Shibani Ghosh

Lysine fortification: past, present, and future.

Fortification with lysine to improve the protein value of human diets that are heavily based on cereals has received support from the results of these recent studies [1,2]. Support also comes from examination of average food and nutrient availability data derived from food balance sheets. Whereas nutritional status is influenced by the nutrient content of foods consumed in relation to need, the requirements for protein and amino acids are influenced by many additional factors [10, 12, 14, 28, 29]. These include age, sex, body size, physical activity, growth, pregnancy and lactation, infection, and the efficiency of nutrient utilization. Even if the immune response was influenced by the added lysine, adequate water and basic sanitation would remain essential. Acute and chronic undernutrition and most micronutrient deficiencies primarily affect poor and deprived people who do not have access to food of adequate nutritional value, live in unsanitary environments without access to clean water and basic services, and lack access to appropriate education and information [30]. A further variable is the possible interaction between protein and food energy availability [31]. This could affect the protein value of diets when food energy is limiting to a significant degree. Thus, the additional effects of food energy deficiency on protein utilization could well be superimposed on the very poorest. The improvement of dietary diversity must be the long-term aim, with dietary fortification considered only a short-term solution. The former should take place as wealth improves and the gaps between rich and poor diminish. Although such changes are taking place, they are highly uneven. Over the last several decades, increases have occurred in the availability of food energy, total protein, and animal protein for both developed and developing countries. However, for the very poorest developing countries over the same period, changes have been almost nonexistent, and the values for some nutritional indicators have even declined. For estimated lysine value, the developed countries showed increases in per capita availability from 5,400 to 6,167 mg per day and the developing countries from 2,400 to 3,454 mg per day, while in contrast, the very poorest countries remained static at about 2,400 to 2,500 mg per day. Thus, although lysine fortification may be theoretically only a short-term solution, in the very poorest countries changes in wealth such that dietary diversity and lysine availability may increase by natural progression remain remote. If we can justify using lysine to fortify animal feed in the rich regions of the world for economic gain, perhaps we should now consider adding lysine to the flour consumed by the deprived people in the poorest regions of the world to improve both their nutrition and their resistance to disease.

Reliability and validity of the center for epidemiologic studies-depression scale in screening for depression among HIV-infected and -uninfected pregnant women attending antenatal services in northern Uganda: a cross-sectional study

BackgroundThere are limited data on the prevalence and approaches to screening for depression among pregnant women living in resource poor settings with high HIV burden.MethodsWe studied the reliability and accuracy of the Center for Epidemiologic Studies Depression (CES-D) scale in 123 (36 HIV-infected and 87 -uninfected) pregnant women receiving antenatal care at Gulu Regional Referral Hospital, Uganda. CES-D scores were compared to results from the psychiatrist-administered Mini-International Neuropsychiatric Interview (MINI) for current major depressive disorder (MDD), a “gold standard” for assessing depression. We employed measures of internal consistency (Cronbach’s alpha), and criterion validity [Area Under the Receiver Operating Characteristic Curve (AUROC), sensitivity (Se), specificity (Sp), and positive predictive value (PPV)] to evaluate the reliability and validity of the CES-D scale.Results35.8% of respondents were currently experiencing an MDD, as defined from outputs of the MINI-depression module. The CES-D had high internal consistency (Cronbach’s alpha = 0.92) and good discriminatory ability in detecting MINI-defined current MDDs (AUROC = 0.82). The optimum CES-D cutoff score for the identification of probable MDD was between 16 and 17. A CES-D cutoff score of 17, corresponding to Se, Sp, and PPV values of 72.7%, 78.5%, and 76.5%, is proposed for adoption in this population and performs well for HIV-infected and -uninfected women. After adjusting for baseline differences between the HIV subgroups (maternal age and marital status), HIV-infected pregnant women scored 6.2 points higher on the CES-D than HIV-uninfected women (p = 0.032).ConclusionsThe CES-D is a suitable instrument for screening for probable major depression among pregnant women of mixed HIV status attending antenatal services in northern Uganda.

Can Smallholder Fruit and Vegetable Production Systems Improve Household Food Security and Nutritional Status of Women? Evidence from Rural Uganda

This paper aims to empirically infer potential causal linkages between fruit and vegetable (F&V) production, individual F&V intake, household food security, and anemia levels for individual women caregivers of childbearing age.

Effect of lysine supplementation on health and morbidity in subjects belonging to poor peri-urban households in Accra, Ghana.

