Tsinuel Girma

Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age.

There is consensus on how to treat severe malnutrition, but there is no agreement on the most cost-effective way to treat infants and young children with moderate malnutrition who consume cereal-dominated diets. The aim of this review is to give an overview of the nutritional qualities of relevant foods and ingredients in relation to the nutritional needs of children with moderate malnutrition and to identify research needs. The following general aspects are covered: energy density, macronutrient content and quality, minerals and vitamins, bioactive substances, antinutritional factors, and food processing. The nutritional values of the main food groups—cereals, legumes, pulses, roots, vegetables, fruits, and animal foods—are discussed. The special beneficial qualities of animal-source foods, which contain high levels of minerals important for growth, high-quality protein, and no antinutrients or fibers, are emphasized. In cereal-dominated diets, the plant foods should be processed to reduce the contents of antinutrients and fibers. Provision of a high fat content to increase energy density is emphasized; however, the content of micronutrients should also be increased to maintain nutrient density. The source of fat should be selected to supply optimal amounts of polyunsaturated fatty acids (PUFAs), especially n-3 fatty acids. Among multiple research needs, the following are highlighted: to identify the minimum quantity of animal foods needed to support acceptable child growth and development, to examine the nutritional gains of reducing contents of antinutrients and fibers in cereal- and legume-based diets, and to examine the role of fat quality, especially PUFA content and ratios, in children with moderate malnutrition.

Fat and fat-free mass at birth: air displacement plethysmography measurements on 350 Ethiopian newborns

LBW increases the risk of a number of noncommunicable diseases in adulthood. However, birth weight (BW) cannot describe variability in infant body composition (BC). Variability in fat mass (FM) and fat-free mass (FFM) at birth may be particularly important in low-income countries because they undergo nutritional transition. There is a need for data on birth BC and its predictors from low-income countries in transition. We assessed absolute FM and FFM at birth and examined the role of gender, parity, GA, and LBW as predictors of birth BC. FM and FFM were assessed within 48 h of birth on 350 Ethiopian newborns using air displacement plethysmography (ADP). Female gender and being an infant of primi- or secundiparous mothers predicted lower BW and lower birth FFM but not FM, compared with male gender and infants of multiparous mothers, respectively. There was a positive linear relationship between BW and relative amount of FM for boys and girls. This study presents reference data on birth FM and FFM from a low-income setting and provides background for further longitudinal mapping of the relationship between fetal BC, childhood growth, and adult disease.

Ototoxicity of artemether/lumefantrine in the treatment of falciparum malaria: a randomized trial

BackgroundDue to increasing drug resistance, artemisinin-based combination chemotherapy (ACT) has become the first-line treatment of falciparum malaria in many endemic countries. However, irreversible ototoxicity associated with artemether/lumefantrine (AL) has been reported recently and suggested to be a serious limitation in the use of ACT. The aim of the study was to compare ototoxicity, tolerability, and efficacy of ACT with that of quinine and atovaquone/proguanil in the treatment of uncomplicated falciparum malaria.MethodsNinety-seven patients in south-west Ethiopia with slide-confirmed malaria were randomly assigned to receive either artemether/lumefantrine or quinine or atovaquone/proguanil and followed-up for 90 days. Comprehensive audiovestibular testing by pure tone audiometry (PTA), transitory evoked (TE) and distortion product (DP) otoacoustic emissions (OAE) and brain stem evoked response audiometry (BERA) was done before enrolment and after seven, 28 and 90 days.ResultsPTA and DP-OAE levels revealed transient significant cochlear hearing loss in patients treated with quinine but not in those treated with artemether/lumefantrine or atovaquone/proguanil. TE-OAE could be elicited in all examinations, except for three patients in the Q group on day 7, who suffered a transient hearing loss greater than 30 dB. There was no evidence of drug-induced brain stem lesions by BERA measurements.ConclusionThere was no detrimental effect of a standard oral regimen of artemether/lumefantrine on peripheral hearing or brainstem auditory pathways in patients with uncomplicated falciparum malaria. In contrast, transient hearing loss is common after quinine therapy and due to temporary outer hair cell dysfunction.

