Willingness to pay for small‐quantity lipid‐based nutrient supplements for women and children: Evidence from Ghana and Malawi

Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) are designed to enrich maternal and child diets with the objective of preventing undernutrition during the first 1,000 days. Scaling up the delivery of supplements such as SQ‐LNS hinges on understanding private demand and creatively leveraging policy‐relevant factors that might influence demand. We used longitudinal stated willingness‐to‐pay (WTP) data from contingent valuation studies that were integrated into randomized controlled nutrition trials in Ghana and Malawi to estimate private valuation of SQ‐LNS during pregnancy, postpartum, and early childhood. We found that average stated WTP for a day's supply of SQ‐LNS was more than twice as high in Ghana than Malawi, indicating that demand for SQ‐LNS (and by extension, the options for effective delivery of SQ‐LNS) may be very context specific. We also examined factors associated with WTP, including intervention group, household socioeconomic status, birth outcomes, child growth, and maternal and child morbidity. In both sites, WTP was consistently negatively associated with household food insecurity, indicating that subsidization might be needed to permit food insecure households to acquire SQ‐LNS if it is made available for purchase. In Ghana, WTP was higher among heads of household than among mothers, which may be related to control over household resources. Personal experience using SQ‐LNS was not associated with WTP in either site.     

Adherence to recommendations on lipid‐based nutrient supplement and iron and folic acid tablet consumption among pregnant and lactating women participating in a community health programme in northwest Bangladesh

Limited knowledge exists on sustained adherence to small‐quantity lipid‐based nutrient supplements for pregnant and lactating women (LNS‐PL) and how this compares with that of other prenatal supplements. To address these gaps, a random subsample of women (n = 360) during pregnancy, early (6‐ to 12‐week post‐partum) and late (12‐ to 24‐week post‐partum) lactation, from an ongoing effectiveness trial in Bangladesh, was selected for in‐home interviews about LNS‐PL or iron/folic acid (IFA) use and preferences. Prevalence of high adherence (≥70% of the recommendation) based on self‐reported supplement consumption was 67%, 68% and 81% among LNS‐PL recipients during pregnancy, early and late lactation, and was 87% and 71% among IFA recipients during pregnancy and early lactation, respectively (P = 0.044). Programmatic factors (e.g. distribution and visits by programme staff) were consistently statistically significantly associated with reported high adherence. Among LNS‐PL recipients, high overall supplement acceptability score [odds ratio (OR): 8.62; 95% confidence interval (CI) 3.53, 20.83] and use of reminder techniques (OR: 4.41; 95%CI 1.65, 11.76) were positively associated, and reported vomiting at enrollment was negatively associated (OR: 0.34; 95%CI 0.14, 0.80), with reported high adherence. Selected women (n = 16) and key informants (n = 18) participated in in‐depth interviews about perceptions and acceptability of LNS‐PL. Women perceived benefits of taking LNS‐PL, but some faced barriers to consumption including aversion to odour and taste during pregnancy, forgetfulness and disruptions in supply. To achieve high adherence, results from this study suggest that maternal supplementation programmes should focus on programmatic barriers and consider incorporating reminder techniques. Organoleptic acceptability of LNS‐PL, particularly during pregnancy, may also need to be addressed.     

Effects of lipid‐based nutrient supplements or multiple micronutrient supplements compared with iron and folic acid supplements during pregnancy on maternal haemoglobin and iron status

We examined the effect of three types of prenatal supplements containing different amounts of iron on haemoglobin (Hb) and iron status (zinc protoporphyrin [ZPP] and soluble transferrin receptor [sTfR]) in late pregnancy among 1,379 women in rural Malawi. Participants were recruited at ≤20 gestational weeks (gw) and randomly assigned to consume daily (1) 60‐mg iron and folic acid (IFA); (2) 20‐mg iron plus 17 micronutrients in a capsule (MMN); or (3) lipid‐based nutrient supplement (LNS; 118 kcal) with 20‐mg iron plus 21 micronutrients, protein, and fat. We analysed differences between intervention groups in mean Hb, ZPP, and sTfR at 36 gw, and the proportion with anaemia (Hb < 100 g L^?1) and iron deficiency (ZPP > 60 μmol mol^?1 haem or sTfR > 6 mg L^?1) at 36 gw. Women in the IFA group had higher Hb at 36 gw than women in the LNS group (P = 0.030) and higher iron status (lower ZPP and sTfR) than women in both the LNS (P < 0.001 for both ZPP and sTfR) and MMN (P = 0.025 and P = 0.046) groups. Results for anaemia and iron deficiency showed similar trends. Further research is needed to elucidate the appropriate amount of iron to improve Hb and iron status, while improving birth outcomes.     

