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Gorham G, Howard K, Zhao Y, Ahmed AMS, Lawton PD, Sajiv C, Majoni SW, Wood P, Conlon T, Signal S, Robinson SL, Brown S, Cass A. Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis. BMC Nephrol 2019; 20:231. [PMID: 31238898 PMCID: PMC6593509 DOI: 10.1186/s12882-019-1421-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT). METHODS We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars. RESULTS There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies. CONCLUSION The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.
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Affiliation(s)
- G Gorham
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.
| | - K Howard
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Y Zhao
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | | | - P D Lawton
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - C Sajiv
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia.,Flinders University Northern Territory Medical Program, Darwin, Northern Territory, Australia
| | - S W Majoni
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.,Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia.,Flinders University Northern Territory Medical Program, Darwin, Northern Territory, Australia
| | - P Wood
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - T Conlon
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S Signal
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S L Robinson
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S Brown
- Western Desert Nganampa Walytja Palyantjaku Tjutaku Northern Territory, Alice Springs, Australia
| | - A Cass
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
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Nelson MI, Mahfuz M, Chhabra P, Haque R, Seidman JC, Hossain I, McGrath M, Ahmed AMS, Knobler S, Vinjé J, Ahmed T. Genetic Diversity of Noroviruses Circulating in a Pediatric Cohort in Bangladesh. J Infect Dis 2018; 218:1937-1942. [PMID: 30053045 PMCID: PMC6217719 DOI: 10.1093/infdis/jiy454] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/20/2018] [Indexed: 01/02/2023] Open
Abstract
Noroviruses are a leading cause of diarrhea in children aged <5 years worldwide. We genotyped 88 viruses collected by active surveillance in a birth cohort of children <2 years of age in Dhaka, Bangladesh, during 2010-2013. Twenty-five of 31 (81%) established GI and GII genotypes were detected, with GII.4 as the predominant genotype (20%). Our results show that children in Bangladesh are infected with a great diversity of norovirus strains. Reinfections are common, but not with closely related genotypes. Birth cohort studies are critical to understand cross-protective immunity and advance the development of pediatric norovirus vaccines.
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Affiliation(s)
- Martha I Nelson
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka
| | - Preeti Chhabra
- Centers for Disease Control and Prevention, Atlanta, Georgia
- Synergy, Atlanta, Georgia
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka
| | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Iqbal Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka
| | - Monica McGrath
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - A M Shamsir Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka
| | - Stacey Knobler
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Jan Vinjé
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka
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Sanin KI, Islam MM, Mahfuz M, Ahmed AMS, Mondal D, Haque R, Ahmed T. Micronutrient adequacy is poor, but not associated with stunting between 12-24 months of age: A cohort study findings from a slum area of Bangladesh. PLoS One 2018; 13:e0195072. [PMID: 29596493 PMCID: PMC5875860 DOI: 10.1371/journal.pone.0195072] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/16/2018] [Indexed: 12/04/2022] Open
Abstract
The prevalence of stunting among children below 5 years of age is higher in the slum-dwelling population of Bangladesh compared to that in both urban and rural areas. Studies have reported that several factors such as inadequate nutrition, low socio-economic status, poor hygiene and sanitation and lack of maternal education are the substantial predictors of childhood stunting. Almost all these factors are universally present in the slum-dwelling population of Bangladesh. However, few studies have prospectively examined such determinants of stunting among slum populations. In this paper, we reveal the findings of a cohort study with an aim to explore the status of micronutrient adequacy among such vulnerable children and establish its association with stunting along with other determinants. Two-hundred-sixty-five children were enrolled and followed since birth until 24 months of age. We collected anthropometric, morbidity and dietary intake data monthly. We used the 24-hour multiple-pass recall approach to collect dietary intake data from the age of 9 months onward. Micronutrient adequacy of the diet was determined by the mean adequacy ratio (MAR) which was constructed from the average intake of 9 vitamins and 4 minerals considered for the analysis. We used generalized estimating equation (GEE) regression models to establish the determinants of stunting between 12–24 months of age in our study population. The prevalence of low-birth-weight (LBW) was about 28.7% and approximately half of the children were stunted by the age of 24 months. The average micronutrient intake was considerably lower than the recommended dietary allowance and the MAR was only 0.48 at 24 months of age compared to the optimum value of 1. However, the MAR was not associated with stunting between 12–24 months of age. Rather, LBW was the significant determinant (AOR = 3.03, 95% CI: 1.69–5.44) after adjusting for other factors such as age (AOR = 2.12, 95% CI: 1.45–3.11 at 24 months and AOR = 1.97, 95% CI: 1.49–2.59 at 18 months, ref: 12 months) and sex (AOR = 1.98, 95% CI: 1.17–3.33, ref: female). Improving the nutritional quality of complementary food in terms of adequacy of micronutrients is imperative for optimum growth but may not be adequate to mitigate under-nutrition in this setting. Further research should focus on identifying multiple strategies that can work synergistically to diminish the burden of stunting in resource-poor settings.
