BMI, birth order and number of antenatal visits influenced child stunting in non-linear ways. Findings across the four quantile and two logistic regression models were largely comparable.

Conclusions

Our analysis confirms the multifactorial nature of child stunting. It emphasizes the need to pursue a systems-based approach and to consider non-linear effects, and suggests that differential effects across the height-for-age distribution do not play a major role.

Vitamin A—Fortified Vegetable Oil Exported from Malaysia and Indonesia Can Significantly Contribute to Vitamin A Intake Worldwide

Background

Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake.

Objective

To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported .

Methods

Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil.

Results

Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Average Requirement (EAR) for an Ethiopian woman, 30.9% and 46.9% of the EAR for a Bangladeshi child and woman, respectively, and 17.5% of the EAR for a Cambodian woman. Although concerns about obesity are valid, fortification of existing vegetable oil supplies does not promote overconsumption of oil but rather promotes consumption of vegetable oil of higher nutrient quality.

Conclusions

Fortifying vegetable oil on a large scale in Malaysia and Indonesia can reach millions of people globally, including children less than 5 years old. The levels of fortification used are far from reaching the Tolerable Upper Intake Level (UL). Vegetable oil fortification has the potential to become a global public health intervention strategy.

Coverage of the vitamin A supplementation programme for child survival in Nepal: success and challenges

BACKGROUND

Nepal's national vitamin A programme, which began in 1993 and continues twice yearly, targets pre-school-aged children in all districts of the country in an effort to reduce morbidity, mortality and nutritional blindness.

OBJECTIVE

To characterize the coverage of the Nepal National Vitamin A Programme (NVAP) for pre-school-aged children in Nepal and to identify risk factors for failure to receive vitamin A supplementation.

METHODS

The relationship between receipt of a vitamin A capsule and demographic and health indicators was examined in a cross-sectional study of 4013 children aged 12-59 months and their families who participated in the 2011 Nepal Demographic and Health Survey (NDHS), a nationally representative survey. Coverage of the vitamin A programme was compared with coverage estimates from surveys in 2001 and 2006.

RESULTS

Coverage estimates of the national vitamin A programme for children aged 12-59 months as assessed by the 2001, 2006 and 2011 NDHS were 84.3%, 96.6% and 92.1%, respectively. Children who missed a vitamin A capsule were more likely to be younger and anaemic, have less educated parents, live in rural areas, and have higher child and infant mortality in the family.

CONCLUSIONS

The national vitamin A supplementation programme in Nepal has relatively high coverage of children aged 12-59 months but still misses children in families with high child mortality. Further measures might be needed to sustain a high level of programme coverage.

The historical evolution of thought regarding multiple micronutrient nutrition

Multiple micronutrient nutrition is an idea that originated in the 1940s and exemplifies the iterative nutritional paradigm. In the first four decades of the 20th century, scientists sought to separate and characterize the vitamins that were responsible for xerophthalmia, rickets, pellagra, scurvy, and beriberi. The dietary requirements of the different micronutrients began to be established in the early 1940s. Surveys showed that multiple micronutrient deficiencies were widespread in industrialized countries, and the problem was addressed by use of cod-liver oil, iodized salt, fortified margarine, and flour fortification with multiple micronutrients, and, with rising living standards, the increased availability and consumption of animal source foods. After World War II, surveys showed that multiple micronutrient deficiencies were widespread in developing countries. Approaches to the elimination of multiple micronutrient deficiencies include periodic vitamin A supplementation, iodized salt, targeted iron/folate supplementation, fortified flour, other fortified foods, home fortification with micronutrient powders, and homestead food production. The prevention of multiple micronutrient malnutrition is a key factor in achieving the Millennium Development Goals, given the important effects of micronutrients on health and survival.

Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis

OBJECTIVE

To determine if vitamin A supplementation is associated with reductions in mortality and morbidity in children aged 6 months to 5 years.

DESIGN

Systematic review and meta-analysis. Two reviewers independently assessed studies for inclusion. Data were double extracted; discrepancies were resolved by discussion. Meta-analyses were performed for mortality, illness, vision, and side effects.