Responsive feeding and child interest in food vary when rural Malawian children are fed lipid‐based nutrient supplements or local complementary food

Caregiver and child behaviours during feeding have been used to measure responsiveness, which has been recognised as important for child growth and development. The aims of this study were to understand how caregiver and child behaviours differ when feeding lipid‐based nutrient supplements (LNS) vs. local complementary food and to detect associations between behaviours and child interest in food. Sixteen moderately underweight 6–17‐month‐old Malawian children receiving 50 g/day of supplementary LNS for 12 weeks were videotaped during LNS (n = 32) and local complementary feeding (n = 28) episodes. Behaviours were coded at the level of the intended bite (1674 total bites). The analysis used regression models adjusted for within‐subject correlation. Caregivers were less likely to allow children to self‐feed and more likely to use physical pressure during LNS vs. complementary food bites. Positive caregiver verbalization was infrequent and did not differ by type of food. Higher odds of accepting a bite were associated with the bite containing LNS, odds ratio (OR) 3.05; 90% confidence interval (CI) (1.98, 4.71), the child self‐feeding, OR 5.70; 90% CI (2.77, 11.69), and positive caregiver verbalization, OR 2.46; 90% CI (1.26, 4.80), while lower odds of acceptance were associated with negative child verbalization during feeding, OR 0.27; 90% CI (0.17, 0.42). In this sample, caregivers used more responsive feeding practices during bites of local complementary food and were more controlling when feeding LNS. Responsive caregiver behaviours predicted child acceptance of food. These results could be used to design interventions in Malawi to improve responsive feeding practices in general and during LNS use.     

Supplementation during pregnancy with small‐quantity lipid‐based nutrient supplements or multiple micronutrients,compared with iron and folic acid,increases women's urinary iodine concentration in semiurban Ghana: A randomized controlled trial

There is little information on whether prenatal multiple micronutrient (MMN) supplements containing iodine affect women's iodine status. In the International Lipid‐based Nutrient Supplements DYAD‐Ghana trial, we aimed to assess women's urinary iodine concentration (UIC, μg/L) during pregnancy, as one of the planned secondary outcomes. Women (n = 1,320) <20 weeks of gestation were randomized to consume 60 mg iron and 400 μg folic acid per day (iron and folic acid [IFA]); 18 vitamins and minerals including 250 μg iodine per day (MMN); or 20 g/day of small‐quantity lipid‐based nutrient supplements (LNS) with the same and additional 4 vitamins and minerals as the MMN (LNS). In a subsample (n = 295), we tested differences in groups' geometric mean UICs at 36 weeks of gestation controlling for baseline UIC and compared the geometric means (approximately median UICs) with the World Health Organization (WHO) cut‐offs: median UIC <150, 150–249, and ≥500 reflecting low, adequate, and excessive iodine intakes, respectively. At baseline, overall median UIC was 137. At 36 weeks of gestation, controlling for baseline UIC, geometric mean (95% confidence interval) UICs of the MMN (161 [133, 184]) and LNS (158 [132, 185]) groups did not differ; both values were significantly greater (overall p = .004) than that of the IFA group (116 [101, 135]). The median UICs of the MMN and LNS groups were within the WHO “adequate” range, whereas that of the IFA group was below the WHO adequate range. In this setting, supplementation during pregnancy with small‐quantity LNS or MMN providing iodine at the WHO‐recommended dose, compared with IFA, increases the likelihood of adequate iodine status.     

Local versus offshore production of ready‐to‐use therapeutic foods and small quantity lipid‐based nutrient supplements

