Food and Nutrition Bulletin

The Transform Nutrition (Transform) research consortium (2012-2017), led by the International Food Policy Research Institute, sought to generate evidence to inform and inspire action to address undernutrition in 4 high-burden countries (India, Bangladesh, Kenya, and Ethiopia) and globally.

Within the context of the literature, this synthesis article brings together core findings of Transform, highlighting priorities for future research.

This article uses a narrative approach to synthesize diverse study findings that collectively address Transform’s three primary research questions: (1) How can nutrition-specific interventions be appropriately designed, implemented, scaled, and sustained in different settings?; (2) How can the nutritional impact of social protection and agriculture be improved?; and (3) How can enabling environments be promoted so as to use existing political and economic resources more effectively?

Highlights of Transform include (1) improved understanding of the relative effectiveness of different combinations of nutrition-specific interventions and the ways in which they can be scaled for maximal impact; (2) evidence that shows that social protection and agriculture need to be explicitly linked to nutrition in order to contribute to stunting reduction; (3) identification of key components of “enabling environments” for nutrition and how they can be cultivated/sustained; (4) research that examines ways in which leaders emerge and operate to change the political and policy landscape in different settings; and (5) “stories of change” that provide in-depth contextual knowledge of how transformative change has been driven in countries that have made inroads in reducing malnutrition. The conclusion highlights the contributions of the consortium and provides recommendations for future research.

Studies on the association between a priori dietary patterns and serum highly sensitive C-reactive protein (hs-CRP) have led to inconsistent results, and we are not aware of any study on interleukin 17A (IL-17A) as an inflammatory marker associated with autoimmune diseases.

The present study aimed to investigate the association between Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean dietary patterns with circulating hs-CRP and IL-17A levels.

In this cross-sectional study, female teachers (aged 20-50 years) who lived in Yazd, Iran, were randomly selected from elementary, guidance, and high schools from September 2015 to February 2016. Anthropometric data, as well as general information and dietary food intakes, were gathered, and each participant gave 1 blood sample. Participants were categorized into tertiles based on the DASH and the Mediterranean diet calculated scores. The associations between the dietary patterns and serum hs-CRP and IL-17A levels were assessed in the crude and multivariable models. In total, 320 female teachers aged 40.38 (8.08) years were included.

The DASH diet was associated with lower serum hs-CRP levels in the crude (P = .05) and the fully adjusted models (P = .02), while it was not significantly associated with IL-17A levels. The participants with the highest adherence to the Mediterranean diet had significantly lower circulating IL-17A levels (P = .04) even controlling for all confounders (P = .02); however, there was not a significant relationship between this diet and hs-CRP levels.

The DASH and the Mediterranean dietary patterns might be differently associated with inflammatory markers. Further prospective studies are recommended to confirm our results.

Production of rice and wheat increased dramatically in India over the past decades, with reduced proportion of coarse cereals in the food supply.

We assess impacts of changes in cereal consumption in India on intake of iron and other micronutrients and whether increased consumption of coarse cereals could help alleviate anemia prevalence.

With consumption data from over 800 000 households, we calculate intake of iron and other micronutrients from 84 food items from 1983 to 2011. We use mixed-effect models to relate state-level anemia prevalence in women and children to micronutrient consumption and household characteristics.

Coarse cereals reduced from 23% to 6% of calories from cereals in rural households (10% to 3% in urban households) between 1983 and 2011, with wide variations across states. Loss of iron from coarse cereals was only partially compensated by increased iron from other cereals and food groups, with a 21% (rural) and 11% (urban) net loss of total iron intake. Models indicate negative association between iron from cereals and anemia prevalence in women. The benefit from increased iron from coarse cereals is partially offset by the adverse effects from antinutrients. For children, anemia was negatively associated with heme–iron consumption but not with iron from cereals.

Loss of coarse cereals in the Indian diet has substantially reduced iron intake without compensation from other food groups, particularly in states where rice rather than wheat replaced coarse cereals. Increased consumption of coarse cereals could reduce anemia prevalence in Indian women along with other interventions.

The Becoming Breastfeeding Friendly (BBF) initiative includes a guide that helps countries worldwide assess their readiness to scale up national breastfeeding programs. Country committees of breastfeeding experts across government, academia, and civil society engage with BBF by applying the BBF toolbox that includes (1) the BBF Index (BBFI) to measure and score a country’s breastfeeding environment, (2) case studies that illustrate how countries have created enabling environments for breastfeeding, and (3) a 5-meeting process, during which country committees develop policy recommendations intended to improve breastfeeding outcomes based on the BBFI scores.

This study seeks to understand how the application of the BBF toolbox impacted plans to improve the enabling environment for breastfeeding in Mexico.

Semi-structured interviews were conducted with Mexico’s 11 BBF country committee members about the 5-meeting process between May and June 2017. Audio recordings were transcribed and were coded and analyzed using a grounded theory approach.