Effects of nutritional supplementation for HIV patients starting antiretroviral treatment: randomised controlled trial in Ethiopia

Objectives To determine the effects of lipid based nutritional supplements with either whey or soy protein in patients with HIV during the first three months of antiretroviral treatment (ART) and to explore effects of timing by comparing supplementation at the start of ART and after three months delay. Design Randomised controlled trial. Setting Three public ART facilities in Jimma, Oromia region, Ethiopia. Participants Adults with HIV eligible for ART with body mass index (BMI) >16. Intervention Daily supplementation with 200 g (4600 kJ) of supplement containing whey or soy during either the first three or the subsequent three months of ART. Outcome measures Primary: lean body mass assessed with deuterium dilution, grip strength measured with dynamometers, and physical activity measured with accelerometer and heart rate monitors. Secondary: viral load and CD4 counts. Auxiliary: weight and CD3 and CD8 counts. Results Of 318 patients enrolled, 210 (66%) were women, mean age was 33 (SD 9), and mean BMI was 19.5 (SD 2.4). At three months, participants receiving the supplements containing whey or soy had increased their lean body mass by 0.85 kg (95% confidence interval 0.16 kg to 1.53 kg) and 0.97 kg (0.29 kg to 1.64 kg), respectively, more than controls. This was accompanied by an increased gain of grip strength of 0.68 kg (−0.11 kg to 1.46 kg) for the whey supplement group and 0.93 kg (0.16 kg to 1.70 kg) for the soy supplement group. There were no effects on physical activity. Total weight gain increased by 2.05 kg (1.12 kg to 2.99 kg) and 2.06 kg (1.14 kg to 2.97 kg) for the whey and soy groups, respectively. In addition, in the whey supplement group overall CD3 counts improved by 150 cells/µL (24 to 275 cells/µL), of which 112 cells/µL (15 to 209 cells/µL) were CD8 and 25 cells/µL (−2 to 53 cells/µL) were CD4. Effects of the soy containing supplement on immune recovery were not significant. The effects of the two supplements, however, were not significantly different in direct comparison. Exploratory analysis showed that relatively more lean body mass was gained by patients with undetectable viral load at three months. Patients receiving delayed supplementation had higher weight gain but lower gains in functional outcomes. Conclusions Lipid based nutritional supplements improved gain of weight, lean body mass, and grip strength in patients with HIV starting ART. Supplements containing whey were associated with improved immune recovery. Trial registration Controlled-trials.com ISRCTN32453477.

Genotype diversity of Mycobacterium isolates from children in Jimma, Ethiopia.

BackgroundPaediatric tuberculosis (TB) is poorly addressed in Ethiopia and information about its magnitude and the genotype distribution of the causative Mycobacterium tuberculosis strains responsible for its spread are scanty.MethodsGastric lavage or sputum samples were collected from consecutively enrolled TB suspect children visiting Jimma University Hospital in 2011 and cultured on Middlebrook 7H11 and Löwenstein-Jensen media. Acid fast bacterial (AFB) isolates were subjected to molecular typing targeting regions of difference (RDs), 16S rDNA gene and the direct repeat (DR) region using multiplex polymerase chain reaction (mPCR), gene sequencing and spoligotyping, respectively. Molecular drug susceptibility testing of M. tuberculosis isolates was performed by Genotype®MTBDRplus line probe assay (LPA) (Hain Life Sciences, Germany).ResultsGastric lavage (n = 43) or sputum (n = 58) samples were collected from 101 children and 31.7% (32/101) of the samples were positive for AFB by microscopy, culture and/or PCR. Out of 25 AFB isolates, 60% (15/25) were identified as M. tuberculosis by PCR, and 40% isolates (10/25) were confirmed to be non-tuberculous mycobacteria (NTM) by genus typing and 16S rDNA gene sequencing. Lineage classification assigned the M. tuberculosis strains into Euro-American (EUA, 66.7%; 10/15), East-African-Indian (EAI; 2/15), East-Asian (EA; 1/15) and Indio-Oceanic (IO; 1/15) lineages. Seven M. tuberculosis strains were new to the SpolDB4 database. All of the M. tuberculosis isolates were susceptible to isoniazid (INH) and rifampicin (RIF), except for one strain (of spoligotype SIT-149 or T3_ETH family) which had a mutation at the inh A locus which often confers resistance to INH (low level) and ethionamide.ConclusionsAnalysis of the genetic population structure of paediatric M. tuberculosis strains suggested similarity with that of adults, indicating an on-going and active transmission of M. tuberculosis from adults to children in Ethiopia. There were no multidrug-resistant TB (MDR-TB) strains among the isolates.