DATA SOURCES

Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, Global Health, Latin American and Caribbean Health Sciences, metaRegister of Controlled Trials, and African Index Medicus. Databases were searched to April 2010 without restriction by language or publication status.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials of synthetic oral vitamin A supplements in children aged 6 months to 5 years. Studies of children with current illness (such as diarrhoea, measles, and HIV), studies of children in hospital, and studies of food fortification or β carotene were excluded.

RESULTS

43 trials with about 215,633 children were included. Seventeen trials including 194,483 participants reported a 24% reduction in all cause mortality (rate ratio=0.76, 95% confidence interval 0.69 to 0.83). Seven trials reported a 28% reduction in mortality associated with diarrhoea (0.72, 0.57 to 0.91). Vitamin A supplementation was associated with a reduced incidence of diarrhoea (0.85, 0.82 to 0.87) and measles (0.50, 0.37 to 0.67) and a reduced prevalence of vision problems, including night blindness (0.32, 0.21 to 0.50) and xerophthalmia (0.31, 0.22 to 0.45). Three trials reported an increased risk of vomiting within the first 48 hours of supplementation (2.75, 1.81 to 4.19).

CONCLUSIONS

Vitamin A supplementation is associated with large reductions in mortality, morbidity, and vision problems in a range of settings, and these results cannot be explained by bias. Further placebo controlled trials of vitamin A supplementation in children between 6 and 59 months of age are not required. However, there is a need for further studies comparing different doses and delivery mechanisms (for example, fortification). Until other sources are available, vitamin A supplements should be given to all children at risk of deficiency, particularly in low and middle income countries.

Preventing food crises using a food policy approach

A food crisis occurs when rates of hunger and malnutrition rise sharply at local, national, or global levels. This definition distinguishes a food crisis from chronic hunger, although food crises are far more likely among populations already suffering from prolonged hunger and malnutrition. A food crisis is usually set off by a shock to either supply or demand for food and often involves a sudden spike in food prices. It is important to remember that in a market economy, food prices measure the scarcity of food, not its value in any nutritional sense. Except in rare circumstances, the straightforward way to prevent a food crisis is to have rapidly rising labor productivity through economic growth and keep food prices stable while maintaining access by the poor. The formula is easier to state than to implement, especially on a global scale, but it is good to have both the objective, reducing short-run spikes in hunger, and the deep mechanisms, pro-poor economic growth and stable food prices, clearly in mind. A coherent food policy seeks to use these mechanisms, and others, to achieve a sustained reduction in chronic hunger over the long run while preventing spikes in hunger in the short run.

Household dietary diversity and food expenditures are closely linked in rural Bangladesh, increasing the risk of malnutrition due to the financial crisis

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

Vitamin A intake and status in populations facing economic stress

Dietary quality and diversity reflect adequacy of vitamin A. Both can deteriorate in response to economic crises. Although the nutritional consequences of the 2008 world food price crisis remain unclear, past studies of diet, status, and socioeconomic standing under usual (deprived) and unusually disruptive times suggest dietary quality and vitamin A status decline in mothers and young children. This is presumably the result of shifting diets to include less preformed vitamin A-rich animal source foods and, to a lesser extent, vegetables and fruits. Cross-sectional assessments of diet, deficiency, and socioeconomic status in a number of countries and surveillance data collected during the Indonesian economic crisis of 1997-8 indicate that the prevalence of vitamin A deficiency, night blindness, and other related disorders (e.g., anemia) may have increased during the 2008 crisis, and that it might not have necessarily recovered once food prices waned later in 2008. Lost employment may be a factor in slow nutritional recovery, despite some easing of food prices. Vitamin A deficiency should still be preventable amid economic instabilities through breast feeding promotion, vitamin A supplementation, fortification of foods targeted to the poor, and homestead food production that can bolster income and diversify the diet.