BACKGROUND Lysine affects diarrhea and anxiety via effects on serotonin receptors, enhanced intestinal repair, and sodium chloride-dependent opioid peptide transport. OBJECTIVE The objective was to investigate the effects of lysine supplementation on morbidity, growth, and anxiety in children and adults of peri-urban areas of Accra, Ghana. DESIGN In a double-blind randomized trial, the effect of lysine supplementation (1 g lysine/d) compared with that of placebo was examined in 2 groups of men, women, and children (n = 271). Primary outcomes included diarrheal and respiratory morbidity, growth, and anxiety and complement C3, C-reactive protein, serum cortisol, transferrin, and ferritin values. Independent-sample t tests, odds ratios, generalized estimating equations, 4-parameter sinusoid regression, and generalized linear models were used. RESULTS Thirty percent of men, 50% of women, and 15% of children were at risk of lysine inadequacy. Supplementation in children reduced diarrheal episodes [19 lysine, 35 placebo; odds ratio (OR): 0.52; 95% CI: 0.29, 0.92; P = 0.046] and the total number of days ill (21 lysine, 47 placebo; OR: 0.44; 95% CI: 0.26, 0.74; P = 0.034). Mean days ill per child per week (0.058 ± 0.039 lysine, 0.132 ± 0.063 placebo; P = 0.017) were negatively associated with weight gain with control for baseline weight and study group (P = 0.04). Men had fewer coryza episodes (23 lysine, 39 placebo; OR: 0.60; 95% CI: 0.36, 1.01; P = 0.05), total number of days ill (lysine: 130; placebo: 266; OR: 0.51; 95% CI: 0.28, 0.93; P = 0.03), and mean days ill per person per week (lysine: 0.21 ± 0.23; placebo: 0.41 ± 0.35; P = 0.04). Serum ferritin (P = 0.045) and C-reactive protein (P = 0.018) decreased in lysine-supplemented women but increased in placebo-supplemented women. CONCLUSION Lysine supplementation reduced diarrheal morbidity in children and respiratory morbidity in men in Ghana.

Protein Quality in the First Thousand Days of Life

The aim of this article is to provide an overview of the role of protein quality within the first 1000 days of life. The article outlines the importance of protein quality in pregnancy and early growth and examines the potential of high-quality protein in prevention of stunting and treatment of severe and moderate acute malnutrition. The article also provides a summary of the recent changes in protein quality evaluation and the development of a new index, the Digestibility Corrected Amino Acid Score, examining the opportunities and challenges this new methodology presents in assessing protein quality.

Improving complementary feeding in Ghana: reaching the vulnerable through innovative business--the case of KOKO Plus.

Reaching vulnerable populations in low‐resource settings with effective business solutions is critical, given the global nature of food and nutrition security. Over a third of deaths of children under 5 years of age are directly or indirectly caused by undernutrition. The Lancet series on malnutrition (2013) estimates that over 220,000 lives of children under 5 years of age can be saved through the implementation of an infant and young child feeding and care package. A unique project being undertaken in Ghana aims to bring in two elements of innovation in infant and young child feeding. The first involves a public–private partnership (PPP) to develop and test the efficacy and effectiveness of the delivery of a low‐cost complementary food supplement in Ghana called KOKO Plus™. The second involves the testing of the concepts of social entrepreneurship and social business models in the distribution and delivery of the product. This paper shares information on the ongoing activities in the testing of concepts of PPPs, social business, social marketing, and demand creation using different delivery platforms to achieve optimal nutrition in Ghanaian infants and young children in the first 2 years of life. It also focuses on outlining the concept of using PPP and base‐of‐the‐pyramid approaches toward achieving nutrition objectives.

Impact of Lysine-Fortified Wheat Flour on Morbidity and Immunologic Variables among Members of Rural Families in Northwest Syria

Background Previous studies have shown an effect of lysine fortification on nutrition and immunity of poor men, women, and children consuming a predominantly wheat-based diet. Objective To examine the lysine value of diets and the effect of lysine fortification on functional protein status, anthropometry, and morbidity of men, women, and children in rural Syria. Methods At baseline of a two-phase study using 7-day household food intake inventories (n = 98), nutrient availabilities per adult male equivalent were estimated. In the intervention phase, a 16-week double-blind trial, households (n = 106) were randomly assigned to control and lysine groups. Hematologic and anthropometric data were collected from men (n = 69; 31 control, 38 lysine), women (n = 99; 51 control, 48 lysine), and children (n = 69; 37 control, 32 lysine) at baseline, 12 weeks, and 16 weeks. Total CD3 T lymphocytes as well as T lymphocytes bearing the receptors CD4, CD8, and CD56, IgM, IgG, IgA, complement C3, C-reactive protein, serum albumin, prealbumin, transferrin, retinol-binding protein, hemoglobin, and hepatitis B surface antigen were determined. Health status and flour usage were monitored. Paired- and independent-sample t-tests and chi-square tests were performed. Results Mean nutrient availability per adult equivalent was 2,650 ± 806 kcal, 70.1 ± 26.4 g protein, 65 ± 14% cereal protein, and 41.9 ± 0.8 mg lysine per gram of protein. Complement C3 was significantly higher in men receiving lysine than in controls (p < .05). Among women, there were significant differences between the control and lysine groups in diarrhea period prevalence (total number of diarrheal episodes during the period of intervention divided by the total number of observations), (20 in the control group, 6 in the lysine group; p = .014), the mean number of days ill (0.4 ± 0.7, control, 0.14 ± 0.4, lysine, p = 0.03), and the number of diarrheal episodes per person per year (1.39 in the control group, 0.47 in the lysine group). No other significant differences between the lysine and the control groups were observed. Conclusions Lysine fortification of wheat flour demonstrated a positive effect on diarrheal morbidity in women. The effect could be attributed to an improvement in protein utilization but possibly also to a direct effect of lysine in gastrointestinal tract. Studies in populations with higher diarrheal prevalence and significant dietary lysine deficiency are needed to determine whether the reported effects on diarrheal prevalence are replicable and whether they are pharmacological or nutritional. It would be particularly desirable to study the effect of lysine on diarrhea in preschool children, who have much higher morbidity and mortality rates from this disease than school-age children or adults.