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Affiliation(s)
- Kazi Istiaque Sanin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M. Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Dinesh Mondal
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rashidul Haque
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Das J, Shamsir Ahmed AM, Ahmed S, Chisti MJ, Golam FaruqueSyed AS, Das SK. The effect of a newly established urban diarrhea treatment facility in Bangladesh: Changing patient characteristics and etiologies. Indian J Public Health 2018; 62:47-51. [PMID: 29512565 DOI: 10.4103/ijph.ijph_374_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Mirpur treatment centre (MTC), Dhaka of the International Centre for Diarrhoeal Disease Research, Bangladesh, was established as a consequence of an outbreak of diarrheal disease during the summer month of April 2007 in Mirpur area. Objective The present study aimed to evaluate the impact of this new facility on patient load, common etiology, and other characteristics of patient population who sought treatment at Dhaka Hospital. Methods As part of the Diarrheal Disease Surveillance System (DDSS), 10% patients (every 10th) seeking care irrespective of age, sex, sociodemographic background, and severity of disease were enrolled at MTC as opposed to 2% (every 50th) at Dhaka Hospital following identical methodology from 2010 to 2013. Moreover, enrolled DDSS patients from 2005 to 2009 at Dhaka Hospital were also included in analysis to further examine the impact of MTC on Dhaka Hospital. Results Patient load from Mirpur area attending the Dhaka Hospital reduced from 13% during epidemic in 2010 to 6% in 2013 (53% reduction), whereas attendance in MTC increased substantially by 33%. This changing trend was also observed among children <5 years old. A significant reduction of patients presenting with moderately severe disease from Mirpur area at Dhaka Hospital was observed (69% reduction); however, attendance at MTC increased by 26% during same period. Conclusion The number of patients from Mirpur area in Dhaka Hospital reduced but increased at MTC explaining the need for establishment of a set up for early treatment and control of diarrheal disease when consistent increase in annual number of cases or at the time of upsurge of cases is observed.