Manufacturers on four continents currently produce ready‐to‐use therapeutic foods (RUTF). Some produce locally, near their intended users, while others produce offshore and ship their product long distances. Small quantity lipid‐based nutrient supplements (SQ‐LNS) such as Nutriset's Enov'Nutributter are not yet in widespread production. There has been speculation whether RUTF and SQ‐LNS should be produced primarily offshore, locally, or both. We analyzed The United Nations Children's Fund (UNICEF) Supply Division data, reviewed published literature, and interviewed local manufacturers to identify key benefits and challenges to local versus offshore manufacture of RUTF. Both prices and estimated costs for locally produced product have consistently been higher than offshore prices. Local manufacture faces challenges in taxation on imported ingredients, low factory utilization, high interest rates, long cash conversion cycle, and less convenient access to quality testing labs. Benefits to local economies are not likely to be significant. Although offshore manufacturers offer RUTF at lower cost, local production is getting closer to cost parity for RUTF. UNICEF, which buys the majority of RUTF globally, continues to support local production, and efforts are underway to narrow the cost gap further. Expansion of RUTF producers into the production of other ready‐to‐use foods, including SQ‐LNS in order to reach a larger market and achieve a more sustainable scale, may further close the cost and price gap. Local production of both RUTF and SQ‐LNS could be encouraged by a favorable tax environment, assistance in lending, consistent forecasts from buyers, investment in reliable input supply chains, and local laboratory testing.     

Ghanaian parents' perceptions of pre and postnatal nutrient supplements and their effects

Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) have been studied in efficacy and effectiveness trials, but little is known about how parents perceive the products and their effects. In a randomised trial in Ghana, efficacy of SQ‐LNS provided to women during pregnancy and the first 6 months postpartum and to their children from 6 to 18 months of age was assessed by comparison with iron‐folic acid (IFA) capsules and multiple micronutrient (MMN) capsules provided to women. In a follow‐up study conducted when the index children from the original trial were between 4 and 6 years of age, we used survey‐based methods to assess retrospective and current parental perceptions of nutrient supplements generally and of SQ‐LNS and their effects compared with perceptions IFA and MMN capsules. Most parents perceived that the assigned supplements (SQ‐LNS, IFA, or MMN) positively impacted the mother during pregnancy (approximately 89% of both mothers and fathers) and during lactation (84% of mothers and 86% of fathers). Almost all (≥90%) of mothers and fathers perceived that the assigned supplement positively impacted the index child and expected continued positive impacts on the child's health and human capital into the future. A smaller percentage of parents perceived negative impacts of the supplements (7%–17% of mothers and 4%–12% of fathers). Perceptions of positive impacts and of negative impacts did not differ by intervention group. The results suggest that similar populations would likely be receptive to programs to deliver SQ‐LNS or micronutrient capsules.     

Acceptability of lipid-based nutrient supplements (LNS) among Ghanaian infants and pregnant or lactating women

Inadequate micronutrient intake during pregnancy, lactation and infancy is a major problem in many developing countries. Lipid-based nutrient supplements (LNS) can improve micronutrient status, growth and development of infants, and also have potential to improve nutritional status of pregnant and lactating women. The objective of the study was to test the acceptability of LNS designed for infants (LNS-20gM) and pregnant or lactating women (LNS-P&L). Participants were infants (n = 22, mean age = 8 months) and pregnant or lactating women (n = 24) attending routine services at a hospital in Ghana. Infants consumed 45 g of a test meal consisting of one part LNS-20gM and three parts fermented maize porridge, while women consumed 50 g of a similar test meal containing LNS-P&L instead. Participants also used their respective LNS at home for 14 days. Primary outcome was the proportion of the test meal consumed. On average, infants consumed 76.2% of the test meal [95% (confidence interval) CI: 65.7, 86.7], while women consumed 87.1% (95% CI: 82.6, 91.6). During the 14-day period, median daily consumption of LNS-20gM was 19.3 g, very close to the recommended 20 g d(-1), while that of LNS-P&L was one sachet, as recommended. We conclude that LNS-20gM and LNS-P&L were well accepted.     

Feeding behaviors during home‐based treatment of moderate acute malnutrition using corn‐soy blends or lipid‐based nutrient supplements

Feeding behaviors have an important impact on children's nutritional status and are essential to consider when implementing nutrition programs. The objective of this study was to explore and compare feeding behaviors related to supplementary feeding with corn‐soy blends (CSB) and lipid‐based nutrient supplements (LNS) based on best practice feeding behaviors. The study was conducted as part of a randomized controlled trial assessing the effectiveness of new formulations of CSB and LNS and comprised 1,546 children from 6 to 23 months. The study included a mixed methods approach using questionnaires, focus group discussions and home visits and interviews with a subsample of 20 caretakers of trial participants. We found that LNS, compared to CSB, were more likely to be mixed into other foods (OR [95% CI] 1.7 [1.3–2.2], p = <.001), served with a meal (OR [95% CI] 1.6 [1.1–2.3], p = <.018)or between meals (OR [95% CI] 1.5 [1.1–1.9], p = <.005), and fed using an encouraging feeding style (mean difference in percentage points [95% CI] 23% [6%:40%], p = .01). CSB were more likely to be fed using a forced feeding style (mean difference in percentage points [95% CI] 18% [3%:33%], p = .02) and were often observed to be served unprepared. The main differences in feeding behaviors between the two diet groups were linked to how and when supplements were served. Educational instructions should therefore be adapted according to the supplement provided; when providing CSB, efforts should be made to promote an encouraging feeding style, and emphasis should be made to ensure preparations are made according to recommendations.     