Three major themes emerged: (1) the unique enabling environment for breastfeeding consisted of obstacles and opportunities for improvement, (2) favorable country committee member dynamics positively affected the utility of the BBF toolbox, and (3) BBF revealed and shaped country committee members’ shared vision of change that laid the foundation for a shared public policy agenda.

Becoming Breastfeeding Friendly can generate multisectoral breastfeeding champions who can advance the public policy agenda to improve breastfeeding outcomes at the national level both in Mexico and elsewhere.

Evidence-based nutrition programs depend on accurate estimates of malnutrition derived from data collected in population representative surveys. The feasibility of obtaining accurate anthropometric data as part of national, multisectoral surveys has been a debated issue.

The study aimed to evaluate changes in anthropometric data quality corresponding to investments by the Kenya Ministry of Health and nutrition sector partners for the 2014 Kenya Demographic Health Survey.

Anthropometric data collected during the 2008 to 2009 and 2014 Kenya surveys were reanalyzed to assess standard parameters of quality: standard deviation, skewness, and kurtosis of z-score values for 3 anthropometric indicators (weight for height, height for age, and weight for age), percentage of children with missing measurements and outlier values, digit preference, and heaping of age.

A total of 9936 households were selected in 2008 to 2009, and 39 679 households were selected in 2014. Standard deviation of z-scores for all 3 indicators was smaller in 2014 than in 2008 to 2009. Applying original Demographic and Health Survey exclusion criteria, weight for height z-scores were 1.16 in 2014, 10.1% narrower than 2008 to 2009. The percentage of outlying values declined significantly from 2008 to 2009 to 2014 for both height for age and weight for height (P < .001). Digit preference scores in 2014 improved for both weight (P = .011) and height (P < .001) suggesting less rounding of terminal digits.

All tests of data quality suggest an improvement in 2014 relative to 2008 to 2009, despite the complexity implied by the larger sample. This improvement corresponds with efforts to enhance training and supervision of anthropometry, suggesting a positive effect of these enhancements.

Cambodia has a high prevalence of moderate acute malnutrition and severe acute malnutrition (SAM). The SAM treatment requires ready-to-use therapeutic foods (RUTFs), whereas ready-to-use supplementary foods (RUSFs) are used for prevention of acute malnutrition. Three locally produced fish-based products were developed: an RUTF paste (NumTrey-Paste) for treatment and 2 wafer versions, one for prevention (NumTrey-RUSF) and one for treatment (NumTrey-RUTF).

To assess the acceptability of NumTrey-Paste and NumTrey-RUSF in comparison to a standard biscuit product (BP-100) used for the treatment of SAM.

Acceptability of NumTrey-RUSF and NumTrey-Paste was tested in a nonblinded crossover taste trial among children (n = 52), aged ≥ 6 months to 18 years, and their caregivers. Eight organoleptic qualities were assessed on a 5-point hedonic scale, as well as a ranking test. A score of 1 to 3 was categorized as acceptable. The acceptability of NumTrey-RUTF was assessed using the caregivers’ perception during an SAM treatment intervention.

Taste trial: The proportion of children categorizing products as overall acceptable was lowest for NumTrey-Paste compared to for BP-100 and NumTrey-RUSF (21% vs 43% [BP-100] and 36% [NumTrey-RUSF]). No difference was found in the proportion of children who ranked BP-100 or NumTrey-RUSF as “liked most” (P > .05). Acceptability of NumTrey-RUSF ranked highest in appearance and taste (caregiver), whereas acceptability of NumTrey-Paste was ranked lowest in appearance and smell among the products. Intervention trial: The acceptability of NumTrey-RUTF increased from 72% to 86%.

The overall acceptability was ranked lowest for a pure paste product. However, filling the paste into a wafer made the product more acceptable.

A therapy based on ready-to-use therapeutic food (RUTF) in outpatient settings is considered the gold standard in the treatment of severe acute malnutrition in children younger than 5 years. The price of RUTF is the key cost driver of the therapy. However, no studies to date have systematically examined the determinants of RUTF prices.

This article presents the first analysis of factors associated with the prices of RUTF, focusing on the impact of competition and tendering.

This article examines data on the prices of RUTF purchased by UNICEF Supply Division from 2006 through 2015 (90% of RUTF purchased globally). To assess the association between price, competition, and tender introduction, controlling for potential confounding factors, regression analysis using a generalized estimating equation was used.

Competition, measured as the number of suppliers, was negatively associated with RUTF price. On the other hand, no statistically significant association was found between RUTF price tendering. Quantities sold were also significantly associated with RUTF prices.

Significant price reductions have been achieved by increasing competition in the RUTF market. In contrast, introduction of tendering did not result in decreases in prices. Tendering is an effective price-lowering mechanism because it awards the bidder(s) with the lowest price with market exclusivity. However, the current tender system promotes market fragmentation and reduces the incentives for price reductions. Further reduction in RUTF prices can likely be achieved by modifying the current tendering procedures and putting a greater emphasis on price competition.