Midupper arm circumference and weight-for-length z scores have different associations with body composition: evidence from a cohort of Ethiopian infants

BACKGROUND A midupper arm circumference (MUAC) <115 mm and weight-for-height z score (WHZ) or weight-for-length z score (WLZ) less than -3, all of which are recommended to identify severe wasting in children, often identify different children. The reasons behind this poor agreement are not well understood. OBJECTIVE We investigated the association between these 2 anthropometric indexes and body composition to help understand why they identify different children as wasted. DESIGN We analyzed weight, length, MUAC, fat-mass (FM), and fat-free mass (FFM) data from 2470 measurements from 595 healthy Ethiopian infants obtained at birth and at 1.5, 2.5, 3.5, 4.5, and 6 mo of age. We derived WLZs by using 2006 WHO growth standards. We derived length-adjusted FM and FFM values as unexplained residuals after regressing each FM and FFM against length. We used a correlation analysis to assess associations between length, FFM, and FM (adjusted and nonadjusted for length) and the MUAC and WLZ and a multivariable regression analysis to assess the independent variability of length and length-adjusted FM and FFM with either the MUAC or the WLZ as the outcome. RESULTS At all ages, length showed consistently strong positive correlations with the MUAC but not with the WLZ. Adjustment for length reduced observed correlation coefficients of FM and FFM with the MUAC but increased those for the WLZ. At all ages, both length-adjusted FM and FFM showed an independent association with the WLZ and MUAC with higher regression coefficients for the WLZ. Conversely, length showed greater regression coefficients for the MUAC. At all ages, the MUAC was shown to be more influenced than was the WLZ by the FM variability relative to the FFM variability. CONCLUSIONS The MUAC and WLZ have different associations with body composition, and length influences these associations differently. Our results suggest that the WLZ is a good marker of tissue masses independent of length. The MUAC acts more as a composite index of poor growth indexing jointly tissue masses and length. This trial was registered at www.controlled-trials.com as ISRCTN46718296.

Drug resistance in HIV patients with virological failure or slow virological response to antiretroviral therapy in Ethiopia

BackgroundThe ongoing scale-up of antiretroviral therapy (ART) in sub-Saharan Africa has prompted the interest in surveillance of transmitted and acquired HIV drug resistance. Resistance data on virological failure and mutations in HIV infected populations initiating treatment in sub-Saharan Africa is sparse.MethodsHIV viral load (VL) and resistance mutations pre-ART and after 6 months were determined in a prospective cohort study of ART-naïve HIV patients initiating first-line therapy in Jimma, Ethiopia. VL measurements were done at baseline and after 3 and 6 months. Genotypic HIV drug resistance (HIVDR) was performed on patients exhibiting virological failure (>1000 copies/mL at 6 months) or slow virological response (>5000 copies/mL at 3 months and <1000 copies/mL at 6 months).ResultsTwo hundred sixty five patients had VL data available at baseline and at 6 months. Virological failure was observed among 14 (5.3%) participants out of 265 patients. Twelve samples were genotyped and six had HIV drug resistance (HIVDR) mutations at baseline. Among virological failures, 9/11 (81.8%) harbored one or more HIVDR mutations at 6 months. The most frequent mutations were K103N and M184VI.ConclusionsOur data confirm that the currently recommended first-line ART regimen is efficient in the vast majority of individuals initiating therapy in Jimma, Ethiopia eight years after the introduction of ART. However, the documented occurrence of transmitted resistance and accumulation of acquired HIVDR mutations among failing patients justify increased vigilance by improving the availability and systematic use of VL testing to monitor ART response, and underlines the need for rapid, inexpensive tests to identify the most common drug resistance mutations.

