Micronutrient Status and Dietary Diversity of Women of Reproductive Age in Rural Pakistan

Consuming a diverse diet is essential to ensure an adequate intake of micronutrients. The aim of this study was to assess the nutritional status and dietary diversity of women of reproductive age (WRA) living in a marginalized community in rural Pakistan. Forty-seven WRA (35 ± 7 years old) who were not pregnant or lactating at enrollment, were recruited to participate in the study. Twenty-four-hour dietary recall interviews were conducted by the study nutritionist, and the data collected were used to create a minimum dietary diversity for women score (MDD-W) on five occasions during the monsoon and winter seasons (October to February). Nutritional status was assessed using anthropometry and biochemical markers of micronutrient status. Height and weight were used to determine body mass index (BMI), and mid-upper-arm circumference was measured. Plasma zinc, iron, and selenium concentrations were measured using inductively coupled mass spectrometry, and iron status was assessed using serum ferritin and blood hemoglobin concentrations. The mean (±SD) food group diversity score was 4 ± 1 with between 26% and 41% of participants achieving an MDD-W of 5. BMI was 27.2 ± 5.5 kg/m² with 28% obese, 34% overweight, and 6% underweight. The prevalence of zinc deficiency, based on plasma zinc concentration, was 29.8%; 17% of the participants had low plasma selenium levels; 8.5% were iron deficient; and 2% were suffering from iron deficiency anemia. The findings indicate that the women living in this community consume a diet that has a low diversity, consistent with a diet low in micronutrients, and that zinc deficiency is prevalent. Public health interventions aimed at increasing the dietary diversity of WRA are needed to improve the micronutrient intake, particularly of zinc, in this population.     

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24–59 months old; 1428 children 6–14 years old; and 1412 non-pregnant, non-lactating women. The study’s objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of fortification of key staple foods. The current intakes of several micronutrients, namely, iron, zinc, folate, vitamin A and vitamin B12, were found to be insufficient to meet the needs of Bangladesh’s children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.     

Food Fortification: The Advantages,Disadvantages and Lessons from Sight and Life Programs

Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A are widespread in low- and middle-income countries and compromise the physical and cognitive capacity of millions of people. Food fortification is a cost-effective strategy with demonstrated health, economic and social benefits. Despite ongoing debates globally and in some countries regarding the performance and safety of food fortification, the practice offers significant benefits across each of the main vehicles for food fortification (large-scale food fortification, biofortification and point-of-use or home fortification) ranging from reducing the prevalence of nutritional deficiencies and economic benefits to societies and economies. Using Sight and Life’s global and national experiences in implementing food fortification efforts, we demonstrate how different programs in LMICs have successfully addressed challenges with food fortification and in doing so, find that these efforts are most successful when partnerships are formed that include the public and private sector as well as other parties that can provide support in key areas such as advocacy, management, capacity building, implementation and regulatory monitoring.     

Poor Knowledge and Practices Related to Iodine Nutrition during Pregnancy and Lactation in Australian Women: Pre- and Post-Iodine Fortification

A before-after review was undertaken to assess whether knowledge and practices related to iodine nutrition, supplementation and fortification has improved in Australian women since the introduction of mandatory iodine fortification in 2009. Surveys of pregnant (n = 139) and non-pregnant (n = 75) women in 2007–2008 are compared with surveys of pregnant (n = 147) and lactating women (n = 60) one to two years post-fortification in a regional area of New South Wales, Australia. A self-administered questionnaire was completed and dietary intake of iodine was assessed using a validated food frequency questionnaire. A generally poor knowledge about the role and sources of iodine in the diet remained after fortification. Post-fortification, iodine-containing supplements were being taken by 60% (up from 20% pre-fortification) and 45% of pregnant and lactating women, respectively. Dairy foods were the highest contributors to dietary iodine intake (57%–62%). A low intake of fish and seafood resulted in this food group contributing only 3%–8% of total intake. A low level of public awareness regarding the role of iodine in health supports the need for public health strategies in addition to fortification, such as an accompanying consumer education campaign, increased uptake of supplementation, and on-going monitoring.     

