Background The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome... more Background The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) and became pandemic after emerging in Wuhan, China, in December 2019. Several studies have been conducted to understand the key features of COVID-19 and its public health impact. However, the prognostic factors of COVID-19 are not well studied in the African setting. In this study, we aim to determine the epidemiological and clinical features of COVID-19 cases, immunological and virological courses, interaction with nutritional status, and response to treatment for COVID-19 patients in Ethiopia. Methods A multi-center cohort study design will be performed. Patients with confirmed COVID-19 infection admitted to selected treatment centers will be enrolled irrespective of their symptoms and followed-up for 12 months. Baseline epidemiological, clinical, laboratory and imaging data will be collected from treatment records, interviews, physical measurements, and biolo...
Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, h... more Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved...
Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding pra... more Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding practices, ensure adequate energy and nutrient intake and prevent linear growth faltering. This study aimed to assess mothers' and health workers' knowledge of timely introduction to complementary foods and evaluate the relationship between delays in complementary feeding and subsequent linear growth. We conducted two rounds of surveys (March/August 2017) among 249 health workers (n = 249) and caregivers (n = 2635) of children 6-23 months of age. We collected information about socio-demographic characteristics, knowledge and practice related to timely introduction to complementary foods. The study was conducted in households from the Productive Safety Net Programme (PSNP) districts, in four highland regions of Ethiopia. Delays in the introduction to complementary feeding were widespread with 53% of children 6-8 months of age not consuming solid, semisolid or soft foods in the past 24 h. After controlling for child, caregiver and household characteristics, children not introduced to complementary foods by 6-8 months had a 0.48 SD lower length-for-age z-score at 12-15 months. Caregivers' knowledge was strongly and inversely correlated with untimely introduction of complementary foods in logistic regressions (OR = 0.55, p < 0.01). In turn, local health extension worker's knowledge was strongly correlated with caregiver's knowledge. Consequently, frequent and timely visits by health extension workers emphasising not only on what to feed but also when and how to feed a child are needed. Innovative ways of increasing reach, intensity and frequency of nutrition messaging by using the PSNP interactions as an additional point of contact would need to be explored further.
Child undernutrition disproportionally affects children in low- and middle-income countries. In E... more Child undernutrition disproportionally affects children in low- and middle-income countries. In Ethiopia, both wasting and stunting are serious public health concerns, with high human and economic costs. Understanding the dynamics in ponderal and linear growth faltering is critical to inform the design of innovative interventions that can prevent both wasting and stunting in poor and complex settings. Using two longitudinal studies conducted in 2017 and 2019 in four highland regions of Ethiopia, we evaluated the dynamics and drivers of child growth faltering in children 6-23 months of age (N = 5003). Child wasting prevalence peaked during the first 6 months of life, whereas stunting increased significantly after 6 months of age. Male sex, child illnesses (i.e., diarrhoea or fever) and low consumption of fruits and vegetables were associated with higher odds of acute undernutrition (P < 0.05). The consumption of animal source foods (ASF) was associated with increases (β: 95% CI) in weight-for-length Z-score (WLZ; 0.12: 0.0002; 0.242), whereas fruit or vegetables consumption was associated with increases in midupper arm circumference (MUAC; 0.11 cm: 0.003; 0.209). Only consumption of ASF was the statistically significant predictor of future linear growth (0.14: 0.029; 0.251). Distinct trends in WLZ and MUAC were observed by child sex and age. Improving diet quality through improved nutrition knowledge and increased access and affordability of ASFs, along with effective infection prevention/control measures could prevent both child wasting and stunting concurrently.
Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one‐th... more Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one‐third of children. In most low‐ and middle‐income countries, linear growth faltering of young children starts in the womb. The 1,000‐days window of opportunity to improve child nutritional status includes pregnancy, as maternal nutritional status is an important determinant of birthweight and child development. In Cambodia, nutritional status of pregnant women is poor, with some studies reporting >20% of pregnant women having a low mid‐upper arm circumference (MUAC < 23 cm). Few studies have investigated associations between maternal nutritional status during pregnancy and neonatal growth. Using data from a Cambodian cohort study conducted from 2016 through 2018 in selected districts of Phnom Penh, Kratie, and Ratanakiri provinces, we investigated associations between maternal MUAC during pregnancy as indicator of maternal nutritional status and their offspring linear growth during e...