Optimization of the Nutrient Content and Protein Quality of Cereal—Legume Blends for Use as Complementary Foods in Ghana

Background Nutritionally adequate complementary foods made from locally available ingredients are of high priority in developing countries, including Ghana. The majority of complementary foods in these countries are cereal-based and are unable to meet the nutrient intakes recommended by the World Health Organization. Objective To evaluate the nutrient content and protein quality of local cereal—legume blends for complementary foods against recommendations and to determine the quantities of additional ingredients required to meet needs by using linear programming. Methods Nine cereal—legume combinations (maize, sorghum, or millet combined with cowpea, peanut, or soybean) and koko (a traditional Ghanaian maize-based complementary food) were evaluated based on the macronutrient targets for a daily ration of complementary food for the age group 12 to 24 months: 264 kcal, 6.5 g of protein, and 8.2 to 11.7 g of fat. Protein quality was assessed by the Protein Digestibility Corrected Amino Acid Score (PDCAAS). Linear programming was then used to determine the amounts of additional oil, sugar, and lysine needed to meet macronutrient requirements. Results No traditional cereal—legume food met all complementary food macronutrient requirements on its own. Cereal—legume blends made with peanut or cowpeas were low in quality protein, while those with soybean were low in fat. Lysine was the limiting amino acid (PDCAAS 0.50 to 0.82) in all blends. Adding lysine increased utilizable protein by 1% to 10% in soybean blends, 35% to 40% in peanut blends, and 14% to 24% in cowpea blends. Peanut—maize, peanut—millet, and all soybean—cereal blends were able to meet macronutrient targets; most micronutrients remained below recommended levels. Conclusions Traditional cereal—legume blends made from locally available ingredients do not meet energy, quality protein, and fat recommendations for complementary foods; however, such complementary food blends may be optimized to meet nutrient requirements by using linear programming as a tool to determine the exact levels of fortificants to be added (including, but not limited to, added fat, amino acids, and micronutrients).

Protein Quality Workshop: importance of protein quality in prevention and treatment of child malnutrition.

Devika Suri is affiliated with the Nevin Scrimshaw International Nutrition Foundation, Boston, Massachusetts, USA; Shelley Marcus is affiliated with Tufts University, Boston; Shibani Ghosh and Irwin Rosenberg are affiliated with Tufts University and the Nevin Scrimshaw International Nutrition Foundation; Anura Kurpad is affiliated with St. John’s Research Institute, Bangalore, India. Please direct queries to the corresponding author: Irwin Rosenberg, Tufts University, 150 Harrison Ave., Boston, MA 02111 USA; e-mail: Irwin.rosenberg@tufts.edu. The Protein Quality Workshop was sponsored by the United States Agency for International Development (USAID) and was coorganized by the Food Aid Quality Review (FAQR) team at the Tufts University Friedman School of Nutrition Science and Policy and the Nevin Scrimshaw International Nutrition Foundation. The workshop was held May 16 and 17, 2012, at the Tufts University/United States Department of Agriculture Human Nutrition Research Center on Aging in Boston.

Assessing Program Coverage of Two Approaches to Distributing a Complementary Feeding Supplement to Infants and Young Children in Ghana

The work reported here assesses the coverage achieved by two sales-based approaches to distributing a complementary food supplement (KOKO Plus™) to infants and young children in Ghana. Delivery Model 1 was conducted in the Northern Region of Ghana and used a mixture of health extension workers (delivering behavior change communications and demand creation activities at primary healthcare centers and in the community) and petty traders recruited from among beneficiaries of a local microfinance initiative (responsible for the sale of the complementary food supplement at market stalls and house to house). Delivery Model 2 was conducted in the Eastern Region of Ghana and used a market-based approach, with the product being sold through micro-retail routes (i.e., small shops and roadside stalls) in three districts supported by behavior change communications and demand creation activities led by a local social marketing company. Both delivery models were implemented sub-nationally as 1-year pilot programs, with the aim of informing the design of a scaled-up program. A series of cross-sectional coverage surveys was implemented in each program area. Results from these surveys show that Delivery Model 1 was successful in achieving and sustaining high (i.e., 86%) effective coverage (i.e., the child had been given the product at least once in the previous 7 days) during implementation. Effective coverage fell to 62% within 3 months of the behavior change communications and demand creation activities stopping. Delivery Model 2 was successful in raising awareness of the product (i.e., 90% message coverage), but effective coverage was low (i.e., 9.4%). Future programming efforts should use the health extension / microfinance / petty trader approach in rural settings and consider adapting this approach for use in urban and peri-urban settings. Ongoing behavior change communications and demand creation activities is likely to be essential to the continued success of such programming.