Co-Occurrence of Overweight/Obesity,Anemia and Micronutrient Deficiencies among Non-Pregnant Women of Reproductive Age in Ghana: Results from a Nationally Representative Survey

Overweight/obesity (OWOB) often co-occurs with anemia or micronutrient deficiencies (MNDs) among women of reproductive age (WRA) in Ghana; identifying the risk factors of these conditions is essential for prevention. We aimed to examine the prevalence of OWOB, anemia, and MNDs and their co-occurrence and risk factors among non-pregnant women 15–49 years of age in Ghana. Data were from a 2017 two-stage national survey of 1063 women. We estimated the weighted prevalence of single and co-occurring malnutrition, and used logistic regression to explore risk factors. The prevalence of OWOB, anemia, and ≥1 MND was 39%, 22%, and 62%, respectively; that of OWOB co-occurring with anemia was 6.7%, and OWOB co-occurring with ≥1 MND was 23.6%. There was no significant difference between observed and expected prevalence of co-occurrence OWOB with anemia or MND. Risk factors were: living in southern (vs. northern) belt, high- (vs. low-) wealth household, being ≥ 25 years old, and being married (vs. single) for OWOB, and living in northern (vs. southern) belt and medium- (vs. low-) wealth household for anemia and ≥1 MND, respectively. Different interventions are required for addressing OWOB in WRA than those for anemia and MNDs.     

Driving Policy Change to Improve Micronutrient Status in Women of Reproductive Age and Children in Southeast Asia: The SMILING Project

Objective The SMILING (Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia) project aimed at creating awareness and improving policies around micronutrient deficiencies in five Southeast Asian countries (Vietnam, Laos, Thailand, Cambodia and Indonesia). Results The project showed large gaps in recent data on micronutrient status in most of the five countries. By updating existing, or creating national food composition tables, the SMILING project enabled analyses of food consumption in women of reproductive age and young children. Linear programming showed a high risk for multiple micronutrient deficiencies in these groups, and especially in pregnant women. Most programs to improve micronutrient status target iodine, iron and vitamin A deficiency. However, the high prevalence of zinc, vitamin D, thiamine and folate deficiency in the region warrant interventions too. For certain micronutrients (zinc, iron, calcium), dietary changes alone appeared not enough to fulfill requirements. Food fortification was identified to be a sustainable, long-term solution to improve micronutrient intake. Multiple criteria mapping by stakeholders in each country resulted in a list of country-specific priority interventions. Surprisingly, food fortification was ranked low, due to concerns on quality control and organoleptic changes of the fortified food. More advocacy is needed for new, innovative interventions such as delayed cord clamping. Conclusions for practice The SMILING project recommends regular surveys to monitor micronutrient status of population, to measure impact of interventions and to guide nutrition policies.

     

The BiZiFED project: Biofortified zinc flour to eliminate deficiency in Pakistan

Zinc deficiency is a global public health problem, affecting ~17% of the world's population, with the greatest burden in low‐ and middle‐income countries. An increasing body of evidence suggests that biofortification may be a cost‐effective and sustainable approach to reducing zinc and other micronutrient deficiencies. Biofortification enhances the nutritional quality of food crops through conventional plant breeding techniques and agronomic practices. This paper presents ongoing research on biofortification in Pakistan, where over 40% of women are zinc deficient. The Biofortified Zinc Flour to Eliminate Deficiency (BiZiFED) project aims to investigate the impact of biofortification as a strategy to alleviate zinc deficiency in Pakistan. The project is supported by the Biotechnology and Biological Sciences Research Council (BBSRC) Global Challenges Research Fund from May 2017 to April 2019. This paper outlines the four objectives and work packages within the BiZiFED project: (1) a double‐blind, randomised controlled trial to examine the effect of consuming flour made from a high zinc variety of biofortified wheat (Zincol‐2016/NR‐421) on dietary zinc intake and status; (2) a cost‐effectiveness study to assess the health and economic impact of agronomic biofortification of wheat; (3) a mixed methods study to explore the cultural acceptability and sustainability of biofortification in Pakistan; (4) capacity building and development of long‐term research partnerships in Pakistan. The findings will contribute to the evidence base for the potential impact of biofortification to alleviate zinc deficiency among the poorest communities.     

A review of the micronutrient intervention cost literature: program design and policy lessons

Since the 1993 publication of Disease Control Priorities in Developing Countries and World Development Report: Investing in Health, micronutrient fortification and supplementation interventions have been recognized as being among the most cost-effective public health interventions. This paper reviews nearly 100 studies of the cost of micronutrient interventions. The literature contains enormous variation in the estimated costs of these programs due to differences in program structure, delivery systems and a host of country-specific factors, differences in the studies' objectives, designs and costing methodologies. The most diverse estimates reported are those of vitamin A supplementation programs, where estimates vary by a factor of more than 1000. The costs of fortification programs, too, vary substantially from a factor of two for iodine, six for iron, and 15 for vitamin A fortification. As the magnitude of these variations suggests, the bulk of these studies are idiosyncratic, and their results are not directly comparable. The review highlights the need for greater specificity in discourse about these programs, and for greater transparency about cost estimation methods. The review provides several insights: (1) average costs are several-fold higher than has traditionally been maintained; (2) fortificants account for 80% of annual, incremental costs of vitamin A fortification; (3) whereas 70% of those of vitamin A supplementation programs are personnel; (4) the imprecision of food fortification coverage and impact estimates owes primarily to the paucity of food consumption data. Addressing the food consumption information gap is an essential next step to improving micronutrient program policies: to better targeting programs and to devising more cost-effective program portfolio mixes. Cost studies have a largely unrealized potential role to play in increasing program efficiency, coverage, and effectiveness.     