Even though limited evidence is available, the relationship between morbidity and under-nutrition... more Even though limited evidence is available, the relationship between morbidity and under-nutrition among children under-five is likely to be a strong two-way association. This study aims to explore this vicious cycle by employing longitudinal data of four periods within a 24 month follow-up, whereby morbidity was captured between two subsequent anthropometric measures. Malnutrition was classified according to z-scores of anthropometric measures and morbidity by number of sick days experienced inbetween. Mixed-effects models were used to assess this relation, where dependency of morbidity and nutritional status were interchanged; models were adjusted for province, age, gender, wealth index score, maternal education level, diet, and Water, Sanitation, and Hygiene indicators. Stunting and wasting prevalences were 29.9% and 8.9%, respectively, where 21.3% of the children hadmultiple anthropometric failures. Children identified as wasted were 35% more likely to experience prolonged illnes...
In Cambodia, existing food products for treating or preventing undernutrition have met with limit... more In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready‐to‐use foods were developed. This trial aimed to assess the acceptability of the novel ready‐to‐use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn–soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9–23 months from communities in peri‐urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were gr...
Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acce... more Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness in Cambodia. This has hampered the treatment and prevention of child malnutrition. An innovative, locally produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) has been developed for use as an RUSF. Unlike most RUSFs, which contain milk, this product contains fish as the animal protein. Few RUSFs have been formulated using non-milk animal-source foods and they have not been widely tested. An acceptability trial that was conducted on this novel RUSF in June 2015 demonstrated that children will eat the RUSF and that caregivers will feed it to their children. The current trial aims to evaluate the effectiveness of the RUSF in preventing growth faltering and improving micronutrient status in Cambodian children. This trial is a six-month, prospective, cluster randomised, non-blinded controlled trial among infants in peri-urban Phnom Penh. Th...
This study aimed to describe the trends over four nationally representative Demographic Health Su... more This study aimed to describe the trends over four nationally representative Demographic Health Surveys (2000, 2005, 2010, and 2014) of the nutritional status of women of reproductive age in Cambodia and to assess the main factors of inequality with regards to nutrition. The prevalence of undernutrition and over-nutrition evolved in opposite trends from 2000 to 2014, with a significant decrease in underweight and a significant increase in overweight women. This results in a shift, with overweight prevalence in women being higher than underweight for the first time in 2014. Anemia was constantly high and still affected 45% of women in 2014. Multivariate analysis showed that age, wealth index, maternal education, number of children, year of survey, and anemia were contributing factors for being underweight. Being overweight was positively related to increase in age, wealth index, number of children, and year of survey; and negatively related to anemia and increase in education level. The risk of anemia was higher in the poorest households and for less-educated women and women living in rural areas. Consequently, policies should target the most vulnerable women, especially the youngest, and support integrated interventions in the health, social, and agriculture sectors to reduce inequalities in nutrition between women.
Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition... more Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition is defined by the World Health Organization as a mid-upper-arm circumference (MUAC) <12.5 cm or a weight-for-height Z-score (WHZ) <-2. MUAC is a simple and low-cost indicator to screen for acute malnutrition in communities, but MUAC cut-offs currently recommended by WHO do not identify the majority of children with weight-for-height Z-score (<-2 (moderate malnourished) or r<-3 (severe malnourished). Also, no cut-offs for MUAC are established for children >5 yrs. Therefore, this study aimed at defining gender and age-specific cut-offs to improve sensitivity of MUAC as an indicator of acute malnutrition. To establish new age and gender-specific MUAC cut-offs, pooled data was obtained for 14,173 children from 5 surveys in Cambodia (2011)(2012)(2013). Sensitivity, false positive rates, and areas under receiver-operator characteristic curves (AUC) were calculated using wasting for children <5yrs and thinness for children 5yrs as gold standards. Among the highest values of AUC, the cut-off with the highest sensitivity and a false positive rate 33% was selected as the optimal cut-off. Optimal cut-off values increased with age. Boys had higher cut-offs than girls, except in the 8-10.9 yrs age range. In children <2yrs, the cut-off was lower for stunted children compared to non stunted children. Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to >80% with the new cut-offs in comparison with the current WHO cut-offs.