Patterns and determinants of small‐quantity LNS utilization in rural Malawi and Mozambique: considerations for interventions with specialized nutritious foods

Small‐quantity, lipid‐based nutrient supplements (SQ‐LNS) show promise to improve the quality of maternal and child diets, particularly during the first 1000 days of life. The potential of SQ‐LNS to impact positively upon nutritional status relies on numerous factors, including complementary dietary intake, disease prevalence and dynamics of household utilization, including sharing practices. Therefore, this study sought to elucidate the patterns and determinants of SQ‐LNS utilization among children 6–23 months and potential sharing practices of other household members prior to intervention development. In Ntchisi, Malawi and Cabo Delgado, Mozambique, both rural, agricultural settings, we conducted two home‐feeding trials of 8 and 6 weeks, respectively, nested within a larger multi‐phase, emergent formative research design. Multiple methods, including in‐depth interviews (n = 38), direct meal observations (n = 80), full‐day child observations (n = 38) and spot checks of SQ‐LNS supply (n = 23), were conducted with households (n = 35 in Malawi; n = 24 in Mozambique). Overall, the SQ‐LNS was utilized contrary to its recommended use, with 50% of households in Malawi reporting running out of stock too early and 87% of households in Mozambique either overusing or underusing the product. Utilization of SQ‐LNS was manifested in four patterns of overuse and two of underuse and was determined by factors at multiple levels of influence. Maternal and child health efforts need to consider the reasons behind choices by households to overuse or underuse SQ‐LNS and design intervention strategies to increase the likelihood of its appropriate utilization.     

The effects of a lipid‐based nutrient supplement and antiretroviral therapy in a randomized controlled trial on iron,copper, and zinc in milk from HIV‐infected Malawian mothers and associations with maternal and infant biomarkers

We evaluated effects of antiretroviral (ARV) therapy and lipid‐based nutrient supplements (LNSs) on iron, copper, and zinc in milk of exclusively breastfeeding HIV‐infected Malawian mothers and their correlations with maternal and infant biomarkers. Human milk and blood at 2, 6, and 24 weeks post‐partum and blood during pregnancy (≤30 weeks gestation) were collected from 535 mothers/infant‐pairs in the Breastfeeding, Antiretrovirals, and Nutrition study. The participants received ARV, LNS, ARV and LNS, or no intervention from 0 to 28 weeks post‐partum. ARVs negatively affected copper and zinc milk concentrations, but only at 2 weeks, whereas LNS had no effect. Among all treatment groups, approximately 80–90% of copper and zinc and <50% of iron concentrations met the current adequate intake for infants at 2 weeks and only 1–19% at 24 weeks. Pregnancy haemoglobin was negatively correlated with milk iron at 2 and 6 weeks (r = ?.18, p < .02 for both). The associations of the milk minerals with each other were the strongest correlations observed (r = .11–.47, p < .05 for all); none were found with infant biomarkers. At 2 weeks, moderately anaemic women produced milk higher in iron when ferritin was higher or TfR lower. At 6 weeks, higher maternal α‐1‐acid glycoprotein and C‐reactive protein were associated with higher milk minerals in mildly anaemic women. Infant TfR was lower when milk mineral concentrations were higher at 6 weeks and when mothers were moderately anaemic during pregnancy. ARV affects copper and zinc milk concentrations in early lactation, and maternal haemoglobin during pregnancy and lactation could influence the association between milk minerals and maternal and infant iron status and biomarkers of inflammation.     