Castel Gandolfo workshop: an introduction to the impact of climate change, the economic crisis, and the increase in the food prices on malnutrition

The global food supply system is facing serious new challenges from economic and related crises and climate change, which directly affect the nutritional well-being of the poor by reducing their access to nutritious food. To cope, vulnerable populations prioritize consumption of calorie-rich but nutrient-poor food. Consequently, dietary quality and eventually quantity decline, increasing micronutrient malnutrition (or hidden hunger) and exacerbating preexisting vulnerabilities that lead to poorer health, lower incomes, and reduced physical and intellectual capabilities. This article introduces the series of papers in this supplement, which explore the relationships between crises and their cumulative impacts among vulnerable populations, particularly through hidden hunger.

Medium- to long-run implications of high food prices for global nutrition

The combined food, fuel, and financial crises of 2007-2009 had severe and widespread negative impacts around the world. Two key questions challenging governments were: how long would the high prices last and with what effects on food security and nutrition over the longer run? This paper considers the drivers of the crisis and explores if, unlike past shocks, the recent price increases reflect structural changes in food price formation that will have lasting global implications. New cross-commodity relationships allowed prices to spike, although there was no shortage of food at the global level nor indeed a significant downturn in recent yields. Yet recent record levels of farm production were also mirrored by growing numbers of people chronically undernourished and/or micronutrient deficient. The gap between supply and need was underpinned by growing urban demand, consumption of processed and higher-value foods (including meat), biofuel policy, and purchasing power erosion, but also by short-term market-distorting policies implemented by governments responding to perceived shortages of food. Thus, the impact of future food price crises will depend largely on what policymakers chose to do in response to the peaks and what they do not do during the troughs. Appropriate investments are urgently needed not just in smallholder developing country agriculture, but in effective food policies and targeted programming that can reverse the recent negative trends in nutrition and that support access globally to improved diet quality as well as food quantity.

Maternal and young child nutrition adversely affected by external shocks such as increasing global food prices

Rising food prices, resulting from the ongoing global economic crisis, fuel price volatility, and climate change, have an adverse impact upon the poor, especially those in food-importing, resource-limited countries. The conventional approach by large organizations has been to advocate for increased staple crop yields of mainly cereals. High food prices are predicted to continue to at least 2015. Past shocks and their known impacts upon nutrition were reviewed. Price instability and increases have long been an existing global problem, which has been exacerbated by recent macroeconomic shocks such as acute emergencies due to war and civil strife, acute climatic events, increase in food prices, fuel price volatility, dysfunction of the global financial systems, long-term climate change, and the emergence of failed states. The FAO estimated that there were 815 million "hungry" people in 2006, with a now additional 75-135 million with increased vulnerability, and currently it is estimated that there are one billion people at risk of food insecurity. The shocks initially compromise maternal and child nutrition, mainly through a reduction in dietary quality and an increase in micronutrient deficiencies and concomitant increases in infectious disease morbidity and mortality. A further reduction in the quantity of diet may follow with greater underweight and wasting. Recent macroeconomic shocks have greatly increased the number of people who are vulnerable to hunger in developing countries. Nutritional surveillance systems need to be strengthened and expanded to inform policy decisions.

Higher household expenditure on animal-source and nongrain foods lowers the risk of stunting among children 0-59 months old in Indonesia: implications of rising food prices

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesia's rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

Household rice expenditure and maternal and child nutritional status in Bangladesh

In Bangladesh, poor rural families often deal with high food costs by purchasing primarily rice. Our objective was to characterize the relationship between household expenditure on rice and nonrice foods with maternal and child malnutrition. Food expenditure data and anthropometry were obtained in a population-based sample of 304,856 households in the Bangladesh Nutrition Surveillance Project, 2000-2005. Food expenditures were categorized as rice and nonrice foods and expressed as quintiles of proportional food expenditure. Of children aged 6-11, 12-23, and 24-59 mo, the prevalence of stunting was 33.5, 56.3, and 53.1%, respectively. The prevalence of maternal underweight (BMI < 18.5 kg/m(2)) was 37.3%. Among children aged 6-11, 12-23, and 24-59 mo, rice expenditures were associated with stunting [odds ratio (OR) 1.11, 95% CI 1.02-1.20, P = 0.01; OR 1.09, 95% CI 1.04-1.13, P < 0.0001; OR 1.13, 95% CI 1.08-1.18, P < 0.0001), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders, and nonrice food expenditures were associated with stunting (OR 0.87, 95% CI 0.80-0.95, P = 0.002; OR 0.86, 95% CI 0.83-0.90, P < 0.0001; OR 0.89, 95% CI 0.85-0.94, P < 0.0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. In the highest compared with the lowest quintile, rice expenditures (OR 1.12, 95% CI 1.08-1.15, P < 0.0001) and nonrice food expenditures (OR 0.93, 95% CI 0.90-0.96, P < 0.0001) were associated with maternal underweight. Households that spent a greater proportion on nonrice foods and less on rice had a lower prevalence of maternal and child malnutrition.