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Affiliation(s)
- Jui Das
- Research Assistant, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
| | - A M Shamsir Ahmed
- Epidemiologist, Menzies School of Health Research, Darwin, Brisbane, Australia
| | - Shahnawaz Ahmed
- Assistant Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
| | - Mohammod Jobayer Chisti
- Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
| | - Abu Syed Golam FaruqueSyed
- Consultant, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, (icddr,b), Bangladesh
| | - Sumon Kumar Das
- Associate Scientist, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh (icddr,b); PhD Candidature, Institute for Social Science Research, The University of Queensland, Brisbane, Australia
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Islam MM, Sanin KI, Mahfuz M, Ahmed AMS, Mondal D, Haque R, Ahmed T. Risk factors of stunting among children living in an urban slum of Bangladesh: findings of a prospective cohort study. BMC Public Health 2018; 18:197. [PMID: 29378556 PMCID: PMC5789576 DOI: 10.1186/s12889-018-5101-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 01/19/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Bangladesh is one of the 20 countries with highest burden of stunting globally. A large portion (around 2.2 million) of the population dwells in the slum areas under severe vulnerable conditions. Children residing in the slums are disproportionately affected with higher burden of undernutrition particularly stunting. In this paper, findings of a prospective cohort study which is part of a larger multi-country study are presented. METHODS Two hundred and sixty five children were enrolled and followed since their birth till 24 months of age. Anthropometric measurements, dietary intake and morbidity information were collected monthly. Data from 9 to 12, 15-18 and 21-24 months were collated to analyze and report findings for 12, 18 and 24 months of age. Generalized estimating equation models were constructed to determine risk factors of stunting between 12 and 24 months of age. RESULT Approximately, 18% of children were already stunted (LAZ < -2SD) at birth and the proportion increased to 48% at 24 months of age. Exclusive breastfeeding prevalence was only 9.4% following the WHO definition at 6 months. Dietary energy intake as well as intakes of carbohydrate, fat and protein were suboptimal for majority of the children. However, in regression analysis, LAZ at birth (AOR = 0.40, 95% CI: 0.26, 0.61), household with poor asset index (AOR = 2.81, 95% CI: 1.43, 5.52; ref.: average asset index), being male children (AOR = 1.75, 95% CI: 1.04, 2.95; ref.: female) and age (AOR = 2.34, 95% CI: 1.56, 3.52 at 24 months, AOR = 2.13, 95% CI: 1.55, 2.92 at 18 months; ref.: 12 months of age) were the significant predictors of stunting among this population. CONCLUSION As the mechanism of stunting begins even before a child is born, strategies must be focused on life course approach and preventive measurement should be initiated during pregnancy. Alongside, government and policymakers have to develop sustainable strategies to improve various social and environmental factors those are closely interrelated with chronic undernutrition particularly concentrating on urban slum areas.
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Affiliation(s)
- M. Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Kazi Istiaque Sanin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | | | - Dinesh Mondal
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Rashidul Haque
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
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Milton AH, Attia J, Alauddin M, McEvoy M, McElduff P, Hussain S, Akhter A, Akter S, Islam MM, Ahmed AMS, Iyengar V, Islam MR. Assessment of Nutritional Status of Infants Living in Arsenic-Contaminated Areas in Bangladesh and Its Association with Arsenic Exposure. Int J Environ Res Public Health 2018; 15:ijerph15010057. [PMID: 29301293 PMCID: PMC5800156 DOI: 10.3390/ijerph15010057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 12/26/2017] [Accepted: 12/27/2017] [Indexed: 11/16/2022]
Abstract
Data is scarce on early life exposure to arsenic and its association with malnutrition during infancy. This study followed the nutritional status of a cohort of 120 infants from birth to 9 months of age in an arsenic contaminated area in Bangladesh. Anthropometric data was collected at 3, 6 and 9 months of the infant's age for nutritional assessment whereas arsenic exposure level was assessed via tube well drinking water arsenic concentration at the initiation of the study. Weight and height measurements were converted to Z-scores of weight for age (WAZ-underweight), height for age (HAZ-stunting), weight for height (WHZ-wasting) for children by comparing with WHO growth standard. Arsenic exposure levels were categorized as <50 μg/L and ≥50 μg/L. Stunting rates (<-2 SD) were 10% at 3 months and 44% at both 6 and 9 months. Wasting rates (<-2 SD) were 23.3% at 3 months and underweight rates (<-2 SD) were 25% and 10% at 3 and 6 months of age, respectively. There was a significant association of stunting with household drinking water arsenic exposure ≥50 μg/L at age of 9 months (p = 0.009). Except for stunting at 9 months of age, we did not find any significant changes in other nutritional indices over time or with levels of household arsenic exposure in this study. Our study suggests no association between household arsenic exposure and under-nutrition during infancy; with limiting factors being small sample size and short follow-up. Difference in stunting at 9 months by arsenic exposure at ≥50 μg/L might be a statistical incongruity. Further longitudinal studies are warranted to establish any association.