Implementing Preventive Iron-Folic Acid Supplementation Among Women of Reproductive Age in Some Western Pacific Countries: Possibilities and Challenges

Lack of effective implementation mechanisms is identified as a major obstacle in the prevention and control of iron-deficiency anemia. This paper discusses experiences gained from implementing iron-folic acid supplementation in the Philippines, Vietnam, and Cambodia. The understanding of contextual elements is proposed as a foundation for planning interventions. Moreover, it is suggested that a social marketing framework should provide a way of thinking about how to influence related behaviors. The application of a social marketing framework applied using a "5 P's" approach: public relations and collaboration, product, price, place, and promotion, is described, as well as enabling factors (possibilities) and inhibiting factors (challenges) of this approach. Although a program to improve iron nutrition among women of reproductive age may not be simple to implement, it is essential to enhancing health, human development, and economic advancement in developing countries.     

Government-Industry Partnership in Weekly Iron-Folic Acid Supplementation for Women of Reproductive Age in the Philippines: Impact on Iron Status

The effectiveness of weekly iron-folic acid supplements promoted through a government-industry partnership was assessed in pregnant and non-pregnant women in the Philippines. Compliance to both weekly and daily supplementation increased during the yearlong study period, but was highest with weekly supplementation. Serum ferritin and hematocrit increased significantly, whereas the hemoglobin level showed minimal change, probably because of lack of other heme-forming nutrients such as vitamin A. Serum ferritin increments were significantly higher in women taking the iron-folic acid supplements for more than 6 weeks. Weekly iron-folic acid supplementation should be recommended as a preventive strategy to control iron deficiency among reproductive-age women in the Philippines.     

Community Mobilization and Social Marketing to Promote Weekly Iron-Folic Acid Supplementation in Women of Reproductive Age in Vietnam: Impact on Anemia and Iron Status

The community mobilization and social marketing program promoting a preventive approach of weekly iron-folic acid supplementation in women of reproductive age improved iron status of non-pregnant women in Vietnam. Three to six months of weekly pre-pregnancy supplementation and regular weekly intake of supplements during pregnancy allowed women to achieve good iron and hemoglobin status during the two first trimesters of pregnancy. In the third trimester, iron deficiency and anemia were notably present but low birth weight prevalence was low. This demonstrates the effectiveness and safety of the preventive approach as implemented here to prevent and control iron deficiency and anemia in women of reproductive age before and during pregnancy.     

流动人口育龄妇女生殖健康知识的需求和就医情况调查

目的 了解乌鲁木齐市流动育龄妇女对生殖健康知识的需求和就医情况.方法 采用整群分层的方法,于2010年4月-2013年3月,对乌鲁木齐市6区1县流动人口较集中的社区共106 568例18～50岁的流动育龄妇女进行生殖健康服务的问卷调查.结果 按生殖健康知识的需求程度,居前三位的为妇女常见病防治（61.82％）、性生理知识（61.50％）及生殖道感染/性传播疾病防护知识（60.70％）;调查对象希望获得知识的途径依次是医务人员的健康检查（80.34％）、医院咨询门诊（74.94％）.调查对象在生殖健康方面如果“觉得不适”会就诊的比例为85.33％.结论 各医疗保健机构应积极为流动育龄妇女开展内容丰富的妇女生殖健康知识教育和服务.     

Community Mobilization and Social Marketing to Promote Weekly Iron-Folic Acid Supplementation: A New Approach Toward Controlling Anemia Among Women of Reproductive Age in Vietnam

Community-based social marketing and mobilization increased knowledge and participation in preventive weekly iron-folic acid supplementation among women of reproductive age in Vietnam. Rates of buying and taking the weekly supplement containing 60 mg elemental iron and 3.5 mg folic acid among non-pregnant women of reproductive age was between 55% and 92%. Free distribution to pregnant women of the weekly supplement containing 120 mg iron and 3.5 mg folic acid covered almost all pregnant women during the project. In developing countries where community women's groups and health networks are strong, preventive supplementation can be successfully promoted to encourage active participation in the prevention and control of iron-deficiency anemia.     

