Keith P. West

The Epidemiology of Global Micronutrient Deficiencies

Micronutrients are essential to sustain life and for optimal physiological function. Widespread global micronutrient deficiencies (MNDs) exist, with pregnant women and their children under 5 years at the highest risk. Iron, iodine, folate, vitamin A, and zinc deficiencies are the most widespread MNDs, and all these MNDs are common contributors to poor growth, intellectual impairments, perinatal complications, and increased risk of morbidity and mortality. Iron deficiency is the most common MND worldwide and leads to microcytic anemia, decreased capacity for work, as well as impaired immune and endocrine function. Iodine deficiency disorder is also widespread and results in goiter, mental retardation, or reduced cognitive function. Adequate zinc is necessary for optimal immune function, and deficiency is associated with an increased incidence of diarrhea and acute respiratory infections, major causes of death in those <5 years of age. Folic acid taken in early pregnancy can prevent neural tube defects. Folate is essential for DNA synthesis and repair, and deficiency results in macrocytic anemia. Vitamin A deficiency is the leading cause of blindness worldwide and also impairs immune function and cell differentiation. Single MNDs rarely occur alone; often, multiple MNDs coexist. The long-term consequences of MNDs are not only seen at the individual level but also have deleterious impacts on the economic development and human capital at the country level. Perhaps of greatest concern is the cycle of MNDs that persists over generations and the intergenerational consequences of MNDs that we are only beginning to understand. Prevention of MNDs is critical and traditionally has been accomplished through supplementation, fortification, and food-based approaches including diversification. It is widely accepted that intervention in the first 1,000 days is critical to break the cycle of malnutrition; however, a coordinated, sustainable commitment to scaling up nutrition at the global level is still needed. Understanding the epidemiology of MNDs is critical to understand what intervention strategies will work best under different conditions.

Data management for large community trials in Nepal.

The current accessibility and sophistication of hardware and software has made it possible to design high-quality data management systems for community-based trials in resource-poor environments. We designed, implemented, and operated an effective data management system for the Nepal Nutrition Intervention Project Sarlahi (NNIPS), a placebo-controlled community trial to assess the impact of vitamin A supplementation on the preschool mortality of 38,000 children in the Sarlahi district of Nepal. A data center was established in Kathmandu, approximately 8 hr drive from the study area. The trial is now completed and over 200,000 forms have been processed. The majority of potential data discrepancies were identified and corrected by field workers during the interviews. Supervisors and forms editors located at the field office corrected most data errors. Once forms reach Kathmandu, the average number of data entry errors was 3.1 per 10,000 keystrokes for the eight data entry operators employed during the study. Extensive computerized checking of data during data entry found out-of-range, missing, or inconsistent data in only 1% of forms. Timely analysis of field worker performance provided ongoing feedback to supervisors and analysis for the Data Safety and Monitoring Committee, and for publication of results.

A Field Training Guide for Human Subjects Research Ethics

Maria Merritt and colleagues report on a Field Training Guide for Human Subjects Research Ethics that they have developed to help train field workers in ethics for research.

Prevalence of hearing loss and ear morbidity among adolescents and young adults in rural southern Nepal

Abstract A cross-sectional survey was conducted among 3646 persons, 15 to 23 years of age, in the southern plains District of Sarlahi, Nepal, to assess the prevalence and severity of hearing loss and middle-ear dysfunction, and adverse effects of hearing loss on social integration. Between 2006 and 2008, subjects were enumerated and underwent otoscopic, tympanometric, and audiometric evaluations at central sites in villages. Hearing loss was diagnosed in subjects who failed a hearing screening and exhibited an average air conduction threshold value greater than or equal to 30 dBHL in the worse ear. Clinically, 32.8% of subjects exhibited a dull or retracted tympanic membrane, and 18% had abnormal tympanometry. Nearly 12% failed the hearing screening test, among whom more than half, or 6.1% overall, had hearing loss. Hearing-impaired subjects were six- to eight-fold (ORs, with 95% CIs excluding 1.0) more likely to report problems in hearing usual sounds or communicating with other people. Among young adults living in southern Nepal, hearing loss is common, and associated with social disability. Sumario Se realizó una investigación transversal en 3646 personas de 15 a 23 años de edad en las llanuras del Distrito de Sarlahi, en el Sur del Nepal, para evaluar la prevalencia y severidad de la hipoacusia y de la disfunción del oído medio y los efectos adversos de la pérdida auditiva en la integración social. Entre 2006 y 2008 se incluyeron los sujetos y se evaluaron otoscópica, timpanométrica y audiométricamente en zonas centrales de los poblados. Se diagnosticó hipoacusia a quienes fallaron el tamiz auditivo y mostraron una vía aérea con promedio de umbrales mayor a 30 dBHL en el oído peor. Clínicamente, el 32.8% tenían membrana timpánica opaca o retraída y 18%, timpanometría anormal. Cerca del 12% fallaron en el tamiz auditivo y de ellos, más de la mitad, globalmente el 6.1%, tenían hipoacusia. Estos sujetos fueron 6 a 8 veces (ORs 95% excluyendo 1.0 CIs) mayor probabilidad de reportar problemas para escuchar sonidos comunes o para comunicarse con otras personas. Entre los adultos jóvenes que viven en el sur de Nepal, la hipoacusia es común y se asocia a discapacidad social.