Level and intensity of objectively assessed physical activity among pregnant women from urban Ethiopia

BackgroundWomen in low-income countries are generally considered to have a high physical workload which is sustained during pregnancy. Although most previous studies have been based on questionnaires a recent meta-analysis of doubly labeled water data has raised questions about the actual amount of physical activity performed. In this study we report objectively assessed levels of physical activity, cardiorespiratory fitness and muscular fitness among pregnant urban Ethiopian women, and their association with demographic characteristics and anthropometric measures.MethodsPhysical activity was measured for seven consecutive days in 304 women using a combined uniaxial accelerometer and heart rate sensor. Activity energy expenditure was determined using a group calibration in a branched equation model framework. Type and duration of activities were reported using a 24-hour physical activity recall and grip strength was assessed using a dynamometer.ResultsMedian (interquartile-range, IQR) activity energy expenditure was 31.1 (23.7-42.0) kJ/kg/day corresponding to a median (IQR) physical activity level of 1.46 (1.39-1.58). Median (IQR) time in sedentary, light, and moderate-to-vigorous intensity was 1100 (999–1175), 303 (223–374) and 40 (22–69) min/day, respectively. Mean (standard deviation) sleeping heart rate was 73.6 (8.0) beats/min and grip strength was 21.6 (4.5) kg. Activity energy expenditure was 14% higher for every 10 cm2 difference in arm muscle area and 10% lower for every 10 cm2 difference in arm fat area and 10-week difference in gestational age.ConclusionThe level and intensity of physical activity among pregnant women from urban Ethiopia is low compared to non-pregnant women from other low income countries as well as pregnant European women from high-income countries.

Acceptability of locally produced ready-to-use therapeutic foods in Ethiopia, Ghana, Pakistan and India

Abstract Successful treatment of severe acute malnutrition has been achieved with ready‐to‐use therapeutic food (RUTF), but only 15% of children with severe acute malnutrition receive RUTF. The objective of this study was to determine whether new formulations of RUTF produced using locally available ingredients were acceptable to young children in Ethiopia, Ghana, Pakistan and India. The local RUTFs were formulated using a linear programming tool that allows for inclusion of only local ingredients and minimizes cost. The study consisted of 4 two‐arm, crossover, site‐randomized food acceptability trials to test the acceptability of an alternative RUTF formula compared with the standard peanut‐based RUTF containing powdered milk. Fifty children with moderate wasting in each country were enrolled in the 2‐week study. Acceptability was measured by overall consumption, likeability and adverse effects reported by caregivers. Two of the four RUTFs did not include peanut, and all four used alternative dairy proteins rather than milk. The ingredient cost of all of the RUTFs was about 60% of standard RUTF. In Ethiopia, Ghana and India, the local RUTF was tolerated well without increased reports of rash, diarrhoea or vomiting. Children consumed similar amounts of local RUTF and standard RUTF and preferred them similarly as well. In Pakistan, local RUTF was consumed in similar quantities, but mothers perceived that children did not enjoy it as much as standard RUTF. Our results support the further investigation of these local RUTFs in Ethiopia, Ghana and India in equivalency trials and suggest that local RUTFs may be of lower cost.

Physical activity and capacity at initiation of antiretroviral treatment in HIV patients in Ethiopia

SUMMARY We described levels of habitual physical activity and physical capacity in HIV patients initiating antiretroviral treatment in Ethiopia and assessed the role of HIV and nutritional indicators on these outcomes. Physical activity energy expenditure (PAEE) and activity levels were measured with combined heart rate and movement sensors. Physical capacity was assessed by grip strength, sleeping heart rate and heart rate economy. Grip strength data was also available from a sex- and age-matched HIV-negative reference group. Median PAEE was 27.9 (interquartile range 17.4-39.8) kJ/kg per day and mean ± s.d. grip strength was 23.6 ± 6.7 kg. Advanced HIV disease predicted reduced levels of both physical activity and capacity; e.g. each unit viral load [log(1+copies/ml)] was associated with -15% PAEE (P < 0.001) and -1.0 kg grip strength (P < 0.001). Grip strength was 4.2 kg lower in patients compared to HIV-negative individuals (P < 0.001). Low body mass index (BMI) predicted poor physical activity and capacity independently of HIV status, e.g. BMI <16 was associated with -42% PAEE (P < 0.001) and -6.8 kg grip strength (P < 0.001) compared to BMI ≥18.5. The study shows that advanced HIV and malnutrition are associated with considerably lower levels of physical activity and capacity in patients at initiation of antiretroviral treatment.