Association between Micronutrient Intake and Breast Cancer Risk According to Body Mass Index in South Korean Adult Women: A Cohort Study

This study investigated the association between micronutrient intake and breast cancer risk in South Korean adult women. This association was stratified according to body mass index (BMI) categories. Data from the Korean Genome and Epidemiology Study (KoGES) and the Health Examinee Study were analyzed. Altogether, 63,337 individuals (aged ≥40 years) completed the baseline and first follow-up surveys; 40,432 women without a history of cancer at baseline were included in this study. The association between micronutrient intake and breast cancer was determined by estimating the hazard ratio (HR) and 95% confidence interval (CI) using the Cox proportional hazard regression model. A stratified analysis by BMI (<25 kg/m² and ≥25 kg/m²) was performed. The an analysis of 15 micronutrients and breast cancer risk revealed that none of the micronutrients were associated with breast cancer risk after adjusting for covariates. In obese women, the risk of breast cancer was significantly reduced in the group that consumed vitamin C more than the recommended level (HR = 0.54, 95% CI: 0.31–0.93) and vitamin B6 levels above the recommended level (HR = 0.48, 95% CI: 0.25–0.89). In obese women, exceeding the recommended daily intake levels of vitamin C and vitamin B6 was associated with a lower risk of breast cancer. However, other micronutrients were not associated with breast cancer risk in these women.     

Effectiveness of Weekly Iron-Folic Acid Supplementation to Prevent and Control Anemia among Women of Reproductive Age in Three Asian Countries: Development of the Master Protocol and Implementation Plan

The master protocol for studying the impact and process of implementation of weekly iron-folic acid supplementation under program conditions is described. Pilot projects guided by the protocol were carried out in the Philippines, Vietnam, and Cambodia, where anemia rates are high and different socioeconomic and cultural conditions exist. Each country utilized the same supplement but adapted implementation processes to their specific conditions. Social marketing and community mobilization were considered to be essential tools for sustainability.     

Weekly Iron-Folic Acid Supplementation to Improve Iron Status and Prevent Pregnancy Anemia in Filipino Women of Reproductive Age: The Philippine Experience through Government and Private Partnership

With the participation of the government and private sectors in the Philippines, weekly iron-folic acid supplementation introduced within a social marketing framework and a social mobilization campaign successfully improved knowledge and practice of buying and regularly taking supplements by women of reproductive age, both pregnant and non-pregnant. Adolescent girls in school were also active participants.     

四川省农村育龄妇女避孕方法知情选择干预项目研究报告

目的:评价开展避孕节育知情选择活动对四川省农村育龄妇女的避孕节育知识和知情选择的知识、能力、态度和避孕行为等影响。方法:在四川省兴文县的2个乡开展持续1·5年的、以社区为基础、20~49岁的已婚育龄妇女为对象的干预性研究,干预活动包括组织社区宣传活动、发放宣传资料、播放录像带、组织讲座、面对面的宣传和开展同伴教育,分析干预效果。结果:干预组育龄妇女对避孕方法的使用、原理、优点、缺点得分明显高于对照组,且在干预后避孕方法使用率及使用避孕套的比例均高于干预前;避孕方法使用的最终决定者由干预前计划生育服务人员转变为干预后为本人。结论:集知识、信息、咨询与服务为一体的社区避孕节育知情选择干预项目的实施,可显著提高农村育龄妇女的避孕节育知识水平和她们选择避孕方法的能力。     

Lentil and Kale: Complementary Nutrient-Rich Whole Food Sources to Combat Micronutrient and Calorie Malnutrition

Lentil (Lens culinaris Medik.) is a nutritious food and a staple for millions of people. Not only are lentils a good source of energy, they also contain a range of micronutrients and prebiotic carbohydrates. Kale (Brassica oleracea v. acephala) has been considered as a health food, but its full range of benefits and composition has not been extensively studied. Recent studies suggest that foods are enrich in prebiotic carbohydrates and dietary fiber that can potentially reduce risks of non-communicable diseases, including obesity, cancer, heart disease, and diabetes. Lentil and kale added to a cereal-based diet would enhance intakes of essential minerals and vitamins to combat micronutrient malnutrition. This review provides an overview of lentil and kale as a complementary nutrient-rich whole food source to combat global malnutrition and calorie issues. In addition, prebiotic carbohydrate profiles and the genetic potential of these crops for further micronutrient enrichment are briefly discussed with respect to developing sustainable and nutritious food systems.