Bangladesh has experienced rapid economic growth and achieved major health improvements in the pa... more 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 ...
Food fortification is implemented to address vitamins A and D deficiencies in numerous countries.... more Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3weeks of storage in dark conditions. After 2months, the vitamin A and D3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.
Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification le... more Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification levels. To assess the capacity of a portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) to quantify retinyl palmitate in fortified milks, flours (wheat, maize), and sugar. The portable fluorometer was assessed in a three-step procedure to determine its working range and linearity, intra-assay precision, and interperson precision. Measurements were compared with the results obtained by high-performance liquid chromatography (HPLC), commonly regarded as the standard method for vitamin A analysis. The portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) precisely determined the vitamin A contents in fortifed flours, sugar, and milks. Its working range was 1 to 10, 0.5 to 3.0, and 5 to 15 mg retinol equivalents (RE) kg(-1) for flours (wheat and corn), milks, and sugar, respectively; these values are in accordance with the World Health Organization recommend...
Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million pr... more Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake. To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported. Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil. Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Avera...
Access to high-grade micronutrients is a recurring challenge that often threatens the long-term s... more Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs. To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia. A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time. The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fo...
In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the indu... more In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the industrial level are fortified with iron. Unfortunately, the food producers and regulatory agencies implementing fortification programs do not always have the capacity to monitor the programs on an ongoing basis. To assess a new portable device for the quantitative measurement of iron content of fortified sauces that could be used to control fortification levels. The linearity, detection limits, and inter- and intraassay variability of this device were assessed on fish sauce and soy sauce fortified with ferrous sulfate, ferrous fumarate, and sodium iron ethylenediaminetetraacetate (NaFeEDTA); the accuracy of the results was determined by comparing them with the results obtained by atomic absorption spectrophotometry. Measurements required a minimum incubation time of 1 hour for iron sulfate or iron fumarate and 24 hours for NaFeEDTA. Linearity of the results ranged from 2 to 10 mg iron/L for...
Despite improved economic conditions, vitamin A deficiency remains a public health problem in Ind... more Despite improved economic conditions, vitamin A deficiency remains a public health problem in Indonesia. This paper aims to describe the development of the Indonesian unbranded cooking oil fortification program and to discuss lessons learned to date and future steps necessary for implementation of mandatory, large-scale oil fortification with vitamin A. An historic overview of the steps involved in developing the Indonesian unbranded cooking oil fortification program is given, followed by a discussion of lessons learned and next steps needed. Indonesia's low-income groups generally consume unbranded vegetable oil, with an average consumption of approximately 25 g/day. Unbranded oil constitutes approximately 70% of the total oil traded in the country. In 2007-10, a pilot project to fortify unbranded vegetable oil was carried out in Makassar, and an effectiveness study found that the project significantly improved the serum retinol concentrations of schoolchildren. In 2010, the pi...
Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implem... more Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. To estimate vitamin A losses in oil with different chemical characteristics. Samples of fortified oils with different chemical characteristics were collected from two Egyptian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during storage to determine losses over time, and peroxide values were determined. Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% (p < .001), respectively. ...
Background The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome... more Background The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) and became pandemic after emerging in Wuhan, China, in December 2019. Several studies have been conducted to understand the key features of COVID-19 and its public health impact. However, the prognostic factors of COVID-19 are not well studied in the African setting. In this study, we aim to determine the epidemiological and clinical features of COVID-19 cases, immunological and virological courses, interaction with nutritional status, and response to treatment for COVID-19 patients in Ethiopia. Methods A multi-center cohort study design will be performed. Patients with confirmed COVID-19 infection admitted to selected treatment centers will be enrolled irrespective of their symptoms and followed-up for 12 months. Baseline epidemiological, clinical, laboratory and imaging data will be collected from treatment records, interviews, physical measurements, and biolo...
Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, h... more Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved...
Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding pra... more Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding practices, ensure adequate energy and nutrient intake and prevent linear growth faltering. This study aimed to assess mothers' and health workers' knowledge of timely introduction to complementary foods and evaluate the relationship between delays in complementary feeding and subsequent linear growth. We conducted two rounds of surveys (March/August 2017) among 249 health workers (n = 249) and caregivers (n = 2635) of children 6-23 months of age. We collected information about socio-demographic characteristics, knowledge and practice related to timely introduction to complementary foods. The study was conducted in households from the Productive Safety Net Programme (PSNP) districts, in four highland regions of Ethiopia. Delays in the introduction to complementary feeding were widespread with 53% of children 6-8 months of age not consuming solid, semisolid or soft foods in the past 24 h. After controlling for child, caregiver and household characteristics, children not introduced to complementary foods by 6-8 months had a 0.48 SD lower length-for-age z-score at 12-15 months. Caregivers' knowledge was strongly and inversely correlated with untimely introduction of complementary foods in logistic regressions (OR = 0.55, p < 0.01). In turn, local health extension worker's knowledge was strongly correlated with caregiver's knowledge. Consequently, frequent and timely visits by health extension workers emphasising not only on what to feed but also when and how to feed a child are needed. Innovative ways of increasing reach, intensity and frequency of nutrition messaging by using the PSNP interactions as an additional point of contact would need to be explored further.
Child undernutrition disproportionally affects children in low- and middle-income countries. In E... more Child undernutrition disproportionally affects children in low- and middle-income countries. In Ethiopia, both wasting and stunting are serious public health concerns, with high human and economic costs. Understanding the dynamics in ponderal and linear growth faltering is critical to inform the design of innovative interventions that can prevent both wasting and stunting in poor and complex settings. Using two longitudinal studies conducted in 2017 and 2019 in four highland regions of Ethiopia, we evaluated the dynamics and drivers of child growth faltering in children 6-23 months of age (N = 5003). Child wasting prevalence peaked during the first 6 months of life, whereas stunting increased significantly after 6 months of age. Male sex, child illnesses (i.e., diarrhoea or fever) and low consumption of fruits and vegetables were associated with higher odds of acute undernutrition (P < 0.05). The consumption of animal source foods (ASF) was associated with increases (β: 95% CI) in weight-for-length Z-score (WLZ; 0.12: 0.0002; 0.242), whereas fruit or vegetables consumption was associated with increases in midupper arm circumference (MUAC; 0.11 cm: 0.003; 0.209). Only consumption of ASF was the statistically significant predictor of future linear growth (0.14: 0.029; 0.251). Distinct trends in WLZ and MUAC were observed by child sex and age. Improving diet quality through improved nutrition knowledge and increased access and affordability of ASFs, along with effective infection prevention/control measures could prevent both child wasting and stunting concurrently.
Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one‐th... more Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one‐third of children. In most low‐ and middle‐income countries, linear growth faltering of young children starts in the womb. The 1,000‐days window of opportunity to improve child nutritional status includes pregnancy, as maternal nutritional status is an important determinant of birthweight and child development. In Cambodia, nutritional status of pregnant women is poor, with some studies reporting >20% of pregnant women having a low mid‐upper arm circumference (MUAC < 23 cm). Few studies have investigated associations between maternal nutritional status during pregnancy and neonatal growth. Using data from a Cambodian cohort study conducted from 2016 through 2018 in selected districts of Phnom Penh, Kratie, and Ratanakiri provinces, we investigated associations between maternal MUAC during pregnancy as indicator of maternal nutritional status and their offspring linear growth during e...
Even though limited evidence is available, the relationship between morbidity and under-nutrition... more Even though limited evidence is available, the relationship between morbidity and under-nutrition among children under-five is likely to be a strong two-way association. This study aims to explore this vicious cycle by employing longitudinal data of four periods within a 24 month follow-up, whereby morbidity was captured between two subsequent anthropometric measures. Malnutrition was classified according to z-scores of anthropometric measures and morbidity by number of sick days experienced inbetween. Mixed-effects models were used to assess this relation, where dependency of morbidity and nutritional status were interchanged; models were adjusted for province, age, gender, wealth index score, maternal education level, diet, and Water, Sanitation, and Hygiene indicators. Stunting and wasting prevalences were 29.9% and 8.9%, respectively, where 21.3% of the children hadmultiple anthropometric failures. Children identified as wasted were 35% more likely to experience prolonged illnes...