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Affiliation(s)
- Abul Hasnat Milton
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
| | - John Attia
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
| | - Mohammad Alauddin
- Department of Chemistry, Wagner College, 1 Campus Road, Staten Island, NY 10301, USA.
| | - Mark McEvoy
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
| | - Patrick McElduff
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
| | - Sumaira Hussain
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
| | - Ayesha Akhter
- Goulburn Valley Health, Graham Street, Shepparton, VIC 3630, Australia.
| | - Shahnaz Akter
- Department of Paediatrics, Institute of Child and Mother Health, Matuail, Dhaka 1212, Bangladesh.
| | - M Munirul Islam
- International Centre for Diarrhoeal Diseases Research, Mohakhali, Dhaka 1212, Bangladesh.
| | - A M Shamsir Ahmed
- International Centre for Diarrhoeal Diseases Research, Mohakhali, Dhaka 1212, Bangladesh.
| | - Vasu Iyengar
- Goulburn Valley Health, Graham Street, Shepparton, VIC 3630, Australia.
- Department of Rural Health, University of Melbourne, Graham Street, Shepparton, VIC 3630, Australia.
- School of Health and Social Development, Deakin University, VIC 3125, Australia.
| | - Md Rafiqul Islam
- Centre for Clinical Epidemiology & Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Kookaburra Close, New Lambton Heights, NSW 2305, Australia.
- Goulburn Valley Health, Graham Street, Shepparton, VIC 3630, Australia.
- Department of Rural Health, University of Melbourne, Graham Street, Shepparton, VIC 3630, Australia.
- School of Health and Social Development, Deakin University, VIC 3125, Australia.
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7
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Mahfuz M, Alam MA, Islam MM, Mondal D, Hossain MI, Ahmed AMS, Choudhury N, Raihan MJ, Haque R, Ahmed T. Effect of micronutrient powder supplementation for two and four months on hemoglobin level of children 6–23 months old in a slum in Dhaka: a community based observational study. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0061-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ahmed AMS, Soares Magalhaes RJ, Long KZ, Ahmed T, Alam MA, Hossain MI, Islam MM, Mahfuz M, Mondal D, Haque R, Mamun AA. Association of vitamin D status with incidence of enterotoxigenic, enteropathogenic and enteroaggregative Escherichia coli diarrhoea in children of urban Bangladesh. Trop Med Int Health 2016; 21:973-984. [PMID: 27253178 DOI: 10.1111/tmi.12731] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the association between vitamin D status and diarrhoeal episodes by enterotoxigenic (ETEC), enteropathogenic (EPEC) and enteroaggregative (EAEC) E. coli in underweight and normal-weight children aged 6-24 months in urban Bangladesh. METHODS Cohorts of 446 normal-weight and 466 underweight children were tested separately for ETEC, EPEC and EAEC from diarrhoeal stool samples collected during 5 months of follow-up while considering vitamin D status at enrolment as the exposure. Cox proportional hazards models with unordered failure events of the same type were used to determine diarrhoeal risk factors after adjusting for sociodemographic and concurrent micronutrient status. RESULTS Vitamin D status was not independently associated with the risk of incidence of ETEC, EPEC and EAEC diarrhoea in underweight children, but moderate-to-severe retinol deficiency was associated with reduced risk for EPEC diarrhoea upon adjustment. Among normal-weight children, insufficient vitamin D status and moderate-to-severe retinol deficiency were independently associated with 44% and 38% reduced risk of incidence of EAEC diarrhoea, respectively. These children were at higher risk of ETEC diarrhoea with vitamin D deficiency status when adjusted for micronutrient status only. CONCLUSION This study demonstrates for the first time that normal-weight children with insufficient vitamin D status have a reduced risk of EAEC diarrhoea than children with sufficient status. Moderate-to-severe deficiency of serum retinol is associated with reduced risk of EPEC and EAEC diarrhoea in underweight and normal-weight children.