The government of Burkina Faso, along with the United Nations Network for Nutrition (UNN), activity REACH (Renewed Efforts Against Child Hunger and undernutrition) partnership, conducted a mapping of nutrition interventions and stakeholders to identify the best approaches for scaling up priority nutrition interventions and to strengthen a multisectoral response to fight malnutrition.

The objectives include describing the process used to map a set of country-prioritized nutrition interventions and to describe how the results contributed to the multisectoral nutrition planning process in Burkina Faso.

The mapping exercise was designed as a cross-sectional study using the Excel-based Scaling Up Nutrition Planning and Monitoring Tool (SUN PMT) to collect, store, and analyze data.

The results present different analyses produced by the SUN PMT for 29 prioritized nutrition interventions. The analyses include the distribution of nutrition stakeholders for each intervention, the calculation of geographic and population coverage for each intervention, and the utilization of delivery mechanisms to reach beneficiaries.

The mapping of key nutrition interventions and stakeholders supporting those interventions in Burkina Faso was an important tool in the multisectoral planning process. The exercise made it possible to identify gaps and needs; launch a discussion on nutrition planning and the scaling up of interventions; and mobilize sectors and development partners around nutrition.

Providing additional nutriment represents one strategy for overcoming moderate–acute malnutrition (MAM) in children younger than 5 years. However, it is important to examine how well received such Supplemental Nutrition Assistance Programs (SNAP) are by caregivers in order to ensure optimal results.

This study explores SNAP’s reception by caregivers of MAM children younger than 5 years.

Qualitative research was conducted through semi-structured, in-depth interviews with 16 selected caregivers and 5 Nutritional Executives from October to November, 2016 at 4 health centers in Denpasar, Bali, Indonesia. The results are presented to highlight the underlying patterns of SNAP’s acceptance.

Overall, the informants responded negatively to SNAP, reporting that it was of limited usefulness. The results show 4 main themes relating to the receipt of SNAP. The first relates to the caregiver’s preferences in terms of the types of supplementary food on offer. Second, caregiver’s perceptions that the child was not, in fact, in a state of illness or disease due to a medical issue. Third, that the caregiver does not require supplementary food as they maintain that they are able to buy it independently. Fourth, factors related to the lack of support for health-care workers working with malnourished children.

The study finds that strengthening the role of health workers in terms of enabling them to effectively communicate the benefits of supplementary food to caregivers as well as adjusting the range of foods available according to the recipient’s preferences is critical in overcoming malnutrition in children younger than 5 years.

There is a growing recognition of the importance of adolescent health and well-being. Yet, little attention has been paid to adolescent nutrition, and few policies and programs are targeting to improve adolescent nutrition in Indonesia.

This analysis aimed to identify (1) the extent to which adolescents are considered in nutrition policy in Indonesia and (2) opportunities to improve nutrition policy content to effectively target adolescents.

We collected data on policy content through a desk review of national and subnational level nutrition-specific strategic plans, laws, regulations, and program guidelines. We then conducted 74 key informant interviews with policy makers and program experts in health, education, and related sectors using semistructured interview guides based on policy theory to examine policy context and implementation. The policy content and interview data were analyzed using thematic synthesis and narrative analysis.

Currently, 2 nutrition-specific policies and programs are designed to improve adolescent nutrition in Indonesia, one focusing on iron–folic acid supplementation for adolescent girls and another on obesity prevention and management in schools. These programs are yet to be implemented at scale. Overall, adolescent nutrition is not yet considered a priority in the national development agenda. An opportunity exists to improve action on adolescent nutrition in Indonesia through scaling up of district-level policies and through improving coordination mechanisms across sectors.

Few policies and programs exist to support adolescent nutrition in Indonesia. Coordinated efforts across relevant sectors and levels of government should be made to mainstream adolescent nutrition into relevant policies.

Although undernutrition and sarcopenia are common among older adults and both result in worse health outcomes, data concerning the burden of these conditions in Portuguese community-dwelling older adults are scarce.

The aim of this study was to firstly describe the occurrence of sarcopenia and undernutrition among a nationwide community-dwelling sample of older adults.

Using a cross-sectional analysis, 1493 Portuguese older adults age ≥65 years from the Nutrition UP 65 study were evaluated. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People, and undernutrition status was evaluated by Mini-Nutritional Assessment-Short Form.

Sarcopenia frequency was 11.6%, and of these, 4.4% were classified with severe sarcopenia. Furthermore, 0.8% presented sarcopenic obesity. Undernutrition frequency was 1.3%, and 14.7% of the older adults were classified as being at undernutrition risk.

Sarcopenia is present in one-tenth of the sample. This frequency taken together with undernutrition data warrants further study and preventive measures.