Impact of small quantity lipid‐based nutrient supplements on infant and young child feeding practices at 18 months of age: results from four randomized controlled trials in Africa

Optimal infant and young child feeding (IYCF) practices can help ensure nutrient adequacy and support healthy growth and development. Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) have been proposed to help fill nutrient gaps, but little is known about the impact of provision of SQ‐LNS on breastfeeding or complementary feeding practices. In the context of four coordinated randomized controlled nutrient supplementation trials in diverse sites in Africa, we compared IYCF practices at infant age 18 months (after 9–12 months of supplementation) between those receiving and not receiving SQ‐LNS. Practices were assessed by caregiver recall. Continued breastfeeding ranged from 74% (Ghana site) to 97% (Burkina Faso site) and did not differ between groups in any site; prevalence of frequent breastfeeding also did not differ. In two sites (Burkina Faso and Malawi), infants receiving SQ‐LNS were more likely to meet the World Health Organization recommendations for frequency of feeding (percentage point differences of 12–14%, P < 0.0001 and P = 0.005, respectively; the remaining two sites did not have data for this indicator). Most indicators of infant dietary diversity did not differ between groups in any site, but in the same two sites where frequency of feeding differed, infants receiving SQ‐LNS were less likely to have low frequency of consumption of animal‐source foods in the previous week (percentage point differences of 9–19% for lowest tertile, P = .02 and P = 0.04, respectively). We conclude that provision of SQ‐LNS did not negatively impact self‐reported IYCF practices and may have positively impacted frequency of feeding.     

Association between prenatal provision of lipid‐based nutrient supplements and caesarean delivery: Findings from a randomised controlled trial in Malawi

In populations with a high prevalence of childhood and adolescent undernutrition, supplementation during pregnancy aiming at improving maternal nutritional status and preventing fetal growth restriction might theoretically lead to cephalopelvic disproportion and delivery complications. We investigated whether the prenatal provision of small‐quantity lipid‐based nutrient supplements (SQ‐LNS) was associated with an increased risk of caesarean section (CS) or other delivery complications. Pregnant Malawian women were randomised to receive daily i) iron–folic acid (IFA) capsule (control), ii) multiple micronutrient (MMN) capsule of 18 micronutrients (second control), or iii) SQ‐LNS with similar micronutrients as MMN, plus four minerals and macronutrients contributing 118 kcal. We analysed the associations of SQ‐LNS, CS, and other delivery complications using log‐binomial regressions. Among 1391 women enrolled, 1255 had delivery information available. The incidence of CS and delivery complications was 6.3% and 8.2%, respectively. The incidence of CS was 4.0%, 6.0%, and 8.9% (p = 0.017) in the IFA, MMN, and LNS groups, respectively. Compared to the IFA group, the relative risk (95% confidence interval) of CS was 2.2 (1.3–3.8) (p = 0.006) in the LNS group and 1.5 (0.8–2.7) (p = 0.200) in the MMN group. We found no significant differences for other delivery complications. Provision of SQ‐LNS to pregnant women may have increased the incidence of CS. The baseline rate was, however, lower than recommended. It is unclear if the higher CS incidence in the SQ‐LNS group resulted from increased obstetric needs or more active health seeking and a better supply of services. Trial registered at clinicaltrials.gov, {"type":"clinical-trial","attrs":{"text":"NCT01239693","term_id":"NCT01239693"}}NCT01239693.     

A behaviour change intervention with lipid‐based nutrient supplements had little impact on young child feeding indicators in rural Kenya

Poor infant and young child feeding (IYCF) practices are associated with linear growth faltering. Our objective was to evaluate the impact of a nutrition and water and sanitation for health intervention on three IYCF indicators—minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) in Kenyan children. Households were randomized into one of eight groups: (a) active control; (b) passive control; (c) water quality (W); (d) sanitation (S); (e) handwashing (H); (f) combined Water, Sanitation, and Handwashing; (g) nutrition (N); and (h) combined WSH + N. In the N and WSH + N arms, community‐based promoters counselled households on optimal IYCF practices, and small‐quantity lipid‐based nutrient supplements (SQ‐LNS) were provided to children 6–24 months of age. Twelve months (Year 1) and 24 months (Year 2) after interventions began, enumerators surveyed mothers to ascertain IYCF practices. We made pairwise comparisons of each intervention arm versus the active control arm using log binomial models. In total, 3,652 caretakers were surveyed at Year 1 and 4,987 caretakers at Year 2. Compared with the active control, there were no differences in any of the arms in MDD, MMF, or MAD, aside from an increase in MDD at Year 1 in the nutrition only arm but not in the combined WSH + N arm (N: 68%; WSH + N: 61%; C: 61%; N arm prevalence ratio: 1.13 95% CI [1.01, 1.25]). In this setting, a nutrition behaviour change communication intervention had little impact on IYCF indicators. The provision of SQ‐LNS was not detrimental to current IYCF indicators in the community.     