In Cambodia, existing food products for treating or preventing undernutrition have met with limit... more In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready‐to‐use foods were developed. This trial aimed to assess the acceptability of the novel ready‐to‐use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn–soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9–23 months from communities in peri‐urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were gr...
Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acce... more Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness in Cambodia. This has hampered the treatment and prevention of child malnutrition. An innovative, locally produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) has been developed for use as an RUSF. Unlike most RUSFs, which contain milk, this product contains fish as the animal protein. Few RUSFs have been formulated using non-milk animal-source foods and they have not been widely tested. An acceptability trial that was conducted on this novel RUSF in June 2015 demonstrated that children will eat the RUSF and that caregivers will feed it to their children. The current trial aims to evaluate the effectiveness of the RUSF in preventing growth faltering and improving micronutrient status in Cambodian children. This trial is a six-month, prospective, cluster randomised, non-blinded controlled trial among infants in peri-urban Phnom Penh. Th...
This study aimed to describe the trends over four nationally representative Demographic Health Su... more This study aimed to describe the trends over four nationally representative Demographic Health Surveys (2000, 2005, 2010, and 2014) of the nutritional status of women of reproductive age in Cambodia and to assess the main factors of inequality with regards to nutrition. The prevalence of undernutrition and over-nutrition evolved in opposite trends from 2000 to 2014, with a significant decrease in underweight and a significant increase in overweight women. This results in a shift, with overweight prevalence in women being higher than underweight for the first time in 2014. Anemia was constantly high and still affected 45% of women in 2014. Multivariate analysis showed that age, wealth index, maternal education, number of children, year of survey, and anemia were contributing factors for being underweight. Being overweight was positively related to increase in age, wealth index, number of children, and year of survey; and negatively related to anemia and increase in education level. The risk of anemia was higher in the poorest households and for less-educated women and women living in rural areas. Consequently, policies should target the most vulnerable women, especially the youngest, and support integrated interventions in the health, social, and agriculture sectors to reduce inequalities in nutrition between women.
Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition... more Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition is defined by the World Health Organization as a mid-upper-arm circumference (MUAC) <12.5 cm or a weight-for-height Z-score (WHZ) <-2. MUAC is a simple and low-cost indicator to screen for acute malnutrition in communities, but MUAC cut-offs currently recommended by WHO do not identify the majority of children with weight-for-height Z-score (<-2 (moderate malnourished) or r<-3 (severe malnourished). Also, no cut-offs for MUAC are established for children >5 yrs. Therefore, this study aimed at defining gender and age-specific cut-offs to improve sensitivity of MUAC as an indicator of acute malnutrition. To establish new age and gender-specific MUAC cut-offs, pooled data was obtained for 14,173 children from 5 surveys in Cambodia (2011)(2012)(2013). Sensitivity, false positive rates, and areas under receiver-operator characteristic curves (AUC) were calculated using wasting for children <5yrs and thinness for children 5yrs as gold standards. Among the highest values of AUC, the cut-off with the highest sensitivity and a false positive rate 33% was selected as the optimal cut-off. Optimal cut-off values increased with age. Boys had higher cut-offs than girls, except in the 8-10.9 yrs age range. In children <2yrs, the cut-off was lower for stunted children compared to non stunted children. Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to >80% with the new cut-offs in comparison with the current WHO cut-offs.
Bangladesh has experienced rapid economic growth and achieved major health improvements in the pa... more 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 ...
Food fortification is implemented to address vitamins A and D deficiencies in numerous countries.... more Food fortification is implemented to address vitamins A and D deficiencies in numerous countries. The stability of vitamins A and D3 was assessed during a two-month period reproducing the usual oil storage conditions before sale to consumers. Soybean oils with different oxidative status and vitamin E contents were stored in the dark, semi-dark, or exposed to natural light. Lipid peroxidation took place after 3weeks of storage in dark conditions. After 2months, the vitamin A and D3 losses reached 60-68% and 61-68%, respectively, for oils exposed to natural light, and 32-39% and 24-44% in semi-dark conditions. The determining factors of vitamin A and D3 losses were (in decreasing order) the storage time, the exposure to light and the oxidative status of the oil, whereas vitamin E content had a protective role. Improving these parameters is thus essential to make vitamins A and D fortification in oils more efficient.
Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification le... more Simple-to-use quantitative methods are needed to check the adequacy of vitamin A fortification levels. To assess the capacity of a portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) to quantify retinyl palmitate in fortified milks, flours (wheat, maize), and sugar. The portable fluorometer was assessed in a three-step procedure to determine its working range and linearity, intra-assay precision, and interperson precision. Measurements were compared with the results obtained by high-performance liquid chromatography (HPLC), commonly regarded as the standard method for vitamin A analysis. The portable fluorometer (iCheck FLUORO) and its test kit vials (iEx Mila) precisely determined the vitamin A contents in fortifed flours, sugar, and milks. Its working range was 1 to 10, 0.5 to 3.0, and 5 to 15 mg retinol equivalents (RE) kg(-1) for flours (wheat and corn), milks, and sugar, respectively; these values are in accordance with the World Health Organization recommend...
Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million pr... more Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake. To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported. Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil. Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Avera...
Access to high-grade micronutrients is a recurring challenge that often threatens the long-term s... more Access to high-grade micronutrients is a recurring challenge that often threatens the long-term sustainability of food fortification programs. To assess the efficiency of the Global Alliance for Improved Nutrition (GAIN) Premix Facility in procuring quality, affordable vitamin A for fortification of edible oil in Indonesia. A global approach to procurement of standard items was used by combining volumes across various demand streams in order to reduce the total cost of acquisition through economies of scale. The GAIN Premix Facility undertook a detailed analysis of vitamin A requirements across its existing customer base, which served as a basis for developing a reliable demand forecast. A consolidated, competitive tender was launched that resulted in the setting up of a long-term commercial agreement with the selected supplier to lock in the most competitive price for a given period of time. The direct benefit to oil manufacturers of fortifying with vitamin A is that the cost of fo...
In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the indu... more In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the industrial level are fortified with iron. Unfortunately, the food producers and regulatory agencies implementing fortification programs do not always have the capacity to monitor the programs on an ongoing basis. To assess a new portable device for the quantitative measurement of iron content of fortified sauces that could be used to control fortification levels. The linearity, detection limits, and inter- and intraassay variability of this device were assessed on fish sauce and soy sauce fortified with ferrous sulfate, ferrous fumarate, and sodium iron ethylenediaminetetraacetate (NaFeEDTA); the accuracy of the results was determined by comparing them with the results obtained by atomic absorption spectrophotometry. Measurements required a minimum incubation time of 1 hour for iron sulfate or iron fumarate and 24 hours for NaFeEDTA. Linearity of the results ranged from 2 to 10 mg iron/L for...
Despite improved economic conditions, vitamin A deficiency remains a public health problem in Ind... more Despite improved economic conditions, vitamin A deficiency remains a public health problem in Indonesia. This paper aims to describe the development of the Indonesian unbranded cooking oil fortification program and to discuss lessons learned to date and future steps necessary for implementation of mandatory, large-scale oil fortification with vitamin A. An historic overview of the steps involved in developing the Indonesian unbranded cooking oil fortification program is given, followed by a discussion of lessons learned and next steps needed. Indonesia's low-income groups generally consume unbranded vegetable oil, with an average consumption of approximately 25 g/day. Unbranded oil constitutes approximately 70% of the total oil traded in the country. In 2007-10, a pilot project to fortify unbranded vegetable oil was carried out in Makassar, and an effectiveness study found that the project significantly improved the serum retinol concentrations of schoolchildren. In 2010, the pi...
Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implem... more Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. To estimate vitamin A losses in oil with different chemical characteristics. Samples of fortified oils with different chemical characteristics were collected from two Egyptian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during storage to determine losses over time, and peroxide values were determined. Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% (p < .001), respectively. ...
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Papers by Arnaud Laillou