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Affiliation(s)
- A M S Ahmed
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia.,Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - R J Soares Magalhaes
- School of Veterinary Science, The University of Queensland, Gatton, Qld, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Qld, Australia
| | - K Z Long
- Child Health Research Centre, The University of Queensland, Brisbane, Qld, Australia.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - T Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md A Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md I Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md M Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - M Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - D Mondal
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - R Haque
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - A A Mamun
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia.,Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Ahmed AMS, Magalhaes RJS, Ahmed T, Long KZ, Hossain M, Islam MM, Mahfuz M, Gaffar SMA, Sharmeen A, Haque R, Guerrant RL, Petri WA, Mamun AA. Vitamin-D status is not a confounder of the relationship between zinc and diarrhoea: a study in 6-24-month-old underweight and normal-weight children of urban Bangladesh. Eur J Clin Nutr 2016; 70:620-8. [PMID: 26956127 DOI: 10.1038/ejcn.2016.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/23/2015] [Accepted: 11/26/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVE The role of micronutrients particularly zinc in childhood diarrhoea is well established. Immunomodulatory functions of vitamin-D in diarrhoea and its role in the effect of other micronutrients are not well understood. This study aimed to investigate whether vitamin-D directly associated or confounded the association between other micronutrient status and diarrhoeal incidence and severity in 6-24-month underweight and normal-weight children in urban Bangladesh. SUBJECTS/METHODS Multivariable generalised estimating equations were used to estimate incidence rate ratios for incidence (Poisson) and severity (binomial) of diarrhoea on cohorts of 446 normal-weight and 466 underweight children. Outcomes of interest included incidence and severity of diarrhoea, measured daily during a follow-up period of 5 months. The exposure of interest was vitamin-D status at enrolment. RESULTS Normal-weight and underweight children contributed 62 117 and 62 967 day observation, with 14.2 and 12.8 days/child/year of diarrhoea, respectively. None of the models showed significant associations of vitamin-D status with diarrhoeal morbidity. In the final model, zinc-insufficient normal-weight children had 1.3 times more days of diarrhoea than sufficient children (P<0.05). Again zinc insufficiency and mother's education (1-5 and >5 years) had 1.8 and 2.3 times more risk of severe diarrhoea. In underweight children, older age and female had 24-63 and 17% fewer days of diarrhoea and 52-54 and 31% fewer chances of severe diarrhoea. CONCLUSION Vitamin-D status was not associated with incidence and severity of diarrhoea in study children. Role of zinc in diarrhoea was only evident in normal-weight children. Our findings demonstrate that vitamin-D is not a confounder of the relationship between zinc and diarrhoea.
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Affiliation(s)
- A M S Ahmed
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia.,Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - R J S Magalhaes
- School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - T Ahmed
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K Z Long
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - MdI Hossain
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M M Islam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Mahfuz
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - S M A Gaffar
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - A Sharmeen
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - R Haque
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - R L Guerrant
- Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - W A Petri
- Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - A A Mamun
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia.,Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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10
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Das SK, Chisti MJ, Ahmed AMS, Malek MA, Ahmed S, Shahunja KM, Ferdous F, Farzana FD, Das J, Rahman A, Al Mamun A, Faruque ASG. Diarrhoea and smoking: an analysis of decades of observational data from Bangladesh. BMC Public Health 2015; 15:646. [PMID: 26164796 PMCID: PMC4499450 DOI: 10.1186/s12889-015-1906-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 06/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although cigarette smoking affects all biological systems of the human body including the gastrointestinal tract, there is a lack of evidence regarding its effect on the severity of diarrhoeal disease and whether a dose-response relationship exists. We therefore tested for the presence of specific causative pathogens for infectious diarrhoea, assessed the independent effect of smoking on its severity and tested whether any dose-response relationship existed while controlling for subjects' age, sociodemographic characteristics and presence of causative pathogens in an urban setting in Bangladesh. METHODS A total of 20,757 patients aged 15 years and above with diarrhoea were enrolled into the Diarrhoeal Disease Surveillance System, managed by the International Centre for Diarrhoeal Disease Research, Bangladesh, from 1993 to 2012. We collected data on individuals' current daily consumption of cigarettes and bidis (traditional hand-rolled cigarettes) and conducted an ordered logistic regression to determine the effect of smoking on diarrhoeal disease severity and whether a dose-response relationship exists. RESULTS We identified 19 % of patients with diarrhoea as smokers, of whom 52 % smoked 1-9 cigarettes per day. While 97 % of smokers were male, 41 % were aged 15-30 years of age. Smokers were found to have a significantly lower severity of diarrhoeal disease (OR: 0.92, 95 % CI: 0.85-0.99, p = 0.025) after adjusting for age, wealth quintile, illiteracy and the presence of specific causative pathogens (Vibrio cholerae and Shigella). We observed no dose-response relationship between the number of cigarettes smoked per day and disease severity when adjusting for the same covariates. Smokers were more frequently infected with Shigella (7 vs. 6 %, p < 0.001) and less often with Vibrio cholerae (22 vs. 26 %, p < 0.001) than their non-smoking counterparts. CONCLUSIONS The aetiology and severity of diarrhoeal disease differed between smokers and non-smokers in our sample. However, we found no dose-response relationship between disease severity and the number of cigarettes smoked per day.