An integrated infant and young child feeding and small‐quantity lipid‐based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.     

Elevated iron status and risk of gestational diabetes mellitus: A systematic review and meta‐analysis

The aim of this systematic review and meta‐analysis of observational studies was to assess the relationship between elevated iron status, measured as hemoglobin and ferritin levels, and the risk of gestational diabetes mellitus (GDM). The present study was recorded in PROSPERO (2013:CRD42013005717). The selected studies were identified through a systematic review of scientific literature published in The Cochrane Library and PubMed/MEDLINE databases from their inception until March 10, 2016, in addition to citation tracking and hand‐searches. The search strategy of original articles combined several terms for hemoglobin, ferritin, pregnancy, and GDM. OR and 95% CI of the selected studies were used to identify associations between hemoglobin and/or ferritin levels with the risk of GDM. Summary estimates were calculated by combining inverse‐variance using fixed‐effects model. 2468 abstracts were initially found during the search. Of these, 11 with hemoglobin and/or ferritin data were selected for the meta‐analyses. We observed that high hemoglobin (OR = 1.52; 95% CI: 1.23–1.88), as well as ferritin (OR = 2.09; 95% CI: 1.48–2.96) levels were linked to an increased risk of GDM. Low heterogeneity was observed in hemoglobin (I² = 33.3%, P = 0.151) and ferritin (I² = 0.7%, P = 0.418) meta‐analyses, respectively. Publication bias was not appreciated. High hemoglobin or ferritin levels increase the risk of GDM by more than 50% and more than double, respectively, in the first and third trimester. Therefore, determining of hemoglobin or ferritin concentration in early pregnancy might be a useful tool for recognizing pregnant women at risk of GDM.     

Early invitation to food and/or multiple micronutrient supplementation in pregnancy does not affect body composition in offspring at 54 months: follow‐up of the MINIMat randomised trial,Bangladesh

Growth patterns in early life are associated with later health. The effect of nutrition during in utero development on later body composition is unclear. We evaluated whether prenatal early invitation to food and/or multiple micronutrient supplementation (MMS) in pregnancy has an effect on offspring body composition at 54 months of age. In Maternal and Infant Nutrition Interventions in Matlab trial (ISRCTN16581394) in Bangladesh, 4436 pregnant women were randomised into six equally sized groups: double‐masked supplementation with capsules of either 30 mg Fe and 400 μg folic acid, or 60 mg Fe and 400 μg folic acid, or MMS (15 micronutrients), was combined with a randomised early invitation (around 9 weeks) or a usual invitation (around 20 weeks) to start food supplementation (608 kcal 6 days per week). At 54 months, the body composition of the offspring was assessed by leg‐to‐leg bioelectrical impedance analysis. Of the 3267 live singletons with birth anthropometry, 2290 children were measured at 54 months, representing 70% of the live births. There was no interaction between the food and micronutrient supplementation on body composition outcomes. There were no significant differences in a range of anthropometric and body composition measurements, including weight, height, mid‐upper arm circumference, head circumference, skinfold thickness, and fat mass and fat‐free mass between the different prenatal food and micronutrient groups using an intention‐to‐treat analysis. This analysis shows that early invitation to food supplementation and MMS provided to rural Bangladeshi women during pregnancy did not affect offspring body composition at 54 months of age.     

Individual and structural environmental influences on utilization of iron and folic acid supplementation among pregnant women in Harare,Zimbabwe

Micronutrient deficiencies are prevalent among Zimbabweans with serious health and social implications. Due to a lack of a national micronutrient food fortification policy, the Zimbabwe Ministry of Health and Child Care established a policy for the prevention of maternal micronutrient deficiencies, which centres on pregnant women receiving daily iron and folic acid (IFA) at their first antenatal care visit and throughout pregnancy. Despite these efforts, utilization of IFA supplementation in pregnancy in Zimbabwe is low. This study aimed to understand the experiences and knowledge of IFA supplementation among pregnant women and healthcare workers in Harare, Zimbabwe, and the influence of health‐service and social environments on utilization. Semi‐structured in‐depth interviews were conducted in Shona and English, with pregnant women (n = 24) and healthcare workers (n = 14) providing direct antenatal care services to pregnant women in two high‐density community clinics. Data were analysed thematically using NVivo 10. Influences on utilization were at the individual and structural environmental levels. Reasons for low utilization of IFA supplementation included forgetting to take IFA, side effects, misconceptions about IFA, limited access to nutrition information, delayed entry or non‐uptake of antenatal care and social norms of pregnant women for IFA supplementation. Utilization was enhanced by knowledge of risks and benefits of supplementation, fear of negative health complications with non‐utilization, family support and healthcare worker recommendation for supplementation. Study findings can inform approaches to strengthen micronutrient supplementation utilization to improve the micronutrient status of pregnant women to decrease maternal mortality and improve overall maternal and child health in Zimbabwe. © 2016 John Wiley & Sons Ltd     