A Quarter of a Century of Progress to Prevent Vitamin A Deficiency Through Supplementation

A quarter of century has passed since FRI published its first comprehensive review on vitamin A deficiency (VAD) and its prevention. At the time, the major impetus to prevent VAD was to reduce xerophthalmia in preschool children. Today, we have a broader understanding of the public health implications of VAD, with disorders including xerophthalmia, mortality, severe infection, and anemia in preschool children and pregnant women. While deficiency affects most developing countries, nearly half of all deficient children and women live in Southern Asia. Prevention has made substantial strides. High potency vitamin A supplementation (with 200,000 IU) remains a prophylactic mainstay, delivered through fixed facilities, enhanced outreach activities, and national child health day campaigns twice annually. Surprisingly, the costs of semi-annual delivery of vitamin A have changed little over the years, with new cost estimates remaining comparable to earlier figures of US ∼

Prevalence and Risk Factors of Elevated Blood Pressure, Overweight, and Dyslipidemia in Adolescent and Young Adults in Rural Nepal

0.50 per child per year. Emerging is the potential to reduce infant mortality by ∼20% in Southern Asia by giving a single, oral, 50,000 IU dose of vitamin A to newborns. While ∼500 million vitamin A capsules are routinely distributed worldwide each year to achieve effective control, progress has been slower with efforts to improve diet on a purposeful global public health scale. Future advances through effective dietary diversification and various means of food fortification will be required before periodic supplementation can be phased down as a major population strategy for controlling vitamin A deficiency.

Preferred Delivery Method and Acceptability of Wheat-Soy Blend (WSB++) as a Daily Complementary Food Supplement in Northwest Bangladesh

BACKGROUND Chronic disease begins early in life, yet population data are sparse on potential causal factors in children and young adults in South Asia. METHODS We assessed risk factors for chronic disease in two population cohorts, aged 9-23 years, in rural Nepal. Assessed variables included short height (less than -2 z), high body mass index (BMI) (z>0.42), waist circumference (WC) >90 cm (male) or 80 cm (female) or age-adjusted child cutoff], high blood pressure (>120/80 mmHg), fasting glucose (≥100 mg/dL), glycosylated hemoglobin (HbA1c) (>7%), blood lipids [triglyceride, high-density lipoprotein cholesterol (HDL-C), and total cholesterol], diet, smoking, alcohol, and socioeconomic status (SES) factors. RESULTS The population was stunted (46%) and few were overweight (∼2%-4% with high BMI or WC). Twelve percent had high blood pressure. Plasma hypertriglyceridemia (≥150 mg/dL) affected ∼8.5%, and 78% had low HDL-C concentrations <40 mg/dL (male) or <50 mg/dL (female)], while few (≤3%) had elevated total cholesterol (≥180 mg/dL), glucose, and HbA1c. Females were at higher risk than males for high blood pressure [odds ratio (OR) 1.9; 95% confidence interval (CI) 1.6-2.3] and overweight (4.2; 3.0-5.8), but had lower risk of dyslipidemia (0.7; 0.6-0.9). Ethnic plains Madheshi were less likely to be overweight (0.3; 0.2-0.4), but had greater risk of dyslipidemia (1.4; 1.1-1.7) versus those of Hill origin. Some dietary factors were significantly associated with high blood pressure or dyslipidemia, but not overweight. CONCLUSIONS Dyslipidemia and high blood pressure are emerging health concerns among young adults in rural Nepal.

Peri‐urban malnutrition in bangladesh: Differential energy, protein, and growth status of children

Fortified blended foods (FBFs) are widely used to prevent undernutrition in early childhood in food-insecure settings. We field tested enhanced Wheat Soy Blend (WSB++)—a FBF fortified with micronutrients, milk powder, sugar, and oil—in preparation for a complementary food supplement (CFS) trial in rural northwestern Bangladesh. Formative work was conducted to determine the optimal delivery method (cooked vs. not) for this CFS, to examine mothers’ child feeding practices with and acceptance of the WSB++, and to identify potential barriers to adherence. Our results suggest WSB++ is an acceptable CFS in rural Bangladesh and the requirement for mothers to cook WSB++ at home is unlikely to be a barrier to its daily use as a CFS in this population.

The epidemiology of trachoma in southern Malawi.

A sample of 292 children 12 to 59 months of age in two large squatter camps near Dhaka underwent nutritional assessment during July and August 1979. Anthropometric measurements included weight, height, left mid‐upper arm circumference, and skinfolds at four sites (triceps, biceps, subscapular, and supra‐iliac). Derived upper arm indicators included muscle and fat areas as estimators of body composition. Findings were compared with previous anthropometric survey data from rural Bangladesh and with normative data from the United States. Twenty‐three percent of camp children were moderately to severely wasted (<80 % WH) and 34 % were severely stunted (<85 % HA). Wasted children of both sexes were of similar body composition though above 90 % WH girls were significantly fatter than boys. This relatively fatter body composition appeared greater than expected for normal sexual dimorphism, but it was not associated with any statural advantage for girls. For both sexes, stature was more strongly associated with m...