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Affiliation(s)
- Sumon Kumar Das
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. .,School of Public Health, The University of Queensland, Brisbane, Australia.
| | - Mohammod Jobayer Chisti
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - A M Shamsir Ahmed
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. .,School of Public Health, The University of Queensland, Brisbane, Australia.
| | - Mohammad Abdul Malek
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Shahnawaz Ahmed
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - K M Shahunja
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Farzana Ferdous
- Department of Clinical Trial and Clinical Epidemiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan.
| | - Fahmida Dil Farzana
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Jui Das
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Aminur Rahman
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Abdullah Al Mamun
- School of Public Health, The University of Queensland, Brisbane, Australia.
| | - Abu Syed Golam Faruque
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
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11
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Patil CL, Turab A, Ambikapathi R, Nesamvuni C, Chandyo RK, Bose A, Islam MM, Ahmed AMS, Olortegui MP, de Moraes ML, Caulfield LE. Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study. J Health Popul Nutr 2015; 34:10. [PMID: 26825923 PMCID: PMC5025973 DOI: 10.1186/s41043-015-0004-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/24/2015] [Indexed: 05/25/2023]
Abstract
We report the infant feeding experiences in the first month of life for 2,053 infants participating in "Malnutrition and Enteric Infections: Consequences for Child Health and Development" (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.
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Affiliation(s)
- Crystal L Patil
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
| | - Ali Turab
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Ramya Ambikapathi
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.
| | - Cebisa Nesamvuni
- Department of Nutrition, School of Health Sciences, University of Venda, Thohoyandou, Limpopo Province, South Africa.
| | - Ram Krishna Chandyo
- Centre for International Health, University of Bergen, Norway and Department of Child Health and Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | | | - M Munirul Islam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | | | | | - Milena Lima de Moraes
- The Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, W2041, Baltimore, MD, USA, 21205.
| | - Laura E Caulfield
- The Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, W2041, Baltimore, MD, USA, 21205.
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12
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Ahmed T, Mahfuz M, Ireen S, Ahmed AMS, Rahman S, Islam MM, Alam N, Hossain MI, Rahman SMM, Ali MM, Choudhury FP, Cravioto A. Nutrition of children and women in Bangladesh: trends and directions for the future. J Health Popul Nutr 2012; 30:1-11. [PMID: 22524113 PMCID: PMC3312353 DOI: 10.3329/jhpn.v30i1.11268] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Although child and maternal malnutrition has been reduced in Bangladesh, the prevalence of underweight (weight-for-age z-score <-2) among children aged less than five years is still high (41%). Nearly one-third of women are undernourished with body mass index of <18.5 kg/m2. The prevalence of anaemia among young infants, adolescent girls, and pregnant women is still at unacceptable levels. Despite the successes in specific programmes, such as the Expanded Programme on Immunization and vitamin A supplementation, programmes for nutrition interventions are yet to be implemented at scale for reaching the entire population. Given the low annual rate of reduction in child undernutrition of 1.27 percentage points per year, it is unlikely that Bangladesh would be able to achieve the United Nations' Millennium Development Goal to address undernutrition. This warrants that the policy-makers and programme managers think urgently about the ways to accelerate the progress. The Government, development partners, non-government organizations, and the academia have to work in concert to improve the coverage of basic and effective nutrition interventions, including exclusive breastfeeding, appropriate complementary feeding, supplementation of micronutrients to children, adolescent girls, pregnant and lactating women, management of severe acute malnutrition and deworming, and hygiene interventions, coupled with those that address more structural causes and indirectly improve nutrition. The entire health system needs to be revitalized to overcome the constraints that exist at the levels of policy, governance, and service-delivery, and also for the creation of demand for the services at the household level. In addition, management of nutrition in the aftermath of natural disasters and stabilization of prices of foods should also be prioritized.