Effect of locally produced complementary foods on fat‐free mass,linear growth,and iron status among Kenyan infants: A randomized controlled trial

The impact of quality complementary food products on infant growth and body composition has not been adequately investigated. This study evaluated the effect on fat‐free mass (FFM) accrual, linear growth, and iron status of locally produced complementary food products comparing to a standard product. In a randomized, double‐blind trial, 499 infants at 6 months received nine monthly rations of (a) WinFood Classic (WFC) comprising germinated amaranth (71%), maize (10.4%), small fish (3%), and edible termites (10%); (b) WinFood Lite (WFL) comprising germinated amaranth (82.5%), maize (10.2%), and multimicronutrient premix; or (c) fortified corn–soy blend plus (CSB+). Primary outcomes were changes in FFM, length, and plasma ferritin and transferrin receptors (TfR). FFM was determined using deuterium dilution. Analysis was by intention to treat, based on available cases. Compared with CSB+, there were no differences in change from 6 to 15 months in FFM for WFC 0.0 kg (95% CI [?0.30, 0.29]) and WFL 0.03 kg (95% CI [?0.25, 0.32]) and length change for WFC ?0.3 cm (95% CI [?0.9, 0.4]) and WFL ?0.3 cm (95% CI [?0.9, 0.3]). TfR increased in WFC group 3.3 mg L^?1 (95% CI [1.7, 4.9]) and WFL group 1.7 mg L^?1 (95% CI [0.1, 3.4]) compared with CSB+. Compared with the increase in Hb in CSB+ group, there was a reduction in Hb in WFC of ?0.9 g dl^?1 (95% CI [?1.3, ?0.5]) and a lower increase in WFL ?0.4 g dl^?1 (95% CI [?0.8, 0.0]). In conclusion, the tested WinFoods had the same effect on FFM and length as CSB+, whereas Hb and iron status decreased, suggesting inhibited iron bioavailability from the amaranth‐based WinFoods.     

Congenital abnormalities in the offspring of pregnant women with type 1, type 2 and gestational diabetes mellitus: A population‐based case‐control study

To estimate the risk of structural birth defects (i.e. congenital abnormalities [CA]) in the offspring of pregnant women with type 1 (DM‐1), type 2 (DM‐2) and gestational diabetes mellitus (GDM) and to check the efficacy of recent specific care of diabetic pregnant women in the reduction of DM‐related CA. Comparison was made of the occurrence of medically recorded types of diabetes mellitus in pregnant women who had malformed fetuses/newborns (cases) and who delivered healthy babies (controls) in the population‐based Hungarian Case‐Control Surveillance System of Congenital Abnormalities, 1980–1996. In the case group, which included 22 843 offspring, there were 79 (0.35%) pregnant women with DM‐1, 77 (0.34%) pregnant women with DM‐2 and 120 (0.53%) pregnant women with GDM. The control group comprised 38 151 newborns, and 88 (0.23%), 141 (0.37%) and 229 (0.60%) pregnant women with DM‐1, DM‐2 and GDM, respectively. The total rate of cases with CA was higher only in the DM‐1 group (adjusted OR with 95% CI: 1.5, 1.1–2.0) and within four specific types/groups: isolated renal a/dysgenesis, obstructive CA of the urinary tract, cardiovascular CA and multiple CA; namely, caudal dysplasia sequence. The risk of total CA was lower in the present study compared to the risk in previous studies and the DM‐1‐related spectrum of CA was also different. There was no higher risk of total CA in the offspring of pregnant women with DM‐2 and GDM. The certain part of maternal teratogenic effect of DM‐1 is preventable with appropriate periconceptional and prenatal care of diabetic women.