Impact of the economic crisis and increase in food prices on child mortality: exploring nutritional pathways

The current economic crisis and food price increase may have a widespread impact on the nutritional and health status of populations, especially in the developing world. Gains in child survival over the past few decades are likely to be threatened and millennium development goals will be harder to achieve. Beyond starvation, which is one of the causes of death in famine situations, there are numerous nutritional pathways by which childhood mortality can increase. These include increases in childhood wasting and stunting, intrauterine growth restriction, and micronutrient deficiencies such as that of vitamin A, iron, and zinc when faced with a food crisis and decreased food availability. These pathways are elucidated and described. Although estimates of the impact of the current crisis on child mortality are yet to be made, data from previous economic crises provide evidence of an increase in childhood mortality that we review. The current situation also emphasizes that there are vast segments of the world's population living in a situation of chronic food insecurity that are likely to be disproportionately affected by an economic crisis. Nutritional and health surveillance data are urgently needed in such populations to monitor both the impacts of a crisis and of interventions. Addressing the nutritional needs of children and women in response to the present crisis is urgent. But, ensuring that vulnerable populations are also targeted with known nutritional interventions at all times is likely to have a substantial impact on child mortality.

How to ensure nutrition security in the global economic crisis to protect and enhance development of young children and our common future

The global economic crisis, commodity price hikes, and climate change have worsened the position of the poorest and most vulnerable people. These crises are compromising the diet and health of up to 80% of the population in most developing countries and threaten the development of almost an entire generation of children ( approximately 250 million), because the period from conception until 24 mo of age irreversibly shapes people's health and intellectual ability. High food prices reduce diversity and nutritional quality of the diet and for many also reduce food quantity. Poor households are hit hardest, because they already spend 50-80% of expenditures on food, little on medicines, education, transport, or cooking fuel, and cannot afford to pay more. Reduced public spending, declining incomes, increased food and fuel prices, and reduced remittance thus impede and reverse progress made toward Millenium Development Goals 1, 4, and 5. Investments in nutrition are among the most cost-effective development interventions because of very high benefit:cost ratios, for individuals and for sustainable growth of countries, because they protect health, prevent disability, boost economic productivity, and save lives. To bridge the gap between nutrient requirements, particularly for groups with high needs, and the realistic dietary intake under the prevailing circumstances, the use of complementary food supplements to increase a meal's nutrient content is recommended. This can be in the form of, e.g., micronutrient powder or low-dose lipid-based nutrient supplements, which can be provided for free, in return for vouchers, at subsidized, or at commercial prices.

Safety nets can help address the risks to nutrition from increasing climate variability

Models of climate change predict increased variability of weather as well as changes in agro-ecology. The increased variability will pose special challenges for nutrition. This study reviews evidence on climate shocks and nutrition and estimates the economic consequences in terms of reduced schooling and economic productivity stemming from nutritional insults in childhood. Panel data covering up to 20 y indicate that that short-term climate shocks have long-term impacts on children that persist, often into their adult lives. Other studies document the potential for relief programs to offset these shocks providing that the programs can be implemented with flexible financing, rapid identification of those affected by the shock, and timely scale-up. The last of these presumes that programs are already in place with contingency plans drawn up. Arguably, direct food distribution, including that of ready-to-use therapeutic food, may be part of the overall strategy. Even if such programs are too expensive for sustainable widespread use in the prevention of malnutrition, scalable food distribution programs may be cost effective to address the heightened risk of malnutrition following weather-related shocks.