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Affiliation(s)
- Tahmeed Ahmed
- Centre for Nutrition and Food Security, icddr,b, GPO Box 128, Dhaka 1000, Bangladesh.
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13
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Alam N, Roy SK, Ahmed T, Ahmed AMS. Nutritional status, dietary intake, and relevant knowledge of adolescent girls in rural Bangladesh. J Health Popul Nutr 2010; 28:86-94. [PMID: 20214090 PMCID: PMC2975850 DOI: 10.3329/jhpn.v28i1.4527] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This study estimated the levels and differentials in nutritional status and dietary intake and relevant knowledge of adolescent girls in rural Bangladesh using data from the Baseline Survey 2004 of the National Nutrition Programme. A stratified two-stage random cluster-sampling was used for selecting 4,993 unmarried adolescent girls aged 13-18 years in 708 rural clusters. Female interviewers visited girls at home to record their education, occupation, dietary knowledge, seven-day food-frequency, intake of iron and folic acid, morbidity, weight, and height. They inquired mothers about age of their daughters and possessions of durable assets to divide households into asset quintiles. Results revealed that 26% of the girls were thin, with body mass index (BMI)-for-age <15th percentile), 0.3% obese (BMI-for-age >95th percentile), and 32% stunted (height-for-age < or = 2SD). Risks of being thin and stunted were higher if girls had general morbidity in the last fortnight and foul-smelling vaginal discharge than their peers. Consumptions of non-staple good-quality food items in the last week were less frequent and correlated well positively with the household asset quintile. Girls of the highest asset quintile ate fish/meat 2.1 (55%) days more and egg/milk two (91%) days more than the girls in the lowest asset quintile. The overall dietary knowledge was low. More than half could not name the main food sources of energy and protein, and 36% were not aware of the importance of taking extra nutrients during adolescence for growth spurt. The use of iron supplement was 21% in nutrition-intervention areas compared to 8% in non-intervention areas. Factors associated with the increased use of iron supplements were related to awareness of the girls about extra nutrients and their access to mass media and education. Community-based adolescent-friendly health and nutrition education and services and economic development may improve the overall health and nutritional knowledge and status of adolescents.
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Affiliation(s)
- Nurul Alam
- Public Health Sciences Division, ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh.
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14
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Affiliation(s)
- Tahmeed Ahmed
- Mainstreaming Nutrition Initiative, Nutrition Programme, International Centre for Diarrhoeal Disease Research, Bangladesh.
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Faruque ASG, Ahmed AMS, Ahmed T, Islam MM, Hossain MI, Roy SK, Alam N, Kabir I, Sack DA. Nutrition: basis for healthy children and mothers in Bangladesh. J Health Popul Nutr 2008; 26:325-39. [PMID: 18831228 PMCID: PMC2740711 DOI: 10.3329/jhpn.v26i3.1899] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR,B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984-2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR,B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR,B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peer-counselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR,B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR,B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place.
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Affiliation(s)
- A S G Faruque
- Clinical Sciences Division, ICDDR,B, GPO Box 128, Dhaka 1000, Mohakhali, Bangladesh.
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