The food, fuel, and financial crises affect the urban and rural poor disproportionately: a review of the evidence

The vulnerability of the urban poor to the recent food and fuel price crisis has been widely acknowledged. The unfolding global financial crisis, which brings higher unemployment and underemployment, is likely to further intensify this vulnerability. This paper reviews the evidence concerning the disproportionate vulnerability of the urban compared with the rural poor to these types of shocks. It reviews some of the unique characteristics of urban life that could make the urban poor particularly susceptible to price and financial shocks and summarizes the evidence regarding the disproportionate vulnerability of the urban poor. The focus is on impacts on poverty, food insecurity, and malnutrition. The review shows that although the urban poor are clearly one of the population groups most affected by the current (and previous) crises, the rural poor, landless, and net buyers are in no better position to confront the crisis without significant suffering. The poorest of the poor are the ones who will be most affected, irrespective of the continent, country, or urban or rural area where they live. The magnitude and severity of their suffering depends on their ability to adapt and on the specific nature, extent, and duration of the coping strategies they adopt. A better understanding of how these coping strategies are used and staggered is critical to help design triggers for action that can prevent households from moving to more desperate measures. Using these early coping strategies as early warning indicators could help prevent dramatic losses in welfare.

High food prices and the global financial crisis have reduced access to nutritious food and worsened nutritional status and health

A global economic and financial crisis is engulfing the developing world, coming on top of high food and fuel prices. This paper assesses the impact of the crises on food consumption, nutrition, and health. Several methods were applied, including risk analysis using the cost of the food basket, assessment surveys, simulations, regression analysis using a food consumption score (FCS), reflecting diet frequency and diversity, and a review of the impact of such dietary changes on nutritional status and health. The cost of the food basket increased in several countries, forcing households to reduce quality and quantity of food consumed. The FCS, which is a measure of diet diversity, is negatively correlated with food prices. Simulations show that energy consumption declined during 2006-2010 in nearly all developing regions, resulting potentially in an additional 457 million people (of 4.5 billion) at risk of being hungry and many more unable to afford the dietary quality required to perform, develop, and grow well. As a result of the crises, large numbers of vulnerable households have reduced the quality and quantity of foods they consume and are at risk of increased malnutrition. Population groups most affected are those with the highest requirements, including young children, pregnant and lactating women, and the chronically ill (particularly people with HIV/AIDS and tuberculosis). Because undernutrition during the first 2 y of life has life-long consequences, even short-term price rises will have long-term effects. Thus, measures to mitigate the impact of the crises are urgently required.

Low intake of vitamin A-rich foods among children, aged 12-35 months, in India: association with malnutrition, anemia, and missed child survival interventions

OBJECTIVE

To determine whether children in India who have a low intake of vitamin A-rich foods are at higher risk of malnutrition, anemia, and not receiving child health interventions.

METHODS

We analyzed data from the India National Family Health Survey, 2005-2006.

RESULTS

Of 17 847 children (41.9%), aged 12-35 months, 7020 did not receive vitamin A-rich foods, based on 24-h recall. The prevalence of stunting, severe stunting, underweight, and severe underweight among children who did and did not receive vitamin A-rich foods was, respectively, 52.5% versus 59.0%, 26.7% versus 32.9%, 43.8% versus 48.5%, and 17.9% versus 21.6% (all P<0.0001). Children who did not receive vitamin A-rich foods were more likely to be anemic, not have completed childhood immunizations, and not to have received vitamin A supplementation in the previous 6 mo (all P<0.0001). Maternal education of ≥10, 7-9, and 1-6 y, respectively, compared with no formal education was associated with the child receiving vitamin A-rich foods (odds ratio 1.41, 95% confidence interval 1.20-1,67, P<0.0001; odds ratio 1.20, 95% confidence interval 1.04-1.37, P=0.01; odds ratio 1.16, 95% confidence interval 1.02-1.32, P=0.02) in a multivariate logistic regression model adjusting for maternal age, household size, socioeconomic status, and location.

CONCLUSION

Children who did not receive vitamin A-rich foods were more likely to be malnourished and to have missed basic child health interventions, including vitamin A supplementation. Children were more likely to receive vitamin A-rich foods if their mothers had previously achieved higher primary